Abstract
Abstract
Objective. International guidelines recommend rehabilitation including supervised exercise therapy in patients with Intermittent Claudication (IC), but knowledge of the implementation in clinical practice is limited. This study aims to investigate current practice and opinions on rehabilitation for patients with IC among vascular surgeons and rehabilitation departments in the municipalities and hospitals. Design. Three electronic cross-sectional surveys were distributed nationally to the Danish vascular surgeons (n = 131) and to rehabilitation departments in the municipalities (n = 92) and hospitals (n = 33). Results. The response rates were 70% among the vascular surgeons, 98% among the municipalities and 94% among the hospitals. Vascular surgeons utilize oral advice to exercise by self-administered walking, pharmacological treatment, and revascularization to improve walking distance in patients with IC. Currently, only 12% of the vascular surgeons referred to rehabilitation to improve walking distance, while almost all vascular surgeons (96%) would refer their patients to IC rehabilitation, if it was available. Only 14% of municipalities and none of the hospitals, who treat patients with IC, have a rehabilitation program designed specifically for patients with IC. However, 59% of the rehabilitation departments in the municipalities and 26% in the hospitals included patients with IC in rehabilitation program designed for other patient groups – mostly cardiac patients. There was consensus among the groups of respondents that future IC specific rehabilitation should include an initial conversation, supervised exercise therapy, smoking cessation, and patient education according to guidelines. Conclusion. Vascular surgeons support referral and participation in IC rehabilitation to improve walking distance in patients with IC. Despite some hospitals and municipalities included patients with IC in rehabilitation nearly all services fail to meet current guideline as specific services tailored to patient with IC is almost non-existent in Denmark. Our findings call for action for services to comply with current recommendations of structured, systematic rehabilitation for patients with IC.
Introduction
Intermittent Claudication (IC) is a marker of systemic atherosclerosis, which is associated with cardiovascular mortality rates at 5 and 10 years of 42% and 65%, respectively [1]. IC is highly prevalent in Western countries affecting approximately 5% of the general population aged 40 years and older [2]. Contemporary, international guidelines recommend supervised exercise therapy (SET) to be one of the cornerstones in the rehabilitation of IC [3–5]. SET is effective as a rehabilitation strategy in >80% of the patients with IC [4–8], and it improves the functional status and health-related quality of life (QOL) [3–5]. Trials with long-term follow-up indicate a persistent benefit of SET in patients with IC [9–11], and SET is cost-effective as rehabilitation [12].
Even though SET is an effective rehabilitation strategy to improve walking distance and health-related QOL in patients with IC, it remains underutilized in clinical practice [13]. As supervision is essential to improve outcomes of rehabilitation including SET [14,15] recommendations of self-administered walking are insufficient [16,17]. Specific knowledge and availability of evidence-based treatment options is important for the health care providers and might partly explain the underutilization [18]. Also, limited availability of qualified therapists and financial barriers in the health-care system can add to the underutilization [19]. Structured, systematic rehabilitation including SET, to which vascular surgeons and general practitioners can refer, might be the solution to comply with current recommendations and improve utilization and outcomes in clinical practice. Before developing and implementing such a program a deeper understanding of current practice and opinions on rehabilitation for patients with IC is needed.
A national survey was therefore conducted among (1) vascular surgeons and (2) rehabilitation departments in municipalities and hospitals in Denmark to map the current practice and opinions on rehabilitation for patients with IC in the public healthcare system.
Materials and methods
General design
This study is based on data from two nationwide cross-sectional electronic surveys and is reported according to the CHERRIES- and STROBE Statement Checklists for E-surveys and Cross-sectional studies [20,21]. The surveys were developed using a guide to design and conduct self-administered surveys for clinicians [22].
Rehabilitation in a Danish context
The management of cardiovascular rehabilitation in Denmark is a shared responsibility between the hospitals (regional level) and the municipalities (municipal level) [23]. Rehabilitation programs including SET can be offered in private physiotherapy clinics, where the treatment is partly paid by the patient, or in the public rehabilitation departments in the municipalities or hospitals, where the treatment is tax financed [24].
Survey among Danish vascular surgeons
All members of the Danish Society of Vascular Surgeons were invited to participate in the survey (131 members). The final 18-question survey was distributed and assembled as a closed online web-based survey. Each member was contacted by e-mail. Initially, they were asked to respond if they considered themselves inappropriate respondents for this survey. Inappropriate respondents included members who had retired or were not working with patients with IC. The survey items were constructed based on a similar Dutch survey [19] and a general literature search. The survey was pilot-tested by two vascular surgeons from the Danish Society of Vascular Surgeons. See Appendix 1 for the survey.
Survey among Danish public rehabilitation departments
The survey concerning rehabilitation for patients with IC was included in a nationwide survey regarding rehabilitation for people with cardiac diseases. All Danish public rehabilitation departments (36 hospitals and 98 municipalities) were invited to participate in the survey. The Danish Cardiac Rehabilitation Database (DHRD) [25] contacted all rehabilitation departments to identify the relevant respondents. At first, the respondents from a previous survey were contacted [26]. If they did not respond, the department head was contacted to identify the relevant respondent. The 17-question survey for the hospitals and 18-question survey for the municipalities were almost identical with few differences in response options and one extra question for the municipalities concerning who refer patients to the municipality. The surveys were pilot-tested by one respondent from each setting. See Appendix 2 for the survey.
Data collection
The electronic surveys were conducted in the Spring 2018, using Survey Xact version 12.6 (Ramboell Management Consulting, Aarhus N., Denmark). Participation by the vascular surgeons was voluntary. The surveys to the Danish public rehabilitation departments were gathered through the DHRD, where the municipalities had voluntary participation and the hospitals are required to respond according to Danish law.
