factors related to first diagnosis time in patients...

FACTORS RELATED TO FIRST DIAGNOSIS TIME IN PATIENTS WITH

PERIPHERAL ARTERIAL OCCLUSIVE DISEASE

SIRIPHORN SAWANGPHONG

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR

THE DEGREE OF MASTER OF NURSING SCIENCE (ADULT NURSING)

FACULTY OF GRADUATE STUDIES MAHIDOL UNIVERSITY

2009

COPYRIGHT OF MAHIDOL UNIVERSITY

Copyright by Mahidol University

iii

ACKNOWLEDGEMENTS

I would like to express my sincere gratitude and deep appreciation to my major-advisor,

Assoc. Prof. Siriorn Sindhu for her valuable guidance, supervision and encouragement. I am equally

grateful to Assoc. Prof. Suvimol Kimpee and Assist. Prof. Chanean Ruangsetakit, my co-advisor, for

their constrictive comments, supervision and encouragement. I would also like to express appreciation

to Assist. Prof. Ameporn Ratinthorn and Assist. Prof. Daungkamon Watradul, the thesis committee

member, for their constructive comments and valuable recommendations for this study.

The greatest appreciation is also due to all the experts involved in the validity assessment

of the instrument. The partial of instrument used in this study was developed by Kathleen Dracup,

Professor of Nursing, UCLA school of Nursing, Los Angeles and her colleague and by Mary E.

Charlson, Cornell University Medical College. I wish to thank for their permission to translate the

instrument into Thai or partially modifying them and use in this study.

I am also thankful to all staff at the Surgical Out-patient department, 3rd floor of Out-

patient Building, and at the Vascular Laboratory, 1st floor of Siamintra Building, Siriraj Hospital for their

co-operation and generous assistance. Most important and most valuable part of this thesis is

contributed by PAOD patients who willingly to participated in this study.

Grateful acknowledgement is also extended to everyone in the Division of Surgical

Nursing, Department of Nursing, Faculty of Medicine Siriraj Hospital, Mahidol University, who

allowed me the time to study.

My sincere thanks is extended to my master’s program classmates for the friendship,

colleagueship and for their kind assistance throughout the process of my study.

Finally, I am very grateful to my family members for their constant support and

understanding throughout my study.

Siriphorn Sawangphong


Fac. of Grad. Studies, Mahidol Univ. Thesis / iv

FACTORS RELATED TO FIRST DIAGNOSIS TIME IN PATIENTS WITH PERIPHERAL ARTERIAL OCCLUSIVE DISEASE SIRIPHORN SAWANGPHONG 5036793 NSAN / M M.N.S. (ADULT NURSING) THESIS ADVISORY COMMITTEE : SIRIORN SINDHU, D.N.Sc., SUVIMOL KIMPEE, M.Ed.

(EDUCATIONAL RESEARCH), CHANEAN RUANGSETAKIT, M.D.

ABSTRACT

The aim of this descriptive study was to examine the correlation between age, the reasons

for not visiting a health care service, knowledge about peripheral arterial occlusive disease (PAOD), the

response of others, and the first diagnosis time. Ninety PAOD patients who visited the outpatient

department and the vascular laboratory in a universal hospital in Bangkok participated in the study.

Data were collected by interview form and analyzed by descriptive statistics, while the correlation

between variables were analyzed by Spearman rank-order correlation coefficient.

The study revealed that the majority of participants was male (64.4%), the mean of age

was 68.68 + 11.31 years. Most participants with femoro-popliteal artery occlusion (47.6%), had three

comorbidities (32.2%), perceived intermittent claudication as an onset symptom (43.3%) and had

ulceration as the chief complaint that induced their first visit (52.2%). The median of first visit time

after perceived symptom was 30 days (range 1-1825 days) and the median of first diagnosis time after

perceived symptom was 90 days (range 1-1825 days). The majority of the participants received their

diagnosis at the university hospital (76.7%). All of the participants had cognitive related reasons for not

visiting health care service when they first perceived symptoms, and the patients who had symptoms

related to the reasons had the longest first diagnosis time (Mdn = 261 days; range 2 – 1050 days).

About 55.6% had knowledge regarding general knowledge about and risk factors of PAOD (less than

half of the questions were answered correctly in this regard). The majority of the participants told their

symptom to others (63.3%). Of this number 37% were escorted by others to a health care service setting

90 days or more after telling. Age and duration from telling others to first visit were significantly

associated with first diagnosis time at ρ = - .251 (p < .05) and ρ = .712 (p < .01) respectively.

This study suggested that health care providers at primary care settings through to tertiary

care settings should be trained about screening for PAOD and a referral and network service set up to

allow the patients to access PAOD diagnosis as soon as possible. Patients with hypertension and

diabetes should have enough information to recognize PAOD symptoms, to be aware the symptoms,

and know how to prevent PAOD in order to reduce the number and severity of the patients.

KEY WORDS : PERIPHERAL ARTERIAL OCCLUSIVE DISEASE / FIRST DIAGNOSIS TIME /

PERCEIVE SYMPTOMS 122 pages


Fac. of Grad. Studies, Mahidol Univ. Thesis / v

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vi

CONTENTS

Page

ACKNOWLEDGEMENTS iii

ABSTRACT (ENGLISH) iv

ABSTRACT (THAI) v

LIST OF TABLES viii

LIST OF FIGURES x

CHAPTER I INTRODUCTION 1

Background and significance of the problem 1

Research questions 6

Research objectives 6

Research hypothesis 7

Conceptual framework of the research 7

Scope of the research 10

Definition of terms 10

Expected benefits of research 12

CHAPTER II LITERATURE REVIEW 13

1. Peripheral arterial occlusive disease patients 14

1.1 The prevalence of PAOD 14

1.2 Pathophysiology of PAOD 15

1.3 Signs and symptoms of PAOD 16

1.4 The severity classification of PAOD 19

1.5 Screening for PAOD 21

1.6 Physical examinations and specific examination 23

for PAOD

1.7 The Outcomes of PAOD treatment 31


vii

CONTENTS (cont.)

Page

2. The first diagnosis time in PAOD patients 33

3. Factors related to PAOD patients’ visiting 36

health care service lead to diagnostic

3.1 Knowledge about PAOD 36

3.2 Reasons for not visiting a health care service 37

3.3 Personal factors: Age 38

3.4 Social factors: Response of others 39

4. Summary 40

CHAPTER III METHODOLOGY 42

Population 42

Sample 42

Sample size 43

Setting 43

Instruments 44

Instrument quality testing 46

Data collection 47

Protection of human rights of the subjects 49

Data analysis 51

CHAPTER IV RESULTS 52

CHAPTER V DISCUSSION 74

CHAPTER VI CONCLUSION 83

REFERENCES 88

APPENDICES 99

BIOGRAPHY 122


viii

LIST OF TABLES

Table Page

1 Fontaine’ s stages Classification 19

2 Rutherford’ s categories 20

3 Summary of procedures 49

4 Frequency and percentage of PAOD patients classified by 53

demographic characteristics

5 Frequency and percentage of sites of arterial occlusion 56

in PAOD patients

6 Frequency and percentage of PAOD patients classified 57

by smoking history

7 Frequency and percentage of Charlson Comorbidity Index 58

(CCI) of PAOD patients

8 Frequency and percentage of perceived onset symptom 60

9 Frequency and percentage of chief complaint at the first visit 62

in health care service


the first visit and first diagnosis time


first visit setting, diagnosis setting and first visit to diagnosis time

12 Frequency, percentage and the median of time of PAOD 67

patients classified by the items of reasons for not visiting a

health care service

13 Frequency and Percentage of PAOD patients classified by 69

knowledge about PAOD and time


response of others time


ix

LIST OF TABLES (cont.)

