An Exploration of Factors Affecting Timely Referral of Patients with Chronic Limb-Threatening Ischaemia

Chronic limb-threatening ischaemia (CLTI) is the end-stage of peripheral arterial disease. It is associated with significant risks of limb loss and mortality, which increase with delays to revascularisation. There is currently little understanding of how pathways from the community to vascular surgery assessment work in practice, but there is clear evidence that delays are present throughout the patient journey. This thesis aims to identify, define and prioritise facilitators and barriers to the timely and appropriate referral of patients with CLTI from primary care into vascular surgery services. It explores potential solutions to delay and how they can be effectively applied. Multiple methodologies were used to meet these aims and answer four research questions.

The results of this work demonstrated that publicly available guidance regarding referral of patients with suspected CLTI was unclear, used vague wording and rarely involved primary care clinicians or representative groups in the writing or endorsement of guidance documents. Referral pathways in place from the community to vascular surgical assessment varied widely according to local context and resource availability. Qualitative work with hospital and primary care clinicians identified that whilst hospital clinicians were aware of the need for speed in the process, multiple barriers existed, while primary care clinicians struggled with the challenge of delivering care in the current environment and a lack of confidence with regards to CLTI. Rich interview data from patients diagnosed with CLTI generated themes relating to individual behaviours, primary care experiences and vascular surgery processes. Finally, the effectiveness of quality improvement collaboratives in UK surgery was assessed, finding limited data to support their use given weak study design and poor reporting quality.

This thesis has identified several overarching factors affecting timely referral and vascular surgery assessment of CLTI. Evidence-based solutions on national and local levels have been suggested.