The web-based questionnaires were sent out by e-mail to the responders using a unique link for each respondent. Two additional reminder-mails were sent to the non-responders. The non-responders in the hospitals and municipalities were afterwards contacted by phone.
The vascular surgeons in one of the health care regions did not respond to the distribution or reminder-mails. The department head and a vascular surgeon from the project were contacted to try to motivate their colleagues to respond. This did not improve the response rate (0% improvement). Therefore, an extra e-mail was distributed to the vascular surgeons in this health care region, which improved the response rate for this region.
Ethics
Approval from the Regional Scientific Ethical Committee was not necessary for this study according to Danish law, since the study was a questionnaire survey [27,28]. The surveys were approved by the Danish Data Protection Agency (University of Southern Denmark, approval number 10.119). In the distribution and reminder e-mails the respondents were informed that by answering the questionnaire they accepted that their answers would be part of the aggregated results and treated anonymously.
Data management and analysis
After data collection was completed, the surveys were screened to ensure that all surveys were completed correctly. In the case of missing answers, no imputation took place.
Data were analyzed using descriptive statistics. All variables were expressed as number (percentages) or mean (standard deviation). All statistical analyses were performed using SPSS 25 software (IBM Corporation, Armonk, New York, USA).
Results
Survey responses
Survey participation is illustrated in Figure 1. The response rates were 70% (n = 78) for the vascular surgeons, 98% (n = 96) for the rehabilitation departments in the municipalities and 94% (n = 31) for the rehabilitation departments in the hospitals. The respondent characteristics are illustrated in Table 1.
Published online:
21 August 2019Figure 1. Survey participation among the vascular surgeons, Danish municipalities and hospitals. 119 was not eligible to participate, 11 had retired, 8 not working with patients with IC. 2One respondent answered on behalf of seven municipalities. The respondent had a coordinating function among seven municipalities regarding rehabilitation of patients with heart diseases. 3One respondent answered on behalf of two hospitals since the two hospitals were connected.
![]({"type":"image","src":"/na101/home/literatum/publisher/tandf/journals/content/icdv20/2019/icdv20.v053.i06/14017431.2019.1654614/20191118/images/medium/icdv_a_1654614_f0001_b.jpg"})
Figure 1. Survey participation among the vascular surgeons, Danish municipalities and hospitals. 119 was not eligible to participate, 11 had retired, 8 not working with patients with IC. 2One respondent answered on behalf of seven municipalities. The respondent had a coordinating function among seven municipalities regarding rehabilitation of patients with heart diseases. 3One respondent answered on behalf of two hospitals since the two hospitals were connected.
Table 1. Respondent characteristics*.
Current practice and knowledge among the vascular surgeons
The current practice by vascular surgeons is illustrated in Table 2. The most common treatment to improve the walking distance in patients with IC consisted of oral advice to self-administered walking with a follow-up (71%) and revascularization (64%). Only 12% of the vascular surgeons referred to SET to improve walking distance.
Table 2. Current practice among the Danish vascular surgeons (n = 78)*.
The knowledge of existing IC rehabilitation programs and referral pattern by the Danish vascular surgeons is illustrated in Figure 2.
Published online:
21 August 2019Figure 2. Knowledge of existing rehabilitation programs for patients with IC and referral pattern by the vascular surgeons (n = 78). The respondent could select more than one response option to the questions E.g. If they knew of rehabilitation in both the municipalities and the hospitals.
![]({"type":"image","src":"/na101/home/literatum/publisher/tandf/journals/content/icdv20/2019/icdv20.v053.i06/14017431.2019.1654614/20191118/images/medium/icdv_a_1654614_f0002_c.jpg"})
Figure 2. Knowledge of existing rehabilitation programs for patients with IC and referral pattern by the vascular surgeons (n = 78). The respondent could select more than one response option to the questions E.g. If they knew of rehabilitation in both the municipalities and the hospitals.
A substantial part of the vascular surgeons (77%) did not know of any existing rehabilitation program for them to refer their patients to and most of the vascular surgeons therefore did not refer patients with IC to rehabilitation (78%).
Current practice in the public rehabilitation departments
The current practice in the Danish rehabilitation departments is illustrated in Table 3.
Table 3. Current practice in the public rehabilitation departments (municipalities n = 96, hospitals n = 31)*.
Most of the rehabilitation departments in the municipalities (59%) treated patients with IC. However, only 14% of those had a rehabilitation program specifically tailored to patients with IC. In the hospitals, only 26% treated patients with IC, and none of them had rehabilitation tailored to patients with IC.
The rehabilitation typically consisted of an initial conversation and SET in both hospitals and municipalities. Only a few of the rehabilitation teams that treated patients with IC included employees with specific knowledge of IC (9% of the municipalities and 29% of the hospitals).
Opinions regarding rehabilitation among vascular surgeons and the public rehabilitation departments
The opinions regarding optimal rehabilitation are illustrated in Table 4.
There seemed to be consensus between the respondents that the rehabilitation should consist of an initial conversation, SET, patient education, and smoking cessation. In general, the three groups of respondents also agreed that the organization should be supervised and in groups.
In the rehabilitation departments only 41% of the municipalities and 30% of the hospitals were aware of the National clinical guideline for patients with IC.
Table 5 lists the Danish vascular surgeons’ opinions on when to offer rehabilitation including SET to patients with IC. Almost all vascular surgeons (96%) would refer patients with IC to rehabilitation if it was available. According to the level of agreement to statements regarding the use of SET, there seemed to be a variety of opinions towards which patients should be referred to SET.
