Mortality in peripheral arterial disease: a comparison of patients managed by vascular specialists and general practitioners.

BACKGROUND

Peripheral arterial disease (PAD) is undertreated by general practitioners (GPs). However, the impact of the suboptimal clinical management is unknown.

OBJECTIVE

To assess the mortality rate of PAD patients in relation to the type of physician who provides their care (GP or vascular specialist).

DESIGN

Prospective study.

SETTING

Primary care practice and academic vascular laboratory.

PARTICIPANTS

GP patients (n = 60) were those of the Peripheral Arteriopathy and Cardiovascular Events study (PACE). Patients managed by specialists (n = 82) were consecutive subjects with established PAD who were referred to our vascular laboratory during the enrollment period of the PACE study.

MEASUREMENTS

All-cause and cardiovascular mortality.

RESULTS

After 32 months of follow-up, specialist management was associated with a lower rate of all-cause mortality (RR = 0.04; 95% CI 0.01-0.34; p = .003) and cardiovascular mortality (RR = 0.07; 95% CI 0.01-0.65; p = .020), after adjustment for patients' characteristics. Specialists were more likely to use antiplatelet agents (93% vs 73%, p < .001), statins (62% vs 25%, p < .001) and beta blockers (28% vs 3%, p < .001). Survival differences between specialists and GPs disappeared once the use of pharmacotherapies was added to the proportional hazard model. The fully adjusted model showed that the use of statins was significantly associated with a reduced risk of all-cause mortality (RR = 0.02; 95% CI 0.01-0.73, p = .034) and cardiovascular mortality (RR = 0.02; 95% CI 0.01-0.71, p = .033).

CONCLUSIONS

Specialist management of patients with symptomatic PAD resulted in better survival than generalist management. This effect appears to be mainly caused by the more frequent use of effective medicines by specialists.