Disease-specific knowledge among veterans with peripheral artery disease

Lower-extremity peripheral artery disease (PAD) is a complex condition linked with functional decline, worsening quality of life, and increased risk for major amputation and cardiovascular events, including death. ¹ Despite this, public awareness and primary care clinician confidence in PAD recognition is poor. ² Although myocardial infarction and cerebrovascular accident are well-known severe medical conditions, PAD is largely unknown and underrecognized, with a recent survey demonstrating that 70% of the lay public has never heard of it. ³ As such, we conducted a qualitative study among our patients with PAD to better comprehend their understanding of their condition.

Veteran-Reported Outcome Measures (VROMs) was a prospective study that explored health status and novel determinants of PAD at the Department of Veterans Affairs (VA) in Atlanta, Georgia between November 1, 2022 and August 15, 2023. This study aimed to identify emerging themes during semistructured interviews among patients who elected to participate in the qualitative portion of VROMs. We conducted 45–90-minute semistructured interviews (trained interviewers: YC, MS) with consecutive patients with PAD in the vascular surgery clinic to assess their disease-specific knowledge based on an interview guide that was structured around key categories (OA, TA). Patients who were offered revascularization during that clinic visit or in the preceding 3 months were ineligible. Each interview was recorded and transcribed via Microsoft Teams. Directed content analysis using NVivo, v1.6.1 (QSR International) was performed to identify emerging themes. The analysis was conducted by two independent researchers (OA, CG) who reviewed transcripts, coded segments of text according to predefined key categories, created themes, and discussed how these fit within the key categories, thus coming to a consensus before finalizing themes. This study was approved by the local institutional review board and VA Research and Development Committee. Informed consent was obtained from all participants and the study followed COREQ reporting guidelines. ⁴

All demographic data were collected via a self-report questionnaire. Outpatient medication and past surgical history were confirmed through chart review. Summary statistics were calculated using median (IQR) for continuous data and frequencies for categorical data. Participants validated themes and quotations. Member-checking was leveraged in this work to ensure the validity and credibility of the results.

Among 54 veterans enrolled in the VROMs study, 47 elected to participate in semistructured interviews. The median age was 70 years (IQR: 63.5–75.5) and 93.6% (n = 44) were men. Additional demographic characteristics are reported in Supplemental Table S1. Only 36.2% (n = 17) of participants knew the name of their diagnosis and, among them, 94.1% (n = 16/17) correctly named some iteration of peripheral artery, arterial, or vascular disease. Chart review revealed that all participants were on guideline-directed medical therapy with both antiplatelet and high-intensity statin therapy. Most participants (68.1%, n = 32) reported they took medications for ‘leg artery disease,’ but only 27.6% (n = 13) correctly named an antithrombotic or lipid-lowering therapy and another 23.4% (n = 11) erroneously attributed medications for analgesia, hypertension, or diabetes as their treatment for PAD.

Consistent themes emerged (Table 1). We found that patients had a range of emotional reactions to being diagnosed with PAD. The most frequently expressed were anger, shock, and devastation. Some expressed frustration over not having been diagnosed sooner, and others experienced relief at finally understanding their condition, despite the emotional toll of the diagnosis. Fears and worries about the future were a central theme, with patients often wondering about the severity of their condition, potential treatment options, and long-term outcomes. Many were particularly anxious about the possibility of experiencing significant pain, mobility limitations, and limb loss. These fears about functional decline were compounded by worries about the progression of PAD, which heightened their concerns about the necessity of managing the disease and avoiding further complications.

Table 1.

Emerging themes identified during semistructured interviews about disease-specific knowledge and future concerns among veterans with peripheral artery disease.