Table 5. Danish vascular surgeons’ opinions on when to offer SET (n = 78)*.
Discussion
Current practice among the vascular surgeons was to give oral advice to start walking, pharmacological treatment (e.g. statins), and revascularization to improve walking distance in patients with IC. Only 1 out of 10 vascular surgeons referred to rehabilitation (SET) to improve walking distance, while almost all Danish vascular surgeons would refer to rehabilitation if available. Only a few of the municipalities and none of the hospitals that treat patients with IC had a specific rehabilitation program designed for the population. Overall, our results highlight the need for a structured, systematic rehabilitation program in hospitals and municipalities following current guidelines for patients with IC.
Even though international guidelines recommend that all patients with IC are referred to SET as part of the initial rehabilitation [3–5], the results of our study indicate that it is far from current practice and confirms previous international research in patients with IC [29,30]. Our results suggest that the lack of a well-designed rehabilitation program including SET in the public rehabilitation departments is one of the barriers against successful rehabilitation of patients with IC. Although, the rehabilitation does not have to consist of walking, not all rehabilitation programs would lead to improved symptoms, as it is essential that a rehabilitation program includes supervised exercise of sufficient dose and length [3–5]. There seemed to be consensus among the respondents of our study that a future rehabilitation program should include an initial conversation (including history taking, goal setting etc.), SET, smoking cessation, and patient education. As almost all the vascular surgeons would refer the patients with IC to rehabilitation if it was available, implementing such a program has the potential to bridge the gap between current high-quality evidence on the effects of rehabilitation including SET [14–16] and the lack of utilization in clinical practice [13]. In patients with IC in the Netherlands (ClaudicatioNet) and osteoarthritis in Denmark, Canada, Australia and China [31–33], training health care practitioners in delivering evidence-based treatment is a successful way to implement evidence in clinical practice. Furthermore, a systematic and structured implementation of rehabilitation including SET as part of everyday clinical practice seems to be cost-effective [12]. Building on these previous experiences and the findings of the current study offers a feasible and attractive way forward to improve the quality of care of patients with IC in Denmark and perhaps to prevent future cardiovascular mortality and morbidity [34].
The vascular surgeons in our study supported rehabilitation of patients with IC and would refer to an evidence-based rehabilitation program if it was available. Surprisingly, only 3 out of 4 of the vascular surgeons agreed that SET should be a cornerstone in the rehabilitation of patients with IC, as recommended by international guidelines [5–7]. Around half of the Danish vascular surgeons found SET to be relevant when IC was caused by significant iliac stenosis and just above half found that SET was useful in patients with a maximal walking distance of less than 100 m. According to the literature, these arguments against SET are not valid [4,9,19,35]. This variety in opinions regarding eligible patients with IC could lead to lack of referrals of eligible patients to rehabilitation including SET, because unawareness of the potential positive effects of SET.
Only 1 out of 3 of the municipalities had patients with IC referred from the general practitioner (GP). A Dutch survey among GPs indicated that the GPs underestimate the importance of treatment of IC (including SET) because their focus is on prevention of coronary artery and cerebrovascular diseases [36]. Even though, that study was done in the Netherlands, it could likely be similar in a Danish setting. The GPs are important stakeholders and their lack of focus on treatment of patients with IC may reduce referral to SET and to vascular surgeons. Therefore, it is important to educate GPs alongside vascular surgeons, physiotherapists and other stakeholders in current evidence-based guidelines and engage them in the development and implementation of a structured, systematic rehabilitation program including SET in order to be able to change current clinical practice. Such a program (ClaudicatioNet) has successfully been implemented in the Netherlands, where vascular surgeons, physiotherapists and GPs collaborate in a national integrated care network [31].
Strengths and limitations
An important strength of the study is that national surveys were conducted with high response rates (70%, 98% and 94%), increasing the generalizability of the study findings. Especially, the survey among the public rehabilitation departments is very close to that of census surveys, where the whole target population is enumerated in the study [37]. This is a considerable strength of this study since the risk of sampling errors is negligible.
The survey among the vascular surgeons was based upon prior surveys from The Netherlands [19]. However, the health-care settings of the two countries are not completely identically. Surveys among the Danish municipalities and hospitals were based upon previous surveys regarding rehabilitation for patients with heart diseases [26]. Nevertheless, there is a crucial difference in how well implemented rehabilitation is for those diseases as compared to IC. Since most of the municipalities does not offer rehabilitation including SET, this may result in insufficient mapping of the rehabilitation for patients with IC.
Given the explorative nature of this study a more thorough pre- and pilot testing of the surveys might have minimized the number of free-text comments from the respondents if the question stems and response options were more adequately constructed for the context.
Conclusion
Despite strong recommendations in several international guidelines this survey highlights that rehabilitation, and in particular SET, is still a largely underutilized tool in the management of patients with IC. Dissemination of the clinical recommendations to all relevant stakeholders in the Danish public healthcare system is highly needed. The results of this study strongly emphasize the importance of translating existing research into evidence-based clinical practice in the Danish public healthcare system.