Table Page

15 Factors associated with first diagnosis time in PAOD patients 73

as presented by Spearman rank-order correlation coeffficient


x

LIST OF FIGURES

Figure Page

1 Cognitive Model of Delay in Seeking Health Care 8

2 Conceptual framework 9


Fac. of Grad. Studies, Mahidol Univ. M.N.S. (Adult Nursing) / 1

CHAPTER I

INTRODUCTION

Background and significance of the study

The duration from the perceiving symptom onset of peripheral arterial

occlusive disease (PAOD) to patients reach health care services for diagnostic makes a

significant difference in the treatment and outcome of this disease. If patients receive

diagnosis and appropriate treatment immediately after the onset of symptoms, or

before the disease becomes severe, treatment is likely to be more successful than

delayed treatment for severe symptoms. If patients receive late diagnosis, the disease

will increase in severity according to the period of time elapsed, thus preventing

maximum treatment effectiveness and potentially resulting in higher prevalence for

complications, disabilities and mortality. Furthermore, patients will have high medical

expenses as they require treatment from a specialist who will use complicated

treatment methods, requiring a large amount of resources to provide specific

treatments. The duration that patients visit to health care services may depend upon

their reasons for not visiting health care services (Noureddine et al, 2006), knowledge

about the disease (Hirsch et al, 2007; Willigendael et al, 2004), age and response of

other individuals (Aquarius, Denollet, Hamming & Vries, 2006 ), which will affect the

decision to visiting a health care services by the patients leading to diagnostic and

treatment. In Thailand, it has been found that most patients receive healthcare services

when the disease become severe (Mutirangura, Ruangsetakit, Wongwanit,

Sermsathanasawadi, & Chinsakchai, 2006), which may contribute to unsuccessful

treatment outcomes.

The duration from PAOD patients’ perceived symptom onset to visit in

health care services, diagnostic and treatment has a significant effect on treatment

outcome; if this duration is long the patients received diagnosis and treatment when

their symptom severe, the treatment may be unsuccessful and patients may not be able

to return to good health. In the United Kingdom, a one-year prospective study of 134


Siriphorn Sawangphong Introduction / 2

patients with critical lower limb ischemia found that 47% were treated conservatively,

42% were treated by revascularization, 11% were treated with primary amputation and

the mortality rate was 27%. There was a significant increase in the number of deaths in

patients presenting with ulceration and gangrene in comparison to those presenting

with rest pain alone. (Bailey, Saha, Magee, & Galland, 2003) Furthermore, there have

been reports PAOD patients with critical limb ischemia had unreconstructable and

required amputations within 6 months following diagnosis. Overall, approximately

40% of these patients will lose a leg within 6 months (Bonham & Kelechi, 2008;

Norgren, et al., 2007) while 55% of these will lose a leg within 1 year post diagnosis.

(Dormandy & Rutherford, 2000) On the contrary, if patients receive treatment more

quickly, treatment will yield better outcomes than after symptoms have already

become severe; if patients receive treatment before the onset of severe PAOD, as when

patients have intermittent claudication or asymptomatics, their treatment outcomes

will be improved. Treatment during this period can be performed by giving anti-

coagulant drugs along with supervised exercise therapy in order to increase peripheral

blood circulation. Only 10-20% of patients with symptoms in this condition required

procedures or bypass surgery to repair occlusion (Dormandy & Rutherford, 2000), 1 –

4% required amputation (Belch, et al., 2003; Schmieder & Comerota, 2001), and only

1% - 3.3% of patients with intermittent claudication (IC) needed major amputation

over a 5-year period. (Dormandy & Rutherford, 2000; Norgren, et al., 2007), which

are considered very minor rates of limb loss when compared with treatments initiated

when patients have severe symptoms.

In Thailand, it was found that most PAOD patients receive treatment from

specialist doctors, vascular surgery when symptoms are severe. In foreign countries,

however, it has been found that most patients will receive treatment from specialist in

vascular surgery when there are no severe symptoms. From the study of Mutirangura,

et al. (2006), it was found that 65.2% of the 385 PAOD patients in Thailand with

chronic ischemic symptoms hospitalized for treatment from 1 January 2000 to 31

December 2004, 65.2% were patients with ischemic ulcers and/or gangrene, while

47.3% suffered with rest pain and 16% were patients with intermittent claudication. As

for foreign countries, one study found that that general practitioners (GPs) consulted

with vascular surgeons in the 873 of the Peripheral Arterial Occlusive Disease patients



studied while 134 patients were patients with severe ischemia (15%). (Bailey, Saha,

Magee, & Galland, 2003)

Factors affecting the duration from perceived symptom onset to receiving

healthcare services for diagnosis and treatment of PAOD patients are 1) The

characteristics of signs and symptoms of the disease; 2) Information regarding the

disease of the patient and 3) Responses of other individuals. The characteristics of

signs and symptoms of PAOD affect the duration in receiving healthcare services

because the early stages of PAOD have no presenting symptoms. Furthermore, 70-

80% of the total number of patients were asymptomatic and these patients will not

know that there is an abnormality without examination from doctors (Abul-Khoudoud,

2006; Norgren, et al., 2007). And from studies in the United States found that the

prevalence of PAOD in populations aged over 60 years were 5 million; of these

number, 1.5 million patients were symptomatic, while 3.5 million patients comprised a

group with asymptomatics (Ostchega, Paulose-Ram, Dillon, Gu, & Hughes, 2007).

According to, most of the patients are in a group asymptomatics, therefore, it would be

difficult for patients to visit in healthcare services during this period.

Information on this disease is another factor affecting the duration from

symptom onset to visiting to healthcare services and diagnosis. The aforementioned

information is 1) Information about signs and symptoms of the disease, 2) Information

about risk factors and 3) Information about the severity of the disease. In the

Netherlands, it has been found in a group of 1,048 of the general population aged 18

years and older, that there is a lack of information about PAOD terminology, signs and

symptoms. While fifteen percent had heard of “peripheral arterial disease”, only five

percent were familiar with the term “intermittent claudication”. When the general

population was asked to classify peripheral arterial disease, ranging from an innocent

condition to a very serious condition, sixty one percent rated the disease as relatively

serious (Willigendael, et al., 2004). In terms of knowledge of risk factors, 2,501

subjects in a public population of adults aged > 50 years in the United States found that

44% of the subjects were unaware that cigarette smoking was a significant cause of

PAOD and 50% were unaware that diabetes was a significant cause of PAOD. These

knowledge gaps were significantly more prominent in older, nonwhite, less educated

and lower-income individuals. Moreover, regarding perceived severity of PAOD, it



was found that 14% of the respondents associated PAOD with a risk of amputation and

14% associated PAOD with a risk of death (Hirsch, et al., 2007). The aforementioned

data may make ordinary people become unaware or fail to give importance to the

symptoms of the disease so they do not visit health care services when symptoms

occur.

Furthermore, a lack of information regarding the disease has also been

found among the group of PAOD patients. Study in Netherlands, in group of 219

PAOD patients aged 35 years and over, it was found that 43% were unaware that the

disease they had occurs in veins or arteries (Willigendael, et al., 2004). And from study

of situations and interviews with 20 PAOD patients while the researcher was training

in the surgical patient ward of Siriraj Hospital during June-September of 2008, it was

found that none of the patients ever knew about PAOD prior to receiving their

diagnoses from doctors. Moreover, upon the onset of the presenting symptoms of the

disease, none of these patients knew the aforementioned symptoms were presenting

symptoms of PAOD, thus preventing 86.7% of the patients from visiting health care

service immediately upon the onset of symptoms and prompting them to see a doctor

when they have chronic ulcers accompanied by increasing pain to the point that the

patients were unable to perform their duties regularly, which is considered a symptom

of critical limb ischemia. In groups of ordinary patients, there have been study in Italy

which found that 44% of patients with intermittent claudication are unaware that the

aforementioned symptoms were symptoms of PAOD (Brevetti, Oliva, Silvestro,

Scopacasa, & Chiariello, 2004). From the aforementioned data, it is evident that

knowledge about the disease is a significant factor affecting the time spent by patients

in receiving health care service leading to diagnosis and treatment.

