Hospital clinicians' perceptions and experiences of care pathways for chronic limb-threatening ischaemia: a qualitative study

Eleanor Atkins; Ian Kellar; Panagiota Birmpili; Jonathan R Boyle; Arun D Pherwani; Ian Chetter; David A Cromwell

doi:10.1186/s13047-023-00664-6

Hospital clinicians' perceptions and experiences of care pathways for chronic limb-threatening ischaemia: a qualitative study

J Foot Ankle Res. 2023 Sep 19;16(1):62. doi: 10.1186/s13047-023-00664-6.

Authors

Eleanor Atkins^{1

2}, Ian Kellar³, Panagiota Birmpili^{4

5}, Jonathan R Boyle⁶, Arun D Pherwani⁷, Ian Chetter⁵, David A Cromwell^{4

8}

Affiliations

¹ Clinical Effectiveness Unit, Royal College of Surgeons of England, 38-43 Lincoln's Inn Fields, Holborn, London, WC2A 3PE, UK. Eleanor.atkins@nhs.net.
² Hull York Medical School, Hull, UK. Eleanor.atkins@nhs.net.
³ University of Sheffield, Sheffield, UK.
⁴ Clinical Effectiveness Unit, Royal College of Surgeons of England, 38-43 Lincoln's Inn Fields, Holborn, London, WC2A 3PE, UK.
⁵ Hull York Medical School, Hull, UK.
⁶ Department of Vascular Surgery, Cambridge University Hospitals, Cambridge, UK.
⁷ Staffordshire & South Cheshire Vascular Network, Royal Stoke University Hospital, Stoke-On-Trent, UK.
⁸ Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.

Abstract

Background: Chronic limb-threatening ischaemia (CLTI) is a condition associated with significant risks of lower limb loss and mortality, which increase with delays in management. Guidance recommends urgent referral and assessment, but delays are evident at every stage of the CLTI patient pathway. This study uses qualitative methods to explore hospital clinicians' experiences and perceptions of the existing CLTI pathway.

Methods: A qualitative interview study was conducted. Semi-structured interviews were undertaken with 13 clinicians involved in the assessment of patients referred to hospital with suspected CLTI, identified via purposive sampling from English vascular surgery units. Clinicians included podiatrists, vascular specialist nurses and doctors. Reflexive thematic analysis was performed on the data from a critical realist position.

Results: The need for speed was the single overarching theme identified. Four linked underlying themes were also identified; 1. Vascular surgery as the poor relation (compared to cancer and other specialties), with a sub-theme of CLTI being a challenging diagnosis. 2. Some patients are more equal than others, with sub-themes of diabetes vs. non-diabetes, hub vs. spoke and frailty vs. non-frail. 3. Life in the National Health Service (NHS) is tough, with sub-themes of lack of resource and we're all under pressure. 4. Non-surgeons can help.

Conclusions: The underlying themes generated from the rich interview data describe barriers to timely referral, assessment and management of CLTI, as well as the utility of non-surgical roles such as podiatrists and vascular specialist nurses as a potential solution for delays. The overarching theme of the need for speed highlights the meaning given to adverse consequences of delays in management of CLTI by clinicians involved in its assessment. Future improvement projects aimed at the CLTI pathway should take these findings into account.

Keywords: Chronic limb threatening ischaemia; Referral and consultation; Vascular surgery.

MeSH terms

Chronic Limb-Threatening Ischemia*
Critical Pathways*
Hospitals
Humans
Qualitative Research
State Medicine