Patient knowledge and activation are key to improving outcomes in peripheral artery disease

This is an invited commentary on Alabi O, et al. ⁷ Disease-specific knowledge among veterans with peripheral artery disease. Vasc Med 2025; 30: 309-311. and Reilly MA, et al. ⁸ Patient factors associated with activation level in peripheral artery disease. Vasc Med 2025; 30: 283-292.

Peripheral artery disease (PAD) affects more than 230 million people worldwide. ¹ In addition to the significant impact PAD has on physical function and quality of life, PAD is associated with an increased risk of amputation, cardiovascular morbidity, and early mortality. ¹ Guideline-directed medical therapy is an important component in the management of PAD and has been shown to reduce the risk of major adverse cardiovascular and limb events. ² Medical therapy for PAD includes antiplatelet and antithrombotic therapy, lipid-lowering therapy, antihypertensive therapy, management of diabetes, and smoking cessation, in addition to structured exercise therapy. ² Unfortunately, analyses indicate that use of guideline-directed medical therapy remains low. ³ A recent retrospective study of 3471 patients with PAD from a tertiary care center revealed that only 45% of patients were receiving guideline-directed medical therapy. ⁴

In addition to improving prescribing of guideline-directed medical therapy, patient knowledge of their condition and engagement in their care is a critical component of the effective management of PAD. Having a chronic disease like PAD requires that patients learn about their condition, develop health skills like taking medication and monitoring their disease, and modify their behavior by engaging in exercise, eating a healthy diet, and quitting smoking. Patient activation, which is defined as a patient’s knowledge about their condition and their readiness and capacity to engage in their health care, is an important element of successful self-management. ⁵ Notably, activation is distinct from compliance or adherence, where the focus is on getting patients to follow medical advice. Instead, activation is centered on the patient’s understanding of and confidence to engage in self-management behaviors. ⁵ Increased patient activation has been linked to positive changes in many self-management behaviors, including testing blood glucose and blood pressure, exercise, and adherence with medications, ⁶ but the role of activation has received less attention in patients with vascular disease.

Two articles^7,8 in this focused issue of Vascular Medicine on implementation science highlight the importance of evaluating patients’ knowledge and confidence in managing PAD as part of provided guideline-directed medical care. Patients with PAD typically have multiple comorbidities, increasing the work of caring for their health and, as a result, potential inactivation due to the number of medications or management strategies required to address their disease.

Alabi and colleagues ⁷ highlight important gaps in patient knowledge about their condition and the need for focused strategies to improve patient knowledge and patient–provider communication. In this study, the authors conducted qualitative interviews with 47 veterans with PAD in an effort to understand what patients know about PAD and their perspectives on their diagnosis and treatment. The authors found that only 36% of patients knew the name of their PAD diagnosis. Patients commonly reported fear and anger related to their diagnosis and described challenges in accessing vascular specialty care. In addition to difficulties related to navigating the healthcare system, patients also reported difficulty adhering to medical recommendations, particularly in relationship to smoking cessation, exercise, and medication management. The findings of this study underscore the importance of improving both patient and provider PAD awareness and education.

Reilly and colleagues ⁸ provide further evidence of the importance of evaluating patient knowledge of PAD due to its relationship to patient activation and, ultimately, patient outcomes. The authors surveyed 91 patients with PAD (approximately 52% with chronic limb-threatening ischemia) about their PAD knowledge, activation, and functional health literacy. They found that most patients were activated (72.6%), which was characterized by taking action/gaining control of their health or maintaining health behaviors. Interestingly, activation was inversely associated with age, which is important given the increase in prevalence of PAD with age and how the complexity of managing multiple chronic conditions also tends to increase with age. Additionally, activation was found to be positively associated with disease-specific knowledge but was not related to functional health literacy. The authors suggest that although increasing knowledge is critical to improving activation, the strategies used to support knowledge growth likely need to be tailored to specific levels of health literacy. These findings highlight the importance of assessing PAD-related knowledge and activation when designing and testing interventions.

The articles by Alabi et al. and Reilly et al. emphasize the importance of evaluating and addressing patient knowledge and activation in people with PAD; however, the best ways to promote patient activation are unknown. Studies suggest that patient activation is modifiable and that interventions targeting patient activation can improve health outcomes like glycated hemoglobin (HbA1c), blood pressure, low-density lipoprotein (LDL) cholesterol, weight, mood, and self-efficacy. ⁹ A recent systematic review and meta-analysis ¹⁰ of 32 activation-focused interventions in individuals living with chronic disease found no overall significant improvements in patient activation at 6 months. The reasons for these negative findings are unclear, but patient activation does tend to increase over time with increased experience with the condition. Successful activation interventions included interdisciplinary teams, social support, and in-person interactions, emphasizing the importance of including these elements in future intervention design.

Patient disease-specific knowledge is associated with activation, yet many patients with PAD lack adequate knowledge of their condition. Efforts are needed to prepare educational resources that are written at an appropriate literacy level and improve primary care provider and allied health professionals’ knowledge of PAD. ⁸ Evidence also suggests that strategies to support activation must be tailored to the patient’s current stage of activation. ⁶ Ultimately, understanding patients’ knowledge, skill, and confidence in their ability to engage in their health care is critical. Including baseline assessments of PAD-specific knowledge and activation as part of PAD-related implementation research is essential to understanding both the effectiveness and the mechanisms of action of interventions designed to support improved disease management.