The response of other individuals to the presenting symptoms of patients is

another factor affecting the time spent receiving health care services by these patients,

because close individuals will play a part in supporting patients to receive treatment as

suitable for the symptoms and severity of the disease. From studies in 99 PAOD

patients aged less than 65 years, it was found that 80% of the patients with family

members, friends or close individuals who provided a high degree of support would

have received the revascularization procedures following diagnosis and 45% of the

patients with family members, friends or close relations who provided a low degree of



support would have received the revascularization procedures (Aquarius, Denollet,

Hamming, & Vries, 2006), thus indicating that patients who receive high degrees of

support or responses from close relations may seek healthcare services in a more

timely manner.

Age may be another factor affecting to the patients’ receipt of healthcare

services, because the disease is usually discovered in elderly and the rate of incidence

will increase with age (Maeda, et al., 2008; Selvin & Elinger, 2004). In Thailand, there

have been studies which found that the average age of PAOD patients was 66.9 years

(Mutirangura, et al., 2006) among the 414 PAOD patients who received treatment in

the hospital. Furthermore, there have been study indicating that the level of

knowledge about the disease both in terms of risk factors and symptoms of the disease

decrease in older groups of patients (Hirsch, et al., 2007). This group of patients tends

to lack information about the disease; therefore, it is possible that the patients’ receipt

of healthcare services will also be affected.

Over the past ten years, very few studies have been found on PAOD

patients in Thailand and there have been study about pain and the impact of pain in

patients (Intasaen, et al. , 1999), pain management (Laohasuwanpanich, 2002;

Panchoowong, Utriyaprasit, Kimpee, & Satayawiwat 2008), prevalence and risk

factors of disease (Sritara, C., 2002; Sritara, P., et al., 2003; Sritara, P., et al., 2007),

prevalence of disease and treatment outcomes (Mutirangura, et al., 2006). From the

aforementioned studies, it has been indicated that most patients received health care

services from health care professionals when symptoms were severe and when it has

been found that treatments have not been as successful as expected as patients have

had amputations, disabilities and fatalities.

It is evident that the duration from perceived symptoms onset to the time

when patients receive diagnostic and treatment affects the success of treatments; if

minimal duration, patients will receive early treatment. The treatment will be more

successful than when longer duration before receiving treatment, because the disease

of the patients will become more severe and medical treatment will become more

complex according to the severity of the symptoms as time passes. As for in the group

of PAOD patients, there have been studies on factors affecting the severity of the

disease but no studies were found on the time spent in receiving health care services



by this group of patients, nor were there studies on the cause of why most patients

allow a long period of time to elapse from symptoms onset to when they receive health

care services and treatment for severe symptoms. In the present study, therefore, the

researcher was interested in studying which factors are related to the duration from

PAOD patients in Thailand perceived onset symptom to visit health care services and

receive their diagnosis. Furthermore, in addition to revealing how much duration as

patients used from symptoms onset to the time as patients visit in health care services

and diagnosis, the research findings will reveal that duration and strategies if the

health care services system arranged for patients to receive appropriate care, in

addition to patient factors in terms of whether or not the health care services system is

involved with the duration so the research findings obtained can be used as a database

for developing health care systems so PAOD patients will have earlier access to health

care services.

Research Questions

1. How long does it take PAOD patients who perceived onset symptoms

visit health care services and receive diagnostic?

2. Are knowledge about PAOD, reasons for not visiting health care

service, age and response of others individuals related to the first diagnosis time or

not? How?

Research Objectives

1. To study the duration from PAOD patients perceive onset symptoms to

the time these patients visit health care services and the time that receive diagnostic.

2. To study the correlation between knowledge about PAOD, reasons for

not visit health care service, age, response of other individuals and the first diagnosis

time of PAOD patients.



Research Hypothesis

1. Knowledge about PAOD is related to the first diagnosis time of PAOD

patients.

2. The reasons for not visiting health care service are related to the first

diagnosis time of PAOD patients.

3. Age is related to the first diagnosis time of PAOD patients.

4. The response of others is related to the first diagnosis time of PAOD

patients.

Conceptual framework of the research

In this research, the researcher utilized the conceptual framework of the

Cognitive Model of Delay in Seeking Health Care (Noureddine, et al., 2006)

developed from the Common – Sense Model of Illness Representations (Diefenbach &

Leventhal, 1996) as a conceptual framework for explaining about coping strategies at

the onset of the symptoms of disease which the researcher modified, as a conceptual

framework in the present study. From the conceptual framework of the Cognitive

Model of Delay in Seeking Health Care, it was explained that individuals will evaluate

symptoms of a disease at their onset, which will stimulate the coping strategies

consisting of cognitive and emotional response, which will afterwards be expressed in

terms of behavioral response to the onset of symptoms in order to manage the

symptoms of a particular illness. The factors affecting the behavioral expressions of

individuals and the duration before receiving healthcare services of patients include

the demographics, symptom context (e.g. the place and time of onset) as well as the

responses of others, and clinical history . (Figure 1)



Figure 1: Cognitive Model of Delay in Seeking Health Care (Noureddine, et al., 2006)

According to the conceptual framework of the Cognitive Model of Delay

in Seeking Health Care (Noureddine, et al., 2006) and literature reviews about PAOD

patients, it was found that occurrence patients who have symptoms but do not receive

health care services was caused by lack of knowledge about the disease, symptoms of

the disease, lack of awareness of the symptoms occurring, personal factors and

response of others. Therefore, the researcher modified the conceptual framework for

compatibility with PAOD patients and used it as the conceptual framework in this

research as shown in Figure 2

The conceptual framework for this study explained that the onset of

PAOD symptoms will differ according to level of disease severity included

intermittent claudication, rest pain and ischemic ulcers or other symptoms that showed

arterial insufficiency consist in atrophy of subcutaneous tissue, abnormality of nails

and hair, blebs, changes in skin temperature, localized cyanosis, pallor or paresthesia

(Mutirangura, 2002; Wilasrasamee, 2007). These symptoms stimulate the occurrence

of thoughts looking for reasons to not receive health care services immediately and the

overall cognitive process (in the present study, the meaning is knowledge about

PAOD) as the aforementioned process is a process of coping strategies preceding

expression into a behavioral response to the symptoms of the illness (in the present

study, a behavioral response is only the behavior of patients receiving healthcare

services). Other factors affecting patients to receive health care services are age and

Nature of

symptoms

Cognitive response

Demographics

Symptom context

Response of others

Clinical history

Affective response

Delay time Behavioral

response:

Action taken



the responses of others. From the aforementioned conceptual framework, it can be

seen that the duration from symptoms onset to the patients’ receipt of healthcare

services depends upon the duration that patients use in coping themselves through

cognitive process with age and the response of others as supporting factors in deciding

to receive healthcare services. However, when patients receive healthcare services,

they may not receive appropriate services or treatment, thus resulting in delay in

starting treatment. Therefore, the researcher added the part of receiving diagnosis and

treatment to the conceptual framework. (Figure 2)

Figure 2: Conceptual Framework

Because the conceptual framework of Cognitive Model of Delay in

Seeking Health Care was developed to study the group of coronary artery disease

patients with the symptom of sudden chest pain, which is a clear presenting symptom

prompting patients to receive correct diagnosis and treatment immediately after

receiving health care services, there are differences in terms of symptoms and

treatment in the group of chronic PAOD patients. The fact that patients are able to

receive health care services does not mean that all patients will receive appropriate

First visiting

a health care

services of

patients

PAOD patients

perceive

symptoms

Age

Response of Others

First diagnosis time

Knowledge

about PAOD

Reasons for

not visiting

a health care

service

Patients

receive

diagnostic

Patients

receive

treatment



diagnosis and treatment immediately. There is a possibility that a long delay in

receiving treatment may not depend solely on the patient but it may also include the

time used by the healthcare system. Therefore, in addition to the duration before

receiving health care services, the researcher also studied the duration before patients

received appropriate diagnosis because the diagnosis will further lead to appropriate

treatment.