| Vascular Surgeons, n = 78 | ||
| Age: | ||
| ≤40 | 23 (30%) | |
| 41–50 | 23 (30%) | |
| 51–60 | 14 (18%) | |
| >60 | 18 (23%) | |
| Gender: | ||
| Male | 47 (60%) | |
| Female | 31 (40%) | |
| Health care region: | ||
| Capital Region of Denmark | 19 (24%) | |
| Region Zealand | 6 (8%) | |
| Region of Southern Denmark | 26 (33%) | |
| Central Denmark Region | 14 (18%) | |
| North Denmark Region | 11 (14%) | |
| Not working in a hospital | 2 (3%) | |
| Experience as vascular surgeon: (years) | ||
| ≤10 | 30 (39%) | |
| 11–20 | 26 (33%) | |
| 21–30 | 17 (22%) | |
| >30 | 5 (6%) | |
| No. of patients with IC annually: | ||
| ≤100 | 35 (45%) | |
| 101–200 | 21 (27%) | |
| 201–300 | 9 (12%) | |
| 301–400 | 6 (8%) | |
| >400 | 7 (9%) | |
| Percentage of patients with IC that the vascular surgeons refer to rehabilitation: (n = 17)a, mean (SD) | 34% (37) | |
| Municipalities | Hospitals | |
| Survey among public rehabilitation departments in municipalities (n = 96) and hospitals (n = 31) | ||
| Job position: | ||
| Responsible for the full rehabilitation program for patients with heart diseases in the municipality | 18 (19%) | 3 (10%) |
| Responsible for part of the rehabilitation program for patients with heart diseases in the municipality | 17 (18%) | 5 (16%) |
| Physiotherapist in the rehabilitation program for patients with heart diseases | 39 (41%) | 18 (58%) |
| Other job positions | 22 (23%)b | 5 (16%)c |
| Health care region: | ||
| Capital Region of Denmark | 29 (30%) | 9 (29%) |
| Region Zealand | 16 (17%) | 6 (19%) |
| Region of Southern Denmark | 21 (22%) | 7 (23%) |
| Central Denmark Region | 19 (20%) | 6 (19%) |
| North Denmark Region | 11 (12%) | 3 (10%) |
a n = 17, because 17 vascular surgeons referred patients with IC to rehabilitation. The 17 vascular surgeons, who answered that they did refer patients to rehabilitation, where asked how many percentage of their patients they referred.
b Most commonly employees with a coordinator function in the rehabilitation program for patients with heart diseases (n = 16), development therapist (n = 5).
c Most commonly employees with responsibility for the medical rehabilitation (n = 2), development therapist (n = 1) and a resource person in the medical rehabilitation team (n = 1).
*n (%) unless otherwise stated; IC: Intermittent Claudication.
| Vascular surgeons | |
|---|---|
| Treatment to improve walking distance: (n = 78) | |
| Advice to self-administered walking without follow-up | 42 (54%) |
| Advice to self-administered walking with follow-up | 55 (71%) |
| Flyer with information | 38 (49%) |
| Referral to rehabilitation | 9 (12%) |
| Referral to a nurse for lifestyle changes | 12 (15%) |
| Pharmacological treatment | 46 (59%) |
| Surgery | 50 (64%) |
| Walking is not addressed during the consultation | 1 (1%) |
| Determinants for when to offer surgery in patients with IC: (n = 71)a | |
| Limitations in daily life (LDL) | 13 (17%) |
| Patient-reported walking ability (WA-P) | 3 (4%) |
| Walking ability determined by functional test (WA-V) | 0 (0%) |
| LDL + WA-P + WA-V | 8 (10%) |
| LDL + WA-P | 47 (60%) |
| LDL + WA-V | 0 (0%) |
| WA-P + WA-V | 0 (0%) |
a Missing data from seven respondents, because they believed the evaluation of eligibility for surgery was more complex than indicated by the categories.
*n (%) unless otherwise stated; IC = Intermittent Claudication.
| Municipalities | Hospitals | |
|---|---|---|
| Do you treat patients with IC? | ||
| Yes | 57 (59%) | 8 (26%) |
| No | 39 (41%) | 23 (74%) |
| How is the rehabilitation program organized? (n = 56, n = 8)a | ||
| Same program as people with heart diseases | 38 (67%) | 8 (100%) |
| Specialized program for people with IC | 8 (14%) | 0 (0%) |
| Free-text commentsb | 10 (18%)b | 0 (0%) |
| Number of patients with IC annually: | ||
| Mean (SD) (n = 50, n = 8)a | 13 (13) | 15 (12) |
| Who refer patients with IC to your municipality:a | ||
| The hospital | 45 (79%) | |
| The general practitioner | 31 (54%) | |
| The patient contacts the municipality | 10 (18%) | – |
| Do not know | 5 (9%) | |
| Free-text commentsc | 10 (18%)c | |
| Elements in the rehabilitation: | ||
| (n = 57, n = 8)a | ||
| Initial conversation | 52 (91%) | 6 (75%) |
| SET | 53 (93%) | 6 (75%) |
| Patient education | 31 (54%) | 5 (63%) |
| Psycho-social intervention | 27 (47%) | 4 (50%) |
| Smoking cessation intervention | 42 (74%) | 4 (50%) |
| Dietary intervention | 39 (68%) | 4 (50%) |
| Organization of the rehabilitation: | ||
| Mean (SD), (n = 57, n = 8)a | ||
| Number of weeks | 11 (7) | 9 (3) |
| Times pr. week | 2 (0) | 2 (0) |
| Length of each session in minutes | 62 (14) | 69 (14) |
| Percentage that is supervised walking | 24 (26) | 20 (14) |
| Number of treadmills available: | ||
| Mean (SD) (n = 55, n = 6)a | 2 (2) | 1 (0) |
| Competencies in the rehabilitation team: | ||
| (n = 56, n = 7)a | ||
| Specific IC competencies | 5 (9%) | 2 (29%) |
| General vascular diseases competencies | 45 (80%) | 4 (57%) |
| No specific IC competencies | 1 (2%) | 1 (14%) |
| Do not know | 3 (5%) | 0 (0%) |
| Free-text comments | 2 (4%) | 0 (0%) |
a Results are only from the respondents who respond that they treat patients with IC (municipalities n = 57, hospitals n = 8).
b Most commonly, individually planned rehabilitation (n = 6) or integrated in programs for other diseases (n = 4).
c Most commonly patients with IC is referred with IC as a secondary diagnosis, n = 7.
