As a general internist, I read the newest American Diabetes Association consensus statement (1) on peripheral arterial disease (PAD) in diabetic patients with great interest. In the statement, it is recommended that “a screening ABI (ankle-brachial index) should be performed in patients >50 years of age who have diabetes.” The justification for this recommendation seems to be that PAD in diabetic patients is common, underdiagnosed, and results in increased morbidity.
I had assumed that the consensus statement was based on solid evidence, such as a systematic review. What seems to be lacking in this recommendation, as pointed out in the consensus statement, is proof that treating risk factors other than smoking halts the progression of or decreases morbidity in PAD.
As a pragmatist, I wonder what percentage of primary care providers currently own a Doppler machine and have been trained to use it and how many will purchase a $500 machine based on the recommendations of this consensus statement? How many minutes will it add to the day to screen all diabetic patients, and will insurance companies reimburse for screening asymptomatic patients? How often should screening be repeated? Will asymptomatic patients under optimal management benefit from knowing they have moderate PAD?
Would it not be better to make such a recommendation for screening after the evidence suggests benefit from tighter control of hyperglycemia, hypertension, and dyslipidemia?
