Dataset Information

Understanding delays in chronic limb-threatening ischaemia care: Application of the theoretical domains framework to identify factors affecting primary care clinicians' referral behaviours.

ABSTRACT:

Introduction

Patients in the community with suspected Chronic limb-threatening ischaemia (CLTI) should be urgently referred to vascular services for investigation and management. The Theoretical Domains Framework (TDF) allows identification of influences on health professional behaviour in order to inform future interventions. Here, the TDF is used to explore primary care clinicians' behaviours with regards to recognition and referral of CLTI.

Methods

Semi-structured interviews were conducted with 20 podiatrists, nurses and general practitioners in primary care. Directed content analysis was performed according to the framework method. Utterances were coded to TDF domains, and belief statements were defined by grouping similar utterances. Relevance of domains was confirmed according to belief frequency, presence of conflicting beliefs and the content of the beliefs indicating relevance.

Results

Nine TDF domains were identified as relevant to primary care clinicians: Knowledge, Environmental context and resources, Memory, Decision and attention processes, Beliefs about capabilities, Skills, Emotions, Reinforcement and Behavioural regulation. Relationships across domains were identified, including how primary care clinician confidence and working in a highly pressurized environment can affect behaviour.

Conclusion

We have identified key barriers and enablers to timely recognition and referral behaviour. These beliefs identify targets for theory-driven behaviour change interventions to reduce delays in CLTI pathways.

SUBMITTER: Atkins E

PROVIDER: S-EPMC11296715 | biostudies-literature | 2024 Jun

REPOSITORIES: biostudies-literature

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Understanding delays in chronic limb-threatening ischaemia care: Application of the theoretical domains framework to identify factors affecting primary care clinicians' referral behaviours.

Atkins Eleanor E Birmpili Panagiota P Kellar Ian I Johal Amundeep S AS Li Qiuju Q Waton Sam S Boyle Jonathan R JR Pherwani Arun D AD Chetter Ian I Cromwell David A DA

Journal of foot and ankle research 20240601 2

<h4>Introduction</h4>Patients in the community with suspected Chronic limb-threatening ischaemia (CLTI) should be urgently referred to vascular services for investigation and management. The Theoretical Domains Framework (TDF) allows identification of influences on health professional behaviour in order to inform future interventions. Here, the TDF is used to explore primary care clinicians' behaviours with regards to recognition and referral of CLTI.<h4>Methods</h4>Semi-structured interviews we ...[more]

PMID: 38703396

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Project description:AimsThe prevalence of chronic limb-threatening ischaemia (CLTI) is increasing and available data often derive from cohorts with various selection criteria. In the present study, we included CLTI patients and studied sex-related differences in their risk profile, vascular procedures, and long-term outcome.Methods and resultsWe analysed 199 953 unselected patients of the largest public health insurance in Germany (AOK: Local healthcare funds), hospitalized between 2010 and 2017 for a main diagnosis of CLTI. A baseline period of 2 years before index hospitalization to assess comorbidities and previous procedures, and a follow-up period until 2018 were included. Female CLTI patients were older (median 81.4 vs. 73.8 years in males; P < 0.001) and more often diagnosed with hypertension, atrial fibrillation, chronic heart failure, and chronic kidney disease. Male patients suffered more frequently from diabetes mellitus, dyslipidaemia, smoking, cerebrovascular disease, and chronic coronary syndrome (all P < 0.001). Within hospitalized CLTI patients, females represent the minority (43% vs. 57%; P < 0.001) and during index hospitalization, women underwent less frequently diagnostic angiographies (67 vs. 70%) and revascularization procedures (61 vs. 65%; both P < 0.001). Moreover, women received less frequently guideline-recommended drugs like statins (35 vs. 43%) and antithrombotic therapy (48 vs. 53%; both P < 0.001) at baseline. Interestingly, after including age and comorbidities in a Cox regression analysis, female sex was associated with increased overall-survival (OS) [hazard ratio (HR) 0.95; 95% confidence interval (CI) 0.94-0.96] and amputation-free survival (AFS) (HR 0.84; 95% CI 0.83-0.85; both P < 0.001).ConclusionFemale patients with CLTI were older, underwent less often vascular procedures, and received less frequently guideline-recommended medication. Nevertheless, female sex was independently associated with better OS and AFS during follow-up.