Scope of the research

This study was a descriptive study aimed at examining the relationships

between knowledge about PAOD, reasons for not visiting a health care service, age,

response of others and the first diagnosis time. The population of the study comprised

both male and female subjects with PAOD that received the diagnostic from their

physician and visit to the Vascular Surgery Outpatient Department and at the Vascular

Surgery Laboratory on the first floor of the Siamintra Building, Siriraj Hospital. Data

collection was conducted from June 2009 to September 2009.

Definition of terms

Knowledge about PAOD refers to data, facts, understanding acquired

from studying, learning, researching or experience, and information received by

hearing, listening, thinking about PAOD of PAOD patients as evaluated by The

Knowledge About PAOD interview form as developed by the researcher from reviews

of related documents and literature (Bush, Kallen, Liles, Bates, & Petersen, 2008;

Hirsch, et al., 2007; Willigendael, et al., 2004). In this study the knowledge about

PAOD are comprise of two domains as follow: 1) The general knowledge comprise

of general knowledge about PAOD and risk factors of PAOD 2) The knowledge

related to patients’ experience comprise of knowledge about symptoms, treatment

and severity of disease.

Reasons for not visiting a health care service means grounds causing the

PAOD patients to did not visiting in a healthcare service immediately following

perceived onset of symptoms.

In this study these reasons comprise of 3 sections as follow: 1) the

emotional related reasons for did not visiting health care service, 2) the cognitive



related reasons for did not visiting health care service, and 3) the symptom

related reasons for did not visiting health care service as evaluated by The Reasons

for not Visiting a Health Care Service interview form as developed by the researcher

by partially modifying of The Modified Response to Symptoms Questionnaire that

developed by Dracup & Moser (1997).

Age means the number of years from the patients’ birth to the date of data

collection wherein fractions of more than 6 months were counted as one year.

Response of others means the patients’ perception about behaviors or

reactions both in terms of gestures, consolation, advice and support of others for

visiting a health care service of patients once the others have acknowledged or are

aware of abnormal symptoms and according the patients.

In this study the response of others were evaluated by 3 domains as: 1)

response of others did not induce first visit, 2) response of others induce first visit,

and 3) the duration from telling others to escort first visit means the number of

days since patients telling others about their percept symptoms until the day that

patients were escorted by others to the first health care service setting. The responses

of others can be evaluated by The Responses of Others interview form as developed

by the researcher by partially modifying of The Modified Response to Symptoms

Questionnaire developed by Dracup & Moser (1997).

First diagnosis time means the number of days since patients perceived

onset symptoms; those symptoms are intermittent claudication, rest pain, ischemic foot

ulcers/ gangrene, or other symptoms that showed arterial insufficiency consist in

atrophy of subcutaneous tissue, abnormality of nails and hair, blebs, changes in skin

temperature, localized cyanosis, pallor or paresthesia of PAOD patients appear until

the day that patients received their diagnosis.

Furthermore, in this study the researcher was examined other time as

follow: 1) first visit time means the number of days since patients perceived onset

symptoms until the day that patients visited first health care service setting, 2) first

visit to diagnosis time means the number of days since patients visited first health

care service setting until they received diagnosis. These factors were evaluated by The

Sequence of Visiting Health Care Services interview form developed by the

researcher.



Expected benefits of the research

1. The health care providers will able to utilize the findings as baseline

data in educating patients at risk for the disease to receive treatment within an

appropriate amount of time.

2. The health care providers will have the ability to implement research

findings as a database in improving the healthcare system, so PAOD patients will be

able to earlier access the health care system.



CHAPTER II

LITERATURE REVIEW

This chapter consists of documents and research associated with peripheral

arterial occlusive disease (PAOD), factors affecting the first diagnosis time and the

conceptual framework used in the research as follows:

1. Peripheral arterial occlusive disease patients

1.1 The prevalence of peripheral arterial occlusive disease

1.2 Pathophysiology of peripheral arterial occlusive disease

1.3 Signs and symptoms of peripheral arterial occlusive disease

1.4 The severity classification of peripheral arterial occlusive disease

1.5 Screening for peripheral arterial occlusive disease

1.6 Physical examinations and specific examinations for peripheral arterial

occlusive disease

1.7 The outcomes of peripheral arterial occlusive disease treatment

2. The duration from symptoms onset to diagnostic of PAOD patients

3. Factors related to PAOD patients’ visiting in health care service lead to diagnostic

3.1 Knowledge about peripheral arterial occlusive disease

3.2 Reasons for not visiting a health care service

3.3 Personal Factors: Age

3.4 Social Factors: Response of others

4. Summary


Siriphorn Sawangphong Literature Review / 14

1. Peripheral arterial occlusive disease patients

Peripheral arterial occlusive disease (PAOD) is a disease involving

occluded arteries in the leg area wherein the etiology of 90% of all PAOD cases cause

by atherosclerosis due to plaque formation. Other causes of occlusion are emboli or

infections of arterial wall which are found only in small numbers (Cimminiello, 2002).

Arterial occlusion involves both chronic and immediate conditions. However, chronic

arterial occlusion will not usually prompt urgent treatment as often as immediate

arterial occlusion, because abnormalities will occur slowly. Ischemia will not be

severe in the early stages. As arterial occlusion becomes more severe, patients can

have critical ischemia (Mutirangura, 2002). Furthermore, if the occlusion is complete,

the blood supply to that area will be obstructed (Cimminiello, 2002). In this study, the

researcher will examine only peripheral arterial occlusive disease patients caused by

plaque formation, which involves only chronic occlusion.

1.1 The prevalence of peripheral arterial occlusive disease

Most PAOD patients are senior adults as prevalence gradually increases

with age and it has been found that the prevalence of the disease is 4.3% in people

aged more than 40 years. This number increases to 13% in people aged more than 65

years (Newman, et al., 1999). In Japan, the prevalence of PAOD in diabetic patients

has been found at 7.6% and people aged more than 65 years at 12.7% while people

aged less than 65 years have only 4.0%.(Maeda, et al., 2008). As for in the United

States, it has been found that the prevalence of PAOD in people aged 40 years and

over has been found to be 4.3% (95% CI 3.1% - 5.5%) while the number of patients is

approximately 5 million people (95% CI 4 to 7 million). As for patients aged 70 years

and over, the prevalence of PAOD comes to 14.5% (95% CI 10.8% - 18.2%) and the

number of patients in this group is approximately 4 million patients (95% CI 3 to 5

million) (Selvin & Erlinger, 2004). In Finland, the prevalence of the disease in patients

aged 30-59 years is 2.1% in males and 1.8% in females aged (Cimminiello, 2002). In

Italy, the prevalence of symptomatic PAOD in patients aged 40-80 years is 1.6%

(2.4% in males and 1.0% in females) (Brevetti, Oliva, Silvestro, Scopacasa, &

Chiariello, 2004).