*n (%) unless otherwise stated; IC: Intermittent Claudication; SET: Supervised exercise therapy.
| Vascular surgeons | Municipalities | Hospitals | |
|---|---|---|---|
| Elements in the rehabilitation: | |||
| Individual initial conversation | 61 (78%) | 50 (88%) | 7 (88%) |
| SET | 74 (95%) | 54 (95%) | 7 (88%) |
| Patient education | 68 (87%) | 44 (77%) | 7 (88%) |
| Psycho-social intervention | 30 (39%) | 41 (72%) | 6 (75%) |
| Smoking cessation intervention | 74 (95%) | 50 (88%) | 6 (75%) |
| Dietary intervention | 43 (55%) | 46 (81%) | 6 (75%) |
| Organization of the SET: | |||
| Supervised | 47 (60%) | 47 (83%) | 5 (63%) |
| Non-supervised | 3 (4%) | 12 (21%) | 0 (0%) |
| General physical exercise | 22 (28%) | 34 (60%) | 5 (63%) |
| Primarily walking | 34 (44%) | 29 (51%) | 4 (50%) |
| In groups | 38 (49%) | 47 (83%) | 5 (63%) |
| Individual | 14 (18%) | 20 (35%) | 0 (0%) |
| Tele rehabilitation | 20 (26%) | 15 (26%) | 1 (13%) |
| Don’t know | 1 (1%) | 1 (2%) | 1 (13%) |
| Content of SET: | |||
| Supervised walking on a treadmill | 53 (68%) | 38 (67%) | 4 (50%) |
| Supervised alternative training (e.g. cycling, strength training) | 38 (49%) | 43 (75%) | 4 (50%) |
| Lifestyle interventions | 70 (90%) | 45 (79%) | 3 (38%) |
| Assessment of medication usage | 39 (50%) | 18 (32%) | 0 (0%) |
| Assessment of medication adherence | 29 (37%) | 17 (30%) | 1 (13%) |
| Assessment of medication side effects | 22 (28%) | 16 (28%) | 1 (13%) |
| Assessment of blood glucose (Diabetes type 2) | 18 (23%) | 17 (30%) | 0 (0%) |
| Don’t know | – | 8 (14%) | 3 (43%) |
| Awareness of existing National clinical guideline for patients with IC: (n = 96, n = 31) | |||
| Yes | 39 (41%) | 10 (30%) | |
| No | – | 19 (20%) | 10 (30%) |
| Don’t know | 37 (39%) | 11 (33%) |
*n (%) unless otherwise stated; IC: Intermittent Claudication; SET: Supervised exercise therapy.
a Was only answered by respondents from the municipalities and hospitals that treated patients with Intermittent Claudication.
| Vascular surgeons | |
|---|---|
| When to offer SET: (n = 75) | |
| To everyone regardless of stage | 25 (32%) |
| To asymptomatic patients | 3 (4%) |
| To patients with pain during function/IC | 52 (67%) |
| To patients with pain at rest | 16 (21%) |
| To patients with ischemic wounds and gangrene | 10 (13%) |
| To patients not suitable for operation | 27 (35%) |
| Before operation | 33 (42%) |
| After operation | 35 (45%) |
| Should not be offered | 0 (0%) |
| Agreement on statement regarding the use of SET: (n = 74) | |
| SET is more effective than single walking advice | 66 (85%) |
| In addition to cardiovascular risk management, SET should be the primary treatment in Intermittent Claudication | 59 (76%) |
| SET in the municipalities or private sector is as effective as hospital-based SET | 41 (53%) |
| Continuation of SET is useful if patients do not improve in the three first months of treatment | 35 (45%) |
| SET is useful in patients with a maximal walking distance of <100 m. | 44 (56%) |
| SET is useful in patients older than 80 years | 57 (73%) |
| SET is useful in patients who underwent angioplasty | 53 (68%) |
| SET is useful in patients who have IC caused by a significant Iliac stenosis | 36 (46%) |
| SET is useful in patients with IC and not-decompensated chronic heart failure | 52 (67%) |
| SET is useful in patients with IC and chronic pulmonary condition | 50 (64%) |
| In critical limb ischemia, SET is useful in addition to angioplasty | 40 (51%) |
| In critical limb ischemia, SET is useful in addition to revascularization | 43 (55%) |
| Would you refer to standardized rehabilitation for patients with IC, if it was available: (n = 77) | |
| Yes | 75 (96%) |
| No | 2 (3%) |
*n (%) unless otherwise stated; IC: Intermittent Claudication; SET: Supervised exercise therapy.
| Ja, individuelt | Ja, på hold | Ja, telebehandling | Andet, uddyb venligst | Nej | |
|---|---|---|---|---|---|
| Indledende samtale | ❑ | ❑ | ❑ | ❑ _____ | ❑ |
| Fysisk træning | ❑ | ❑ | ❑ | ❑ _____ | ❑ |
| Patientuddannelse | ❑ | ❑ | ❑ | ❑ _____ | ❑ |
| Psykosocial indsats | ❑ | ❑ | ❑ | ❑ _____ | ❑ |
| Rygestop-intervention | ❑ | ❑ | ❑ | ❑ _____ | ❑ |
| Kostintervention og ernæringsindsats | ❑ | ❑ | ❑ | ❑ _____ | ❑ |
Acknowledgements
The authors would like to thank the Danish Heart Rehabilitation Database (DHRD) [25] for their contribution to the data collection in the Danish rehabilitation departments in the municipalities and hospitals. Furthermore, we would like to thank all the respondents, who participated in these surveys.
