Chronic limb-threatening ischemia represents the morbid end stage of severe peripheral artery disease, with significant impact on patient quality of life. Early diagnosis of arterial insufficiency and referral for vascular intervention are essential for successful limb salvage. Disparate outcomes have been reported among patients residing in rural areas due to decreased access to care. Remote telemedicine outreach programs represent an opportunity to improve access to care in these rural communities. Establishment of a telehealth program requires identification of communities most in need of specialty care. After locating an ideal site, collaboration with local providers is necessary to develop a program that meets the specific needs of providers and patients. Surgeon guidance in development of screening and management algorithms ensures that patients obtain care reliably and with adjustments as needed to suit the referring provider, the patient, and the specialist. Telehealth evaluations can limit the financial burden associated with travel, while ensuring access to higher levels of care than are available in the patients' immediate area. Multiple barriers to telehealth exist. These include limited reimbursement, local provider resistance to new referral patterns, lack of in-person interaction and evaluation, and the inability to do a physical examination. Improved reimbursement models have made telehealth feasible, although care must be taken to ensure that practice patterns complement existing resources and are designed in a way that omits the need for in-person evaluation until the time of specialist intervention. Telemedicine is an underused tool in the arsenal of vascular surgeons. Targeted telehealth programs aid in increasing patient access to expert-level care, thereby improving health disparities that exist in rural populations.

Eagle syndrome represents an anatomic variant present in 4% of the population. It is characterized by an elongated styloid process or ossified stylohyoid ligament with resultant irritation of cervical neurovascular structures. Common manifestations include craniofacial or cervical pain related to compression of the glossopharyngeal nerve. In rare cases, patients can present with a stroke or transient ischemic attack due to associated carotid artery injury. Fewer than 25 prior case reports describe vascular symptoms in the setting of associated carotid artery dissection and, in one case, a pseudoaneurysm. Our case report details the diagnosis and management of symptomatic carotid artery stenosis secondary to vascular Eagle syndrome.

Objective

Utilization of evidence-based specialty guidelines is low in primary care settings. Early use of ankle-brachial index (ABI) testing and a validated wound classification system allows prompt referral of patients for specialty care. We implemented a program to teach providers ABI testing and the use of the Wound, Ischemia, and foot Infection (WIfI) classification tool. Here, we report program outcomes and provider perceptions.

Methods

Physicians and non-physicians from wound care centers, nursing and physician education programs, primary care offices, and federally qualified health centers were invited to participate in the educational program teaching ABI testing and the use of the WIfI tool. Pretest and posttest responses and intention to use content in the future were assessed with descriptive statistics.

Results

A total of 101 subjects completed the ABI module, and 84 indicated their occupation (59 physicians, 25 non-physicians). Seventy-nine subjects completed the WIfI module, and 89% indicated their occupation (50 physicians, 20 non-physicians). Physicians had lower pre-test knowledge scores for the ABI module than non-physicians (mean scores of 7.9 and 8.2, respectively). Both groups had improved knowledge scores on the post-test (physicians, 13.4; non-physicians, 13.8; P < .001). Non-physicians in practice longer than 10 years at wound care centers had the lowest baseline knowledge scores, whereas physicians in practice for over 10 years had the highest. In the ABI module, the largest knowledge gap included accurately calculating the ABI, followed by the correct use of the Doppler, and management of incompressible vessels. For the WIfI module, providers struggled to accurately score patients based on wound classification. The greatest barriers to the implementation of ABI testing were the availability of trained personnel, followed by limited time for testing. Barriers to the use of the WIfI tool for physicians included lack of time and national guideline support. For non-physicians, the most notable barrier was a lack of training.

Conclusions

Provider understanding of ABI and WIfI tools are limited in wound care centers, primary care offices, and federally qualified health centers. Further barriers include a lack of training in the use of tools, limited potential for point-of-care testing reimbursement, and insufficient dissemination of WIfI guidelines. Such barriers discourage widespread adoption and result in delayed diagnosis of arterial insufficiency.

Background

Access to care plays a critical role in limb salvage in chronic limb-threatening ischemia (CLTI). A "medical desert" describes a community lacking access to medical necessities, resulting in increased morbidity and mortality. We sought to describe vascular deserts, which we defined as regions with decreased access to specialty care.

Methods

All California providers performing vascular surgery procedures were identified through online provider and health care facility searches. Facility participation in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) lower extremity bypass (LEB) and peripheral vascular intervention (PVI) modules was also determined. Addresses were geocoded with a 30-mile surrounding buffer using ArcGIS (Geographic information systems), creating maps based on care type, including all providers performing vascular procedures, board-certified vascular surgeons, and facilities participating in VQI modules. Public census data overlayed on the maps demonstrated population composition in desert versus nondesert regions. Subsequently, data from the Healthy Places Index (HPI) was overlayed, providing data regarding 25 social factors, comprising an overall HPI score and percent, with lower scores corresponding to poorer health and outcomes.

Results

Maps depicting care regions demonstrated decreased provider coverage with increasing specialty care, with the VQI provider map showing the most prominent "desert" regions. When comparing nondesert versus desert regions by care type, demographics including race, the percentage of the population 200% below the poverty line, and the rate of uninsured residents were described. Social determinants of health were then described for desert and nondesert regions by care type, including the HPI percentage and specific domain factors. The percentage of uninsured residents was significant only in the desert and nondesert areas served by board-certified vascular surgeons (19.6 vs. 16.8%, P < 0.001). The mean HPI percentile was significantly lower in board-certified provider and VQI facility deserts than nondeserts (50.48% vs. 40.65%, P < 0.001 and 52.68% vs. 43.12%, P < 0.001, respectively). The economic and education factor percentiles were significantly lower in all desert populations, while the housing, social, and pollution factors were significantly higher in nondesert regions. Health care access, transportation, and neighborhood factor percentiles were significantly lower in board-certified and VQI facility deserts than in the nondesert areas.

Conclusions

Access to vascular care plays a significant role in limb salvage. Through mapping vascular deserts, patient demographics, and social factors in desert regions are better understood, and areas that would benefit most from targeted outreach and limb preservation programs for CLTI are identified.