In Thailand, the prevalence of PAOD has been found to be 5.2% (Sritara,

C., 2002; Sritara,P., Sritara, C., Woodward, Wangsuphachart, Barzi, et al., 2007) with

75% occurring in males at the mean age of 66.9 years (Mutirangura, et al., 2006).This

finding, however, is in conflict with the studies of Sritara (2002) and Sritara, et al.

(2007) which discovered the disease to be less prevalent in males than in females.

These studies were conducted in a middle class Thai population with an average age of

59.8 (52-73 years) and found the prevalence of PAOD to be 3.88% in males and

9.00% in females. Furthermore, from the statistics of the division of Vascular

Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University from 2000-2006,

the number of PAOD patients hospitalized have gradually increased with the numbers

of 55, 113, 165 and 195 patients in 2000, 2002, 2004, 2006, respectively.

1.2 Pathophysiology of peripheral arterial occlusive disease

Arterial structures will consist of the following 3-layer walls (Sydenham &

Medic, 2004; Lungstrom & Emerson, 2005):

1. The inner wall is called the tunica intima consists of endothelial cells

and elastic membranes. The artery has a smooth surface, which elastic membrane will

be the thickest in aortas and will be thin or less according to sizes of smaller arteries.

2. The middle is called tunica media and constitutes the thickest layer of

arteries. Large arteries will consist of smooth muscles and elastic fibers, but small

arteries will consist only of smooth muscles. The smooth muscles in walls of these

arteries will increase the strength and limit arterial expansion.

3.The outer layer is called the tunica adventitia and consists of collagenous

connective tissue and the large arteries may consist of smooth muscles.

When there are anomalies in the arterial walls that may be the result of

atheromatous plaque or various types of infections that caused slow occlusion within

the artery. The first period of arterial occlusion will not have any visible

pathophysiological changes in the limbs. Many of the small arteries around the areas

with occlusion (collateral circulation) will expand in order to bring blood to replace

the amount lost in the parts with occlusion. But in the next period when the arterial

occlusion is so severe that blood from collateral circulation is unable to sufficiently

replace the blood supply to the peripheral limbs, pathophysiological changes will take



place in the limbs in that area in the form of chronic ischemia. Furthermore, that

organ will shrivel and wither beginning with thinner skin and hair loss as these

patients become at risk for slow-to-heal ulcers in the fingers or toes as the muscles in

that area become clearly atrophied. When the limbs are used, the ischemic areas will

be unable to produce sufficient energy and ischemic symptoms will be evident in the

form of pain. This pain is caused by the process of carbohydrate metabolism in

muscles, as protein is stored in the form of glycogen to become incomplete energy due

to oxygen deficiency, causing the clotting of various types of acids e.g. lactic acid and

other acids, etc. These acids will stimulate muscular pain. And collections will

increase according to the amount of performance of that organ. When these acids

reach a certain level, severe pains will result and thus compelling the patient to

discontinue use of that limb. While resting, that muscle will not require more energy

and the amount of oxygen that supplied to this area will be sufficient for consuming

those residual acids as carbon-dioxide and water, which ends the process of complete

carbohydrate metabolism. The pain will be completely gone. The pains caused while

using the ischemic limb are called “intermittent claudication”. As peripheral ischemia

increases, it will cause severe pain even while resting. This pain is called “rest pain”,

including the occurrence of ischemic ulcers that will not heal (Mutirangura, 2002).

1.3 Signs and symptoms of peripheral arterial occlusive disease

The signs and symptoms prompting patients to see doctors include the

following (Mutirangura, 2002):

• Intermittent claudication.

• Rest pains.

• Ischemic ulcers.

Intermittent claudication usually occurs while walking and the

significant indications that claudication has occurred will not appear while start

walking, but will begin to occur after walking for a period of time. Intermittent

claudication will increase according to the distance walked until the claudication

eventually becomes so severe that the patient will have to rest. The distance walked is

called “claudication distance” as this point, which is a distance quite close to another

in walking each time. Therefore, this distance is used to evaluate severity and disease



progression of atherosclerosis. The pain will decrease and completely gone while

resting with a period of approximately 10-15 minutes until the patient can begin to

walk further. The pain will recur similarly to the previous claudication. Sites with

intermittent claudication will depend upon the following arterial occlusion sites:

Sites of Arterial Occlusion Sites of Claudication

aorto - iliac artery Buttocks claudication and downward

ilio – femoral artery Thigh claudication

femoro – popliteal artery Calf claudication

tibio – peroneal artery Foot claudication

Intermittent claudication can be a severe problem depending upon the age

and ADL (Activities of Daily Living) capacity of each individual. Senior adults who

do not walk far will not feel this symptom is much of a problem in living their daily

lives, even though the claudication distance is short. This condition, therefore, is

called “capacitating intermittent claudication”. In contrast, the group of people who

are not very old and have regular exercise will feel their symptoms a problem in their

daily lives, even though the claudication distance tends to be long in this group of

people. This condition, therefore, is called “incapacitating intermittent claudication”,

Both conditions will receive different care and treatment. The first condition may not

require surgical treatment while the second condition may be require the consideration

of using surgical treatment to help increase the blood supply to the peripheral organs.

Rest pain is a severe pain in the foot region that occurs while resting as

the result of extremely severe ischemia. The mechanism of this pain is a result of the

patients’ resting, at that time, the heart rate for pumping blood to supply various parts

of the body is lower than usual. And when patients have severe arterial occlusion, the

amount of blood supplying the feet will be very limited so patients have severe pain at

all times. The feet will be a dependent rubor in color. When this symptom occurs, it

is considered to be a dangerous indicator of future amputation for that leg.



Ischaemic ulcers: The following significant ulcer characteristics must be

considered (Mutirangura, 2002):

- Origination at the ends of the toes before other areas.

- The ulcer expands and spreads gradually towards the feet.

- The bottom of the ulcer has a pale color and no blood comes from the

wound.

- The skin surrounding the ulcer may be blackish due to neurotic skin.

- Dry gangrene may be encountered.

- The skin surrounding the ulcer is fragile and tears easily.

- Tendencies toward infections may be encountered and the infections may

spread quickly. Moreover, PAOD patients may presented others signs and symptoms that

showed arterial insufficiency consisted atrophy of subcutaneous tissue, abnormality of

nails and hair, blebs, changes in skin temperature, localized cyanosis, pallor or

paresthesia. (DiSabatino & Veasey, 2008; Wilasrasamee, 2007)



1.4 The Severity Classification of peripheral arterial occlusive disease

The severity classification of PAOD depends upon the signs and

symptoms of the disease. There are 2 types of criteria used in categorizing disease

severity levels consist of 1) Fontaine’s Stages Classification and 2) Rutherford’s

Grades Classification, with the following details:

1) Fontaine’s Stages Classification (cited in Abul-Khoudoud, 2006;

Norgren, Hiatt, Dormandy, Nehler, Harris, et al., 2007) categorizes severity levels

according to the signs and symptoms of patients into the following 4 stages:

Table 1: Fontaine’s Stages Classification

Stage

Clinical

Stage I No Presenting Symptoms of the disease Stage II Periodical pain while walking, categorized as: IIa Periodical leg pain while walking; the pain vanishes while resting

(intermittent claudication), the pain is at a low level of severity. claudication distance > 100 meters

IIb Periodical leg pains while walking; the pain vanishes while resting (intermittent claudication). The pain is at a moderate to severe level. Claudication distance < 100 meters

Stage III Rest pain IIIa Ankle Pressure Index > 50 mmHg IIIb Ankle Pressure Index < 50 mmHg

Stage IV Ischemic ulcers or gangrene at the feet.