Disclosure statement
No potential conflict of interest was reported by the authors.
Appendix 1. Survey 1: the Danish vascular surgeons
Spørgsmål vedrørende dig som informant:
1: Alder:
__
2: Køn:
Mand
Kvinde
3: I hvilken region ligger det sygehus arbejder du på:
Region Hovedstaden
Region Sjaelland
Region Syddanmark
Region Midtjylland
Region Nordjylland
Jeg arbejder ikke på et sygehus
4: Hvor mange år har du cirka arbejdet med patienter med Claudicatio Intermittens:
__
5: Hvor mange patienter med Claudicatio Intermittens ser du cirka om året:
____
Spørgsmål vedr. din nuvaerende praksis i forhold til henvisning til rehabiliteringsforløb:
I det følgende vil der spørges ind til elementer indenfor rehabilitering. Der opereres med rehabilitering ud fra følgende definition:
”Rehabilitering kan defineres som en raekke indsatser, der støtter det enkelte menneske, som har eller er i risiko for at få nedsat funktionsevne, i at opnå og vedligeholde bedst mulig funktionsevne, herunder at fungere i samspil med det omgivende samfund”.
Rehabilitering har til formål at forbedre patientens funktionsniveau, fjerne eller mindske aktivitetsrelaterede symptomer, minimere graden af invaliditet, og gøre det muligt for patienten at vende tilbage til en personligt tilfredsstillende rolle i samfundet.
Den samlede rehabiliteringsindsats omfatter såvel non-farmakologiske interventioner som fx patientuddannelse og fysisk traening, som sikring af korrekt medicinsk behandling og medicinsk risikofaktorkontrol.
Det er blevet anbefalet, at rehabilitering etableres som integrerede behandlingstilbud med individuelt tilrettelagte og sammenhaengende rehabiliteringsforløb.
6: Viderehenviser du patienter med Claudicatio Intermittens til rehabiliteringsforløb?
(sæt gerne flere krydser)
Ja, til rehabiliteringsforløb i kommunen
Ja, til rehabiliteringsforløb i privat praksis
Ja, til rehabiliteringsforløb på sygehus
Nej
Andet:_____
7: Hvor mange procent af dine patienter med Claudicatio Intermittens viderehenviser du cirka årligt?
___
8: Hvad tilbyder du på nuværende tidspunkt patienter med Claudicatio Intermittens ift. forbedring af gangfunktion?
(sæt gerne flere krydser)
Anbefaling om gangtraening uden opfølgning
Anbefaling om gangtraening med opfølgning
Flyer med information om deres muligheder
Henviser til genoptraening
Tilknytning til projektsygeplejersker, der hjaelper med livstilsaendringer herunder forbedring af gangfunktion
Medicinsk behandling med henblik på forbedring af gangfunktion
Revaskularisering
Jeg taler ikke med patienterne om gangfunktionen
Andet:_____
9: Hvad tilbyder du patienter med Claudicatio Intermittens ift. rygestop?
(sæt gerne flere krydser)
Mundtlig anbefaling om rygestop
Mundtlig anbefaling om at kontakte egen laege ift. rygestopintervention
Flyer om rygestop
Viderehenviser til rygestopintervention i sygehus regi
Viderehenviser til rygestopintervention i kommunalt regi
Tilknytning til projektsygeplejersker, der bl.a. hjaelper med rygestop
Jeg taler ikke med patienterne om rygestop
Andet:_____
10: Hvad tilbyder du patienter med Claudicatio Intermittens for at give dem den bedste forståelse for deres lidelse og hvad der kan gøres ved den?
(sæt gerne flere krydser)
Jeg bruger tid på at sætte patienten godt ind i deres lidelse/situation
Tilknytning til sygeplejerske på afdelingen, der følger op på råd og vejledning vedr. livsstilsaendringer
Viderehenviser til patientuddannelse i sygehus regi
Viderehenviser til patientuddannelse i kommunalt regi
Viderehenviser til patientuddannelse i privat regi
Viderehenviser til patientuddannelse hos egen laege
Jeg gør ikke noget for at patienten for en bedre forståelse af deres lidelse
Andet:_____
11: Hvilke af følgende determinanter for operation er gaeldende for dig ved invaliderende Claudicatio Intermittens?
(sæt kun er kryds)
Forkortelser:
LDL: begraensninger i daglig livet
WA-P: patient rapporteret gangevne
WA-V: funktionel gangtest resultater
LDL + WA-P + WA-V
LDL
LDL + WA-P
LDL + WA-V
WA-P + WA-V
WA-P
WA-V
Evt. kommentar:_____
12: Kender du til eksisterende forløb særligt tilrettelagt for patienter med Claudicatio Intermittens?
(sæt gerne flere krydser)
Ja, i sygehusets rehabiliteringsafdeling
Ja, i privat praksis
Ja, i kommunale rehabiliteringsafdelinger
Nej
evt. kommentar:_____
Hvis du kender til et forløb, uddyb da gerne hvad du kender til:
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Spørgsmål vedr. din holdning i forhold til fremtidig rehabiliteringsforløb:
I det følgende stilles der spørgsmål vedr. din professionelle holdning til forskellige elementer i rehabilitering ud fra følgende definition (samme som før):
”Rehabilitering kan defineres som en raekke indsatser, der støtter det enkelte menneske, som har eller er i risiko for at få nedsat funktionsevne, i at opnå og vedligeholde bedst mulig funktionsevne, herunder at fungere i samspil med det omgivende samfund”.
