Patient-reported outcomes put revascularisation ahead of medical management for claudication
medwireNews: Revascularisation for intermittent leg claudication appears to be more effective than standard medical management when comparing outcomes of greatest importance to patients, study findings show.
“This comparative effectiveness research study of interventions for [intermittent claudication] demonstrated significantly higher function, better HRQoL [health-related quality of life], and fewer symptoms for those in the revascularization cohort compared with the medical cohort”, the research team reports in JAMA Surgery.
They enrolled 323 adults with newly diagnosed or established intermittent leg claudication, of whom 282 received standard medical management (walking program, smoking cessation counselling and medications) while 41 underwent revascularisation (endovascular or surgical).
At baseline, the participants had similar scores on six of seven domains measured – the distance, speed, stair-climb and pain domains of the Walking Impairment Questionnaire (WIQ), the Vascular Quality of Life Questionnaire (VascuQoL) and the Claudication Symptom Instrument (CSI). The only exception was on the European Quality of Life-5 Dimension Questionnaire (EQ-5D), mean scores on which were slightly higher among the revascularisation group.
At 12 months, patients in the revascularisation group showed significant improvements across all seven measures, with percentage improvements of 56.9% for distance, 37.6% for speed, 26.6% for stair climb, 141.8% for pain, 57.9% for VascuQoL, 29.7% for EQ-5D and 16.1% for CSI.
By comparison, patients in the medical management group showed significant improvements across just three measures, namely speed, VascuQoL and EQ-5D, with percentage improvements of 21.9%, 17.0%, and 11.7%, respectively.
This equated to superior percentage changes with revascularisation over medical management at 12 months of 39.1% for walking distance, 15.6% for speed, 9.7% for stair climbing, 116.9% for pain, 41.0% for VascuQoL, 18.0% for EQ-5D and 13.5% for CSI.
The researchers, led by Emily Devine (University of Washington, Seattle, USA), also note that improvements in the revascularisation group exceeded the minimally importance difference for the VascuQoL and EQ-5D, whereas they did not in the medical management group.
“These results suggest that revascularization interventions for patients with moderate to severe [intermittent claudication] represent a reasonable alternative to medical management, providing important information to inform treatment strategies in the community”, they report.
But they note that they do not demonstrate that “revascularization care is better than optimal medical care, for which we should continue to strive.”
This was echoed in a related commentary by Philip Goodney (Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA) and Matthew Corriere (Wake Forest University, Winston Salem, North Carolina, USA) who note that the medical programme in the study was “not standardized or robust in terms of symptomatic disease management”.
They cite this and the potential for short-term gains following revascularisation preventing patients from receiving the best medical treatment and needing more complex and riskier treatments later down the line as a result as reasons why it would be premature for clinicians to invasively treat more individuals with claudication on the basis of the findings.
By Lucy Piper
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