2) Rutherford’s Categories categorize the levels of severity into the

following 3 stages (cited in Abul-Khoudoud, 2006; Baumgartner, Schainfeld, &

Graziane, 2005):

Table 2: Rutherford’s Categories

Grade Category Clinical Description Objective Criteria

I

0 No symptoms Treadmill test results are normal.

1 Mild IC

After beginning to test with treadmill walking for five minutes:

- ankle pressure > 50 mmHg

- The ankle pressure value is at least 20 mmHg lower than while resting for.

2 Moderate IC Between Categories 1 and 3.

3 Severe IC After testing by walking on a treadmill for 5 minutes: ankle pressure < 50 mmHg

II 4 Rest pain

- ankle pressure < 40 mmHg and/ or - great toe pressure < 30 mmHg - pulse volume recording barely pulsatile or flat

III 5 Limited ischemic lesion

- great toe pressure < 30 mmHg - pulse volume recording barely pulsatile or flat - minor tissue loss

6

Extended ischemic lesion (above metatarsal level)

- major tissue loss

* IC = Intermittent claudication

Critical Limb Ischemia (CLI) is PAOD patients at Level III – IV of

disease severity (Fontaine’s Stage Classification) or at level II – III (Rutherford’s

Grades Classification). The characteristics of patients who can be categorized as

having critical limb ischemia include symptoms rest pain due to deficient blood supply

to the peripheral organs, chronic ulcers or gangrene, ankle pressure < 50 mmHg, toe

pressure < 30 mmHg, TCPO2 < 30 mmHg (Hirsch, et al.,2006; Norgren, et al., 2007).

Some study have found approximately 500 – 1,000 new case CLI /the population of 1



million/ year and this number is similar to numbers in Europe and North America

(Norgren, et al., 2007).

1.5 Screening for peripheral arterial occlusive disease

Peripheral arterial occlusive disease screening from associated diseases

will help diagnose patients and prompt people at risk for peripheral arterial occlusive

disease to receive treatment within a suitable amount of time without extending the

time until the disease becomes severe. However, from literature reviews, it has been

found that people at risk for the disease were not examined to screen from relevant

diseases; therefore, patients were not properly diagnosed and did not receive specific

treatment from the early stages. For example, among 3,865 general patients aged 40-

80 years who received treatment from general practitioners when they were evaluated

the intermittent claudication by Rose Questionnaire form, it was found that 760

patients had intermittent claudication (19.6%) (Brevetti, Oliva, Silvestro, Scopacasa,

& Chiariello, 2004).

When peripheral arterial occlusive disease screening was conducted in a

group of 162 general female patients aged between 40-85 years who received

treatment at the Out-Patient Department in a tertiary hospital in Texas by using ABI

evaluations, 3.7% of the patients were found have ABI < 0.9 and 30 patients had

diabetes (19.7%) while 71 patients had hypertension (47%), 89 patients had high blood

cholesterol (58.9%) (Bush, Kallen, Liles, Bates, & Petersen, 2008). As for another

group of 1,410 cardiovascular disease patients who went to receive treatment in a

hospital in Spain with symptoms of acute coronary syndrome, 100 patients (7.1%)

were diagnosed with PAOD. However, when the Ankle Brachial Index (ABI) was

evaluated in all of these patients, it was found that 561 patients had ABI < 0.9 (39.8%)

(Bertomeu, et al., 2008). Furthermore, peripheral arterial occlusive disease screening

was conducted by using 1) The Edinburgh Claudication Questionnaire for evaluation

of intermittent claudication, 2) The evaluation form of walking impairment, 3)

Evaluation of the pulse at the posterior tibial and dorsalis pedis and 4) Evaluation of

the Ankle Brachial Index (ABI) along with studies of backgrounds in the medical

records of 291 hospitalized patients aged over 40 years and recovering in a university

hospital in France (Excluded patients hospitalized in intensive care unit, paediatrics,



obstetrics gynaecology and patients in vascular department). Twenty-one patients

(7.2%) were diagnosed with PAOD and found 65 patients (22.33%) with abnormal

values of Ankle Brachial Index (ABI) (< 0.9 or > 1.4) but never diagnosed with

PAOD, these patients categorized as the “Unrecognized PAD” group. And in the

group of “Unrecognized PAD”, there were patients with comorbidities as

hypertension 49 patients (75.4%), 25 patients with cardiovascular or cerebrovascular

diseases (38.5%), 14 patients with diabetes (21.5%) and 22 patients with high blood

cholesterol (33.8%) (Lacroix, Aboyans, Voronin, Le Guyader, Cuatres, et al., 2008).

Moreover, from Ankle Brachial Index (ABI) evaluations in 239 patients

aged over 55 years who visit to the Out Patient Medical Department of Chicago

University Hospital in the United States, it was found that 34 patients (14.2%) had

Ankle Brachial Index (ABI) < 0.9 but had never been diagnosed with PAOD. Of this

number, there comorbidities as hypertension 25 patients (74%), 3 patients with brain

arterial diseases (9%), 4 patients with Myocardial infarction (12%), 9 patients with

Angina (26%), 8 patients with diabetes (24%) and 15 patients with high blood

cholesterol levels (56%) (McDermott, et al., 2001).

Furthermore, studies in France have found that, of the patients recovering

in the university hospital for other reasons than arterial disease and aged 40 years and

over, 22% of PAOD patients were not diagnosed; 11.7 percent had ABI of < 0.9,

10.7% had ABI > 1.4 (Patients were screened by pulse evaluation, ABI calculation

and used the Edinburgh Claudication Questionnaire in evaluating intermittent

claudication) (Lacroix, Aboyans, Voronin, Le Guyader, Cuatres, et al., 2008).

As for the United States, it has been found that a group of patients aged 55

years and over who visit to the Out Patient Medical Department in a university

hospital had 14% in “unrecognized PAD” patients (ABI values < 0.9 but without ever

receiving PAD diagnosis). Of this number, only 12% had consistent with intermittent

claudication (McDermott, et al., 2001). From research findings, it has been indicated

that more than half of the patients in the group of “unrecognized PAD” were

asymptomatics, which caused these patients to not receive diagnosis because they

could not be detected without evaluation of ABI values.



1.6 Physical examinations and specific examinations for peripheral arterial

occlusive disease

Peripheral arterial occlusive disease patients can be diagnosed by a variety

of methods as follows:

1.6.1 History of illness Assessment - In assessment the history of patients,

the items that must be added and given significance in addition to the usual history

assessment are history of leg pain, occurrence of ischemic ulcers and history about

various risk factors of the disease (Khan, Rahim, Anand, Simel, & Panju, 2006),

which have the following characteristics:

Leg pain - The relevant information that must be questioned from the

patient is the onset and duration of pain (differentiating characteristics between acute

and chronic ischemia), factors exacerbating pain severity and strategies that relieve the

pain. Pain discovered in chronic PAOD is divided into 1) Intermittent claudication

and 2) Rest pain. However, because 50% of all PAOD patients are asymptomatic,

therefore the history assessment about pain alone is insufficient for diagnosis

(Bonham, & Kelechi, 2008):

History about various risk factors of the disease as risk factors of

atherosclerosis, including both changeable and unchangeable factors. The

aforementioned factors are hyperlipidemia, genetic predisposition, hyperglycemia, and

smoking (Bonham, & Kelechi, 2008; Sydenham & Medic , 2004).

1.6.2 Physical Examination

Physical examinations to diagnose peripheral arterial disease patients

consist of the following: (Abul-Khoudoud, 2006; Bonham, & Kelechi, 2008)

• Functional-Sensory Assessment consists of walking and movement

performance evaluation, balance, use of supporting equipment, evaluation of

neuropathy; reduced sensitivity evaluated by using 5.07 Semmes-Weinstein

monofilament, evaluation of vibratory perception by using tuning forks, evaluation of

deep tendon reflexes by using percussion hammers, ankle/foot weakness and foot

drop/foot drag symptoms.