Rehabilitering har til formål at forbedre patientens funktionsniveau, fjerne eller mindske aktivitetsrelaterede symptomer, minimere graden af invaliditet, og gøre det muligt for patienten at vende tilbage til en personligt tilfredsstillende rolle i samfundet.
Den samlede rehabiliteringsindsats omfatter såvel non-farmakologiske interventioner som fx patientuddannelse og fysisk træning, som sikring af korrekt medicinsk behandling og medicinsk risikofaktorkontrol.
Det er blevet anbefalet, at rehabilitering etableres som integrerede behandlingstilbud med individuelt tilrettelagte og sammenhaengende rehabiliteringsforløb.
13: Hvilke elementer tænker du bør indgå i et rehabiliteringsforløb til patienter med Claudicatio Intermittens?
(sæt gerne flere krydser)
Individuelle indledende samtaler
Fysisk træning
Patientuddannelse
Psykosocial indsats (f.eks. rettet imod isolation pga. smerter og traethed, stress eller bekymringer)
Rygestopintervention
Kostintervention og ernaeringsindsats
Andet:_____
14: Hvordan tænker du den fysiske træning skal tilrettelægges?
(sæt gerne flere krydser)
Superviseret: under vejledning af en fagperson
Generel træning: træning af hele kroppen med fokus på flere elementer fx. styrketræning, kredsløbstræning og balancetræning.
Superviseret
Ikke-superviseret
Generel fysisk træning
Primaert gangtræning
Holdtræning
Individuel træning
Telerehabilitering (rehabilitering med brug af informations- og kommunikationsteknologier. F.eks. rehabilitering i form af træning, vurdering, monitorering, uddannelse, konsultation, rådgivning over distance med brug af ny teknologi fx skridttaeller eller Ipad)
Ved ikke
Andet:_____
15: Hvad tænker du rehabiliteringsprogrammet ellers kan indeholde?
(sæt gerne flere krydser)
Superviseret gangtræning på løbebånd
Livsstilsinterventioner (rygestop, kostvejdledning m.m.)
Superviseret træning (f.eks. cykling og styrketræning)
Kontrol af medicin
Kontrol af medicin adherence
Vurdering af medicinske bivirkninger
Måling af glykoseniveauet i blodet (i tilfaelde af Diabetes type II)
Andet:_____
16: Hvornår bør et rehabiliteringsforløb tilbydes til patienter med Claudicatio Intermittens?
(sæt gerne flere krydser)
Bør tilbydes alle uanset stadie
Når de er asymptomatiske (Fontaine grad I)
Funktionssmerter/Claudicatio Intermittens (Fontaine grad II)
Hvilesmerter (Fontaine grad III)
Iskaemiske sår og gangraen (Fontaine grad IV)
Hvis de ikke er egnet til operation
Før operation
Efter operation
Bør ikke tilbydes
Andet:_____
17: Udtalelser vedrørende brugen af superviseret træning til patienter med Claudicatio Intermittens:
I dette spørgsmål skal du sætte kryds i de udtalelser du er enig i:
(sæt gerne flere krydser)
Forkortelse:
SET: superviseret træning (indeholder primaert superviseret gangtræning)
SET er mere effektivt en enkeltstående råd om gangtræning
Kardiovaskulaer risikohåndtering og SET bør vaere den primaere behandling for patienter med Claudicatio Intermittens
SET i kommunalt eller privat klinik regi er ligeså effektiv som en specialiseret indsats på hospitalerne
Hvis patienten ikke forbedre sin gangdistance i løbet af de første 3 måneder, bør SET fortsat tilbydes
SET er relevant hos patienter hvis maximale gangdistance er under 100 m
SET er relevant selvom patienten er over 80 år
SET er relevant for patienter som har fået angioplastik
SET er relevant hvis Claudicatio Intermittens skyldes betydelig arterie Iliacusforsnaevring
SET træning er relevant hos patienter med stabilt kronisk hjertesvigt
SET er relevant hos patienter der udover Claudicatio Intermittens lider af KOL
Ved kritisk iskaemi er SET relevant som supplement til angioplastik
Ved kritisk iskaemi er SET relevant som supplement til revaskularisering
Evt. kommentar _____
18: Vil du henvise til et standardiseret rehabiliteringsforløb vedr. Claudicatio Intermittens, hvis et sådant fandtes?
Ja
Nej
Begrund gerne dit svar:
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Du er nu færdig med spørgeskemaet.
Husk at trykke afslut (X).
Tusind tak for hjælpen!!!
Appendix 2. Survey 2 and 3: Physical therapy departments at Danish hospitals and municipalities
1. Er du den person, som det elektroniske spørgeskema oprindeligt var sendt til?
Ja
Nej
2. Hvilken funktion har du i forhold til fysisk træning af hjertesyge borgere?
Leder/chef med ansvar for det samlede rehabiliteringstilbud rettet mod hjertesyge borgere
Leder/chef med ansvar for en del af det samlede rehabiliteringstilbud rettet mod hjertesyge borgere
Fysioterapeut i rehabiliteringstilbuddet rettet mod hjertesyge borgere
Andet, uddyb venligst_____
Spørgsmål vedrørende rehabilitering af borgere med Claudicatio Intermittens.
De følgende spørgsmål er med henblik at kortlægge de nuværende rehabiliteringstilbud til borgere med Claudicatio Intermittens i den offentlige sektor, samt dine anbefalinger til udformning af et fremtidigt rehabiliteringsforløb.
