An Investigation of Time Delays in the Management of Patients with Chronic Limb-Threatening Ischaemia

Chronic limb-threatening ischaemia (CLTI) represents the end-stage of peripheral arterial disease and is associated with significant morbidity and mortality. Despite recent improvements in treatments, limited attention has been given to evaluating time delays in the clinical pathways through which patients are managed. The publication of the Vascular Society of Great Britain and Ireland’s Peripheral Arterial Disease Quality Improvement Framework (PAD QIF) represents the first attempt to standardise and improve pathways, however there is a paucity of supporting evidence and limited understanding about its implementation. This thesis aims to provide a detailed exploration of the nature of time delays and evaluate how clinical pathways can be improved. To meet these aims, five questions were defined, and multiple methodologies employed, to explore their answers.

The results demonstrate that time delays are evident throughout the CLTI management pathway and are associated with detrimental patient outcomes. These findings provide the first validation of the PAD QIF’s time-to-treatment targets. Furthermore, exploring primary care consultations identified that opportunities to recognise CLTI are being missed, even in patients at highest risk of amputation.

Through surveying United Kingdom (UK) vascular surgeons, wide variations in patient care were identified and it was deemed that aspects of the PAD QIF were unfeasible to implement. It was subsequently postulated that adapting pathways towards an ‘urgent care’ model, which utilised vascular limb salvage services, could benefit care. Finally, this thesis explored the novel concept of vascular limb salvage services and provides evidence that services are both clinically and cost effective at managing patients with CLTI.

In conclusion, this thesis represents an innovative and detailed exploration of time delays and provides unique evidence that the implementation of the PAD QIF, along with the adaption of an ‘urgent’ model of care and vascular limb salvage services, can help improve pathways and outcomes for patients.