• Skin and Tissue Assessment consists of evaluations of skin color, turgor,

flexibility, moisture, fragility, swelling, cleanliness, nail characteristics, foot



deformities and foot ulcers, including the details of the ulcers; the onset and duration

of ulcers.

• Peripheral Circulation consists of an evaluation of skin temperature,

capillary refill, changes in skin color (pale when lifting a leg and turned rubor when

the leg is put down) and symptoms of numbness.

• Pulse palpation involves the evaluation of pulses in both legs at the

positions of the femoral and popliteal arteries and whether any anomalies can be

detected by listening through a stethoscope. If there is arterial occlusion, “bruits”

sounds will be heard. The positions of the dorsalis pedis and posterior tibial can be

evaluated by palpitation. Pulse rates are categorized as follows:

0 No pulse found.

1 Low pulse rate

2 Normal

3 Bounding

However, accurate pulse palpation requires skill and experience on the part

of the examiner. Furthermore, the examiner may not find the pulse at the dorsalis pedis

in some patients, but the patient may have no arterial abnormality.

1.6.3 Non- Invasive examinations

Non-invasive examinations of peripheral arterial occlusive disease has

been implemented to increase effectiveness in diagnosing peripheral arterial occlusive

disease and, to evaluate the position and severity of arterial occlusion, the success or

failure of the treatment must be evaluated, including monitoring treatment outcomes,

which can be done by various methods as follows (Wongwanit, Chinsakchai,

Sermsathanasawadi, Ruangsetakit, & Mutirangura, 2008):

1) Limb blood pressure

The measuring of systolic blood pressure from the arteries in the leg can

be done by listening to arterial flow through a hand-held doppler 4-MHz instrument or

an 8-MHz continuous wave doppler probe by placing the probe of the aforementioned

instrument on the location of the artery to be measured and on the distal area of the

position of the pneumatic cuff. The process of inflating and deflating the pneumatic

cuff can be done similar to the measurement of blood pressure of arm arteries and the

acquired values to can be used to diagnose by the following principles:



A) The systolic blood pressure values measured from the arteries at the

distal positions with severe occlusion are generally lower than the values measured

from arteries that are more proximal than the area of occlusion, thus enabling us to tell

the area of arteries and occlusion severity from the reducing tendencies of blood

pressure at each length of artery throughout in what it called regional hypotension.

B) The systolic blood pressure values of the arterial system will gradually

increase respectively from the central aorta to the peripheral arteries, because the aorta

has higher flexibility and better ability to absorb impact than peripheral arteries and

the rebound of arterial waves at the arterioles, bifurcations and minor branches of

arteries cause an increase in the systolic pressure waves of the peripheral arteries.

C) The occurrence of calcium accumulations in the peripheral arteries will

cause the arteries to have conditions of incompressible arteries and it will cause the

blood pressure values of the leg arteries to be higher than reality.

2) Ankle brachial Index (ABI)

The Ankle Brachial Index is a value used for evaluating arterial occlusion

severity but is not used to tell the location of occlusion. An ABI value is the ratio

between the systolic blood pressure values measured in the posterior tibial artery or

the dorsalis pedis artery (Generally, the highest value between the measurements from

both arteries will be used) with the highest systolic blood pressure measured from the

brachial arteries of both arms, which can be done by using a pneumatic cuff hand-held

doppler 4-MHz device or an 8-MHz continuous wave doppler probe. While

measuring ABI values, the patient must be lying down flat and the patient must rest for

2-3 minutes prior to binding the pneumatic cuff in the ankle area slightly above the

malleolus level and the width of the pneumatic cuff will have direct effect on the value

of blood pressure at the leg. The wideness of the cuff should be longer than 50% of

the leg diameter in the part where blood pressure is being measured. In ordinary

people the value of systolic blood pressure measured at the ankle artery will be slightly

higher than the value measured from the arm artery. The reduction of ABI values

indicates a reduction in the rate of blood flowing to supply that leg. ABI is a value

with effectiveness and accuracy in detecting PAD (Belch, et al., 2003) and is

considered an examination capable of evaluating severity of peripheral arterial

occlusive disease well with 95% sensitivity and near 100% specificity (Oka, &



Sanders, 2005) and it is a good predictor of conditions of peripheral arterial occlusion

(Belch, 2003; Ng, Cheng, Chu, Lui & Lo, 2003). The values used in diagnosing

patients with peripheral arterial occlusive disease can only occur when ABI < 0.9

while resting (Nogren, et al., 2007). The severity of artery occlusion could be

evaluated from reduced ABI values with results interpreted as follows (Moses, 2008;

Wongwanit, et al., 2008):

Ankle-Brachial Index (ABI) Interpretation of the Findings

>1.3 Non-compressable vessels, Calcified

0.9 – 1.2 Normal

<0.9 Peripheral Vascular Disease

(Begins to have Intermittent claudication)

0.7 - 0.89 Mild disease

< 0.5 Multi-level disease

0.4 - 0.69 Moderate disease

< 0.4 Critical limb ischemia (Have rest pain, tissue loss)

< 0.2 Gangrenous extremity

In cases where ABI > 1.3, the arterial walls may be found hardened from

calcification, thus preventing the arteries from being pressed by the pneumatic cuff

(usually found in diabetic patients and chronic renal failure patients). The measured

ABI will be higher than reality and cannot be implemented in evaluation results. In

this case, it is necessary to measure the Toe Brachia Index (TBI); a measurement of

the ratio between systolic blood pressure, which can be measured in the toe area, to

compare with the values measured from the brachial artery of the arm, which can be

interpreted as follows (Wongwanit, et al., 2008):



Toe-Brachial Index (TBI) Interpretation

0.8 – 0.9 Normal

0.35 + 0.15 Intermittent claudication

0.11 + 0.10 rest pain/ ischemic ulcers

In cases where the Ankle-Brachial Index is found to be abnormal (ABI <

0.9 or ABI >1.3), the test results can be confirmed by other types of examinations such

as segmental arterial pressure, standard angiography, CT angiography or magnetic

resonance angiography (Moses, 2008).

3) Segmental limb pressures

Segmental limb pressure values were implemented to evaluate the systolic

blood pressure at the upper and lower thighs and ankles, which will reveal the level,

position and severity of arterial occlusion in the legs. This can be done by measuring

ABI values from the levels of the upper and lower thighs, calves to the end at the ankle

level. These values are generally measured at each adjacent level of the same leg

should not have a difference of more than 20 mercury millimeters and there should be

no difference between arteries at the same level of each leg. Ankle pressure that is

lower than 50 mercury millimeters indicates poor perfusion and is considered a

predictor of poorly healing ulcers. In people with normal health, systolic blood

pressure at the upper thigh level should be higher than the value measured from the

upper arm by approximately 30-40 mercury millimeters or with a ratio of systolic

pressure of high thigh : brachial artery of 1 : 2.

4) Doppler velocity patterns

Doppler velocity patterns are an evaluation of velocity waveforms of blood

flow within the arteries by using the doppler ultrasound machine to measure at various

positions of the arteries in the leg along with sound beams, which will indicate

changes of direction and arterial flow rate in the form of audio output and it can be

shown in an analogue wave form by a monitor or printed out as a strip chart recorder.

5) Pulse volume recordings (PVR)

A pulse volume recording is a special examination to measure the arterial

flow of the leg that changes between the systolic and diastolic phases by using the

principal of measuring pulsatile volume changes between the rhythm of heartbeats



equal to the capacity of blood supply to the legs, which is directly related to arterial

flow, by assuming that the capacity of leg tissue and deoxygenated blood is a stable

value. The measurement can be performed by using a pneumatic cuff along with the

use of pulse volume recorders in order to measure the capacity of the leg which

changes at each different level of the leg. Pulse volume recordings are considered a

quantitative assessment of changes in arterial flow, especially when used with

segmental limb pressures in order to use in evaluating arterial flow in the leg.