Med Claudicatio Intermittens menes der ”Vindueskiggersyndrom”. Det er en lidelse hvor man pga. forsnaevringer i underekstremiteternes arterier, får smerter i forbindelse med gang. Disse smerter ophører/mindskes efter en kort pause, hvorefter man kan gå videre igen.
3. Behandler I borgere med Claudicatio Intermittens i jeres dagligdag?
Ja
Nej
If no, they jump to question 16
4. Hvor mange borgere med Claudicatio Intermittens behandler I årligt, cirka?
______
5. Hvordan tilrettelægger I rehabiliteringstilbud målrettet borgere med Claudicatio Intermittens?
De får de samme rehabiliteringstilbud som hjertepatienter
De får et særligt rehabiliteringstilbud
Andet, uddyb venligst_____
If they answer response option 1, they get question 6 and then jump to 11.
6. Indgår følgende komponenter i jeres rehabiliteringstilbud til borgere med Claudicatio Intermittens? (Sæt gerne flere krydser)
Table
Du har i det foregående spørgsmål svaret, at der tilbydes fysisk træning til borgere med Claudicatio Intermittens.
Du bedes venligst uddybe dette i følgende spørgsmål:
7. Over hvor mange uger foregår den superviserede træning? _________________________
8. Hvor mange gange om ugen? _____
9. Hvor lang er træningssessionen typisk i minutter? _____
10. Hvor stor en procentdel af den fysiske træning er superviseret gangtræning på løbebånd?
________
11. Hvor mange gangbånd har I til rådighed: ________
12. Hvor stor en procentdel er gangtræning andet steds, da I ikke har gangbånd til rådighed? ________ (question only activated if they answer 0 in question 11)
13. Du har i et foregående spørgsmål svaret, at der tilbydes patientuddannelse til borgere med Claudicatio Intermittens. Du bedes venligst uddybe hvad undervisningen går ud på: (Sæt gerne flere kryds) (question only activated if they answer yes to patient education in question 6)
Generel information vedr. Claudicatio Intermittens aetiologi
Effekt af gangtræning og fysisk aktivitet
Self-management strategier (rygestop, kostvejledning ect.)
Identifikation og adressering af personlige barrierer ift. fysisk aktivitet
Individuel målsætning (f.eks. med udgangspunkt i” Den motiverende samtale”)
Mulige hjælpemidler til monitorering (f.eks. skridttaeller eller anden form for monitorering)
Andet, uddyb venligst_____
14. Hvorfra henvises borgere med Claudicatio Intermittens? (question only asked to the physical therapy departments in the Danish municipalities)
Henvisning fra sygehus
Henvisning fra praktiserende læge
Personer med Claudicatio Intermittens henvender sig selv til visitator
Andet, uddyb venligst_____
Ved ikke
15. Hvilke kompetencer haves i træningsteamet for at kunne varetage behandlingen af borgere med Claudicatio Intermittens?
Specifikke kompetencer rettet imod Claudicatio Intermittens
Generelle kompetencer rettet imod diverse kredsløbsproblematikker
Der er ikke nogen med kompetencer indenfor Claudicatio Intermittens
Andet, uddyb venligst_____
Ved ikke
16. Er kommunen bekendt med anbefalingerne i den nationale behandlingsvejledning til borgere med Claudicatio Intermittens?
Ja
Nej
Ved ikke
17. Vil din kommune vaere interesseret i at arbejde med et standardiseret evidensbaseret rehabiliteringsforløb til patienter med Claudicatio Intermittens, hvis et sådant bliver udviklet?
Ja, vi vil gerne høre mere
Nej, vi føler at vi lever op til anbefalingerne
Nej, det er ikke en patientgruppe vi beskæftiger os med
Ved ikke
Eventuelle kommentarer__________________________________
Question 18, 19 and 20 are only activated if they treat patients with IC. Yes, in question 3.
18. Hvilke elementer tænker du bør indgå i et rehabiliteringsforløb til borgere med Claudicatio Intermittens? (Sæt gerne flere krydser)
Individuelle indledende samtaler
Fysisk træning
Patientuddannelse
Psykosocial indsats (f.eks. rettet imod isolation pga. smerter og traethed, stress eller bekymringer)
Rygestop intervention
Kostintervention og ernaeringsindsats
Andet, uddyb venligst________________________________________
Ved ikke
19. Hvordan tænker du den fysiske træning skal tilrettelægges til borgere med Claudicatio Intermittens? (Sæt gerne flere krydser)
Superviseret
Ikke-superviseret
Generel fysisk træning
Primaert gangtræning
Holdtræning
Individuel træning
Telerehabilitering
Andet, uddyb venligst_____
Ved ikke
20. Hvad tænker du, at rehabiliteringsprogrammet ellers kan indeholde til borgere med Claudicatio Intermittens? (Sæt gerne flere krydser)
Superviseret gangtræning
Livsstilsinterventioner
Superviseret træning (f.eks. Cykling og styrketræning)
Kontrol af medicin
Kontrol af medicin adherence/compliance
Vurdering af medicinske bivirkninger
Måling af glukoseniveau i blodet (ved Diabetes type ll)
Andet, uddyb venligst_____
Ved ikke
Uddybende kommentarer
Du er nu ved at vaere færdig med spørgeskemaet om fysisk træning i din kommune.
Som afslutning vil vi bede dig om at overveje, om der er nogle oplysninger eller udfordringer ved fysisk træning, som vi ikke har fået belyst tilstrækkeligt i de stillede spørgsmål.
21. Her kan du komme med uddybende kommentarer til den fysiske træning, som tilbydes hjertesyge borgere og borgere med Claudicatio Intermittens i din kommune.
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