Questions	Theme and responses
What are your thoughts and feelings when the doctor told you that you had a diagnosis of peripheral artery disease (or poor blood flow in your legs)?	Anger
	‘I was devastated because she told me my toes were not going to heal.’
	‘I felt down.’
	‘It was a shock out of the wazoo.’ (n = 3)
	‘I knew something was wrong and I wasn’t surprised.’
	‘I was pissed. It’s not that I had it. It’s that I never got a diagnosis [earlier].’
	Concerns about the future
	‘First thing I thought was, what can we do about it?’
	‘I was just hoping that it was something that wouldn’t cause me to have too much pain or distress, or even to lose my leg, you know. . .’
	‘My first reaction was how severe, is it treatable, will I improve, will it go away?’
	‘[Although I was concerned] I was happy in a way. She was the first one to tell me in over 2 years what was wrong with my body.’
What are your concerns/fears/worries about having peripheral artery disease?	Limb loss
	‘Amputation. That’s my primary concern.’ (n = 2)
	‘I don’t want to lose a limb . . .’
	‘About losing the limb, that was my only fear.’ (n = 2)
	‘. . . because you get limbs cut off!’
	Poor functional outcome
	‘. . . whether or not I’m going to continue to be mobile.’
	‘I was . . . hoping that the surgery [would] make me feel better and it did. . . . my problem is I can’t walk like I want to.’
	‘The main concern . . . is there anything that can be done to at least get my mobility back?’
	‘If you’re going to do it [amputation], do it below the knee.’
	Poor prognosis
	‘. . . How are we going to manage this so it doesn’t get worse?’
	‘. . . maybe it’ll affect my other leg. But I’m still alive and I’m grateful.’
	‘I wanted to know what it was.’
	‘. . . I can’t quit smoking. That’s an issue. I know what it is, but then I’m thinking you know, if I quit smoking, and still lose my leg, I’m giving up everything!’
In your opinion, what barriers were present that did not allow you to see a vascular specialist sooner?	Long wait times
	‘. . . you try to call and get the run around. You can’t just call and get an appointment.’
	‘Having an earlier appointment.’
	‘Seeing a doctor sooner.’
	‘Coming to vascular surgery easier . . .’
	‘Seeing the same doctor on a consistent basis.’
	Untimely/delayed referrals
	‘[I couldn’t get] my primary care doctor to hear me.’ (n = 2)
	‘I wasn’t aware that I had vascular problems . . .’
	Wife: ‘They should have sent him to the vascular surgeon a lot sooner.’
	‘Wasn’t having any troubles with it until I got diagnosed with it in my toes.’
	‘I just want the doctors to . . . understand . . . we are the best source of how we’re doing.’
	‘. . . the communication between primary care physician and vascular surgeon.’
	Personal limitations (or concerns)
	‘[I didn’t listen] to my doctors . . . [they told me] to exercise . . . and take my prescription.’
	‘They told me . . . if I quit smoking and my diabetes was better [controlled]. . . I’d do better. . . but I didn’t.’

Barriers to early diagnosis and treatment emerged as another theme. Participants described challenges in accessing specialized care, citing long wait times, delayed referrals, and poor communication between primary care providers and vascular specialists. These barriers often led to frustration and a sense of being unheard by the medical system. Lastly, patient-related challenges, such as difficulty adhering to medical advice, were frequently mentioned. Some participants noted struggles with lifestyle changes, such as smoking cessation, exercise, and medication management.

PAD is increasing in prevalence, yet our study suggests that patients with PAD have poor disease-specific knowledge (even those receiving PAD care for more than 1 year). This lack of disease-specific knowledge combined with low health literacy among patients with PAD has been linked to worse outcomes and may present a significant barrier to improving quality of life and patient-provider trust. PAD-specific knowledge cannot be wholly improved by the primary care workforce, given that primary physician knowledge of PAD is also poor. ² The inclusion of community health workers and other allied health professionals in care teams may mitigate these challenges. ⁵ Educational resources for PAD are often written above rather than at or below the sixth-grade level, which is recommended for patient education materials by the American Medical Association and National Institutes of Health; thus, modifications to PAD resources are necessary. ⁶

Limitations of this study include its sole focus on veterans with PAD, potentially limiting its generalizability to both nonveteran populations and women with PAD. However, similar studies, worldwide, have shown poor disease-specific knowledge among patients with PAD, suggesting that this finding is not unique to veterans. A qualitative study by Treat-Jacobson et al. found similar emotional consequences of PAD, suggesting that poor disease-specific knowledge is found in other patient populations. ⁷

Improving PAD awareness and education is imperative. Vascular providers are key to this effort, and accountable to their colleagues, the public, and their patients. Public campaigns have proven benefit in improving awareness for other conditions. ⁸ Hosting community-level PAD awareness and screening events, improving the readability of educational materials, leveraging social media for greater visibility to the lay public, and engaging patients and caregivers as stakeholders in the development and dissemination of pragmatic interventions are essential steps toward improving PAD disease-specific knowledge and, subsequently, patient outcomes. Given the high proportion of individuals with PAD who have limited knowledge regarding their condition, patients enrolled into implementation trials focused on topics such as PAD disease management, device dissemination, and guideline-directed medical therapy utilization should have baseline disease-specific knowledge assessments performed to understand the study population’s understanding of their disease.

Supplemental Material

sj-pdf-1-vmj-10.1177_1358863X251333764 – Supplemental material for Disease-specific knowledge among veterans with peripheral artery disease

Supplemental material, sj-pdf-1-vmj-10.1177_1358863X251333764 for Disease-specific knowledge among veterans with peripheral artery disease by Olamide Alabi, Yakia Clark, Madhur Sancheti, Cori Grant, Aishat Mustapha, Rachel E Patzer and Tabia Henry Akintobi in Vascular Medicine