Project description:ObjectivesAntiplatelet therapy following peripheral arterial endovascular intervention lacks high quality evidence to guide practice. The aim of this study was to assess the effect of three months of dual antiplatelet therapy on amputation-free survival following peripheral arterial endovascular intervention in patients with chronic limb threatening ischemia.MethodsA retrospective review of symptomatic patients undergoing primary peripheral arterial endovascular intervention over a seven-year period was performed. The primary outcome measure was amputation-free survival. A sample size calculation based on previous cohort studies suggested that 629 limbs would be required to show a difference between single and dual therapy. Kaplan-Meier estimates and multivariate logistic regression analysis of recorded baseline characteristics was performed to determine predictors of amputation-free survival. Dual antiplatelet therapy was routinely given for 3 months.Results754 limbs were treated with primary angioplasty and/or stenting over a 7-year period, 508 of these for chronic limb threatening ischemia. There was no difference in unadjusted amputation-free survival between patients with chronic limb threatening ischaemia taking single vs. dual antiplatelet therapy (69% vs. 74% respectively Log rank Chi2 = 0.1, p = .72). After adjusting for confounders, at 1 year there was also no significant difference in amputation-free survival between patients taking single vs. dual antiplatelet therapy [OR 0.8, 95% CI 0.5-1.2, p = .3]. There was no difference in rates of major bleeding between single and dual antiplatelet therapy.ConclusionsThere was no clear evidence of reduced amputation-free survival in patients with chronic limb threatening ischemia undergoing peripheral arterial endovascular intervention being treated with dual antiplatelet therapy for 3 months. This is at odds with other retrospective case series and highlights the limitations in basing clinical practice on such data. There is a need for an adequately powered, independent randomised trial to definitively answer the question.

Project description:ObjectiveMicrocirculation focused evaluations may provide physiological insights that complement those of the established clinical criteria for patients with chronic limb threatening ischaemia (CLTI), since complex treatments are needed in this high risk population. However, current methods for quantitatively assessing foot microcirculation are limited. Thus, in this study, the aim was to demonstrate a proof of concept non-invasive method with novel parameters for assessing foot microcirculation.MethodsThis was a single centre prospective cohort pilot study. The lower limbs of 13 patients diagnosed with CLTI were evaluated by radionuclide (RN) angiography with 99mTc-tetrofosmin two weeks after revascularisation or non-revascularisation procedures. Novel parameters (pedal transit time and peak pedal count) were derived by processing the time-activity curves of the detected tracers in each region of interest in the limbs. The Mann-Whitney U test was used for the analysis of associations between these two parameters and limb fate at one year, and Pearson and Spearman tests were used to analyse associations with transcutaneous partial oxygen pressure (tcPO2), a conventional perfusion test result.ResultsThe mean pedal transit time of the affected limbs in the non-healing group was longer than that in the healing group (19.1 ± 18.6 vs. 2.9 ± 2.1 seconds, p = .001). The mean peak pedal count of nucleotides in the non-healing group was lower than that in the healing group (24.4 ± 19.0 vs. 72.0 ± 36.1 counts/sec/GBq, p = .008). The pedal transit time and peak pedal count showed little to no correlation with the conventional tcPO2 at the midfoot (r = 0.26 for pedal transit time; r = -0.11 for peak pedal count).ConclusionTwo novel microcirculation parameters derived from RN angiography were associated with one year limb outcomes in patients with CLTI. Non-invasive radiotracer imaging derived parameters may provide an additional dimension to indices of pathophysiological microcirculation in CLTI.

Dataset Information

Understanding delays in chronic limb-threatening ischaemia care: Application of the theoretical domains framework to identify factors affecting primary care clinicians' referral behaviours.

Introduction

Methods

Results

Conclusion

Publications

Understanding delays in chronic limb-threatening ischaemia care: Application of the theoretical domains framework to identify factors affecting primary care clinicians' referral behaviours.

Similar Datasets

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