6) Exercise testing

Exercise testing is a test aimed at evaluating the severity of intermittent

claudication by having patients walk on treadmills according to specified speed rate,

slope and duration (such as at the speed of 3.2 kilometers/hour at a slope level of 12%

for a duration of 5 minutes). These values will be adjusted appropriately according to

each patient while there will be monitoring of symptoms that indicate claudication,

time period the patients are able to walk and by changes in ankle systolic pressure due

to exercise. People with normal health can finish walking 5 minutes without

symptoms of claudication and with little or no reduction of ankle systolic pressure

(less than 20 mercury millimeters), which will return to normal pressure levels within

2-3 minutes after the patient has stopped walking.

For patients who stop walking due to claudication within the first minutes

after they begin, severe arterial disease is indicated. If the patient stops walking within

3-5 minutes after starting to walk, it will be indicated that the patient has less severity

of occlusion but lifestyle-limiting claudication possibly requiring revascularization

treatment. In cases where there is a reduction of ankle systolic pressure of more than

20 mercury millimeters, the test results will be considered as positive obstructive

disease . Furthermore, the time period used in returning to normal pressure levels will

vary according to the severity level of occlusion in the leg arteries. As for patients

with leg pain without reduction of ankle systolic pressure, the cause of leg pain will be

indicated to have been caused by other than limb ischemia.

Benefits of exercising testing:

• Diagnosis of PA)D in patients with symptoms of claudication but found

to have normal ABI values or minimum reduction in ABI values.

• For evaluation of functional impairment in patients.



• For use in comparing treatment outcomes before and after the treatment

by any methods; medical, endovascular or operations as an evaluation of treatment

success.

• As an objective assessment for follow-up on long-term treatment

outcomes.

7) Duplex ultrasonography

Duplex ultrasonography is a special examination combining 2 types of

examinations; B-mode imaging and Pulse-wave Doppler untrasonography, which can

both see the characteristics of atheroma and measure arterial occlusion severity of

arteries the image cross sections. This type of examination is very useful in screening

and classifying disease severity.

8) Computerized Tomographic Angiography (CTA)

Computerized tomographic angiography is performed by injecting contrast

media into the veins. This method allows a view of arterial images from the

abdominal aorta down to the arteries in both legs and requires approximately 45

minutes for the examination. The advantages of this type of examination are that

vascular occlusion can be seen clearly and the examination results can be used in

considering procedures for patients and saving patients with metal or prosthetic in

their bodies while using less time for examination than MRA examinations. There

may, however, be limitations in patients with abnormal kidney function because the

examination requires injecting contrast media, which may affect the kidneys (Hirsch,

et al., 2006).

9) Magnetic resonance angiography (MRA)

MRA is the method that require the technique of 2 dimension time-of-

flight (2D TOF) without using contrast media. In a complete peripheral MRA

examination, the artery examinations will have to be divided into 3 segments include

the aorto-iliac segment, the femoro-popliteal segment and the infra-popliteal run-off

arteries. The data obtained can be used to create a 3-dimension image to review at

different angles for evaluation and planning before providing treatment. The

sensitivity and specificity of MRA in examining for significant stenosis (> 50%

diameter reduction) and occlusion of arteries in legs at approximately 88-100% and

87-99%, respectively.



10) Transcutaneous oximetry

Transcutaneous eximetry is an examination for evaluating the viability of

skin perfusion by using partial pressure measurement of oxygen diffusion through the

skin or by measuring oxygen tension in the tissues under the skin layer by using an

instrument called a Transcutaneous Oxygen Monitor (TCOM), which is used to

measure the amount of oxygen concentration in tissues (Transcutaneous oxygen

tension; TcpO2) at various levels of the leg from the use of oxygen at regular

metabolism. The value of TcpO2 is caused by cutaneous blood flow, abnormal venous

pressure, metabolic activity, oxyhemoglobin dissociation and oxygen diffusion of

tissues in that area. The principle of measuring the value of TcpO2 from the TCOM

instrument is performed by placing a membrane pad with potassium chloride and

phosphate buffer solutions and then connecting an electrode line to the TCOM

measuring instrument and increasing the temperature of the solution in the membrane

pad for approximately 42-45o C, causing the expansion of the hair follicles in the skin

area along with the capillary arteries with reduction of oxygen solubility and increased

oxygen release from oxyhemoglobin into the TCOM receiver measuring instrument

measuring the TcpO2 value of tissues in that area. The sites used for placing the

membrane in order to measure TcpO2 are: the areas of the toe, inner foot and

approximately 10 centimeters below and above the knee joint by having a membrane

pad attached at the chest lower than the mid clavicle. TCOM measurements should be

performed in a room with temperature levels of approximately 23- 24 oc in order to

acquire the correct values according to standard criteria. TCOM results can be

implemented as follows:

1. Evaluate the healing rate of ulcers at various sites on the leg. It has been

found that TcpO2 values higher than 40 mmHg when patients are lying down can

increase the ulcer’s chance of healing by as much as 80 %. However, if the

aforementioned value is lower than 20 mmHg, the chance the ulcer will not heal can

be as high as 80%. If the aforementioned value is between 20-40 mmHg, the patient

will have to raise the leg 30o-45o for 5 minutes and measure again. If the TcpO2

values are found to have reduced by 10 mmHg, the chance that the ulcer will not heal

will be approximately 80%. If the value is reduced to less than 10 mmHg, however,

the chance the would will heal will be approximately 80%.



2. Evaluate the level of leg amputation by using the TCOM value at a level

of more than 30 mmHg so the ulcer will be able to heal when the amputation is made

at that site.

3. Evaluate the effectiveness of revascularization before and after the

surgery.

4. Evaluate the disease progress of patients diagnosed with PAOD.

5. In order to select patients for treatment by Hyperbaric Oxygen (HBO),

cases with a TcpO2 value of more than 40 mmHg when given 100% O2 and beginning

value changes from a base line of more than 50% will be selected. TCOM

measurement will not affect the calcification of arteries. Therefore, the TcpO2 level of

Diabetes Mellitus patients and Chronic Renal Failure patients can be evaluated more

accurately than with other types of instruments.

1.7 The outcomes of peripheral arterial occlusive disease treatment

The guidelines for the care and treatment of PAOD patients state that

treatment of PAOD patients at a period with severe ischemia symptoms involves

procedures and/or by revascularization (Hirsch, Haskal, Hertzer, Bakal, Creager, et al.,

2006). In this group, 40% of the patients have such severe symptoms that they may

lose their legs within 6 months after diagnosis (Bonham & Kelechi, 2008). And

within a year after being diagnosed with severe ischemia symptoms, only 45% of these

patients do not lose their legs as a result of ischemia. Moreover, although they do not

lose their legs, these patients will have to suffer with chronic pain due to insufficient

blood supply to the peripheral organs (Dormandy & Rutherford, 2000).

According to the studies of Bailey, Saha, Magee & Galland (2003) in

England that examined the management and management outcomes of 134 PAOD

with critical limb ischemia (CLI) patients, which is considered to be 15% of the total

number of arterial disease patients, by following the treatment outcomes of PAOD

patients who started to receive treatment when there were symptoms of CLI within a

year, it was found that the treatment provided for patients in this period comprised

conservative treatment (47%), primary amputation (7%), revascularization; surgery

(23%), percutaneous transluminal angioplasty (PTA) (19%) and secondary amputation

(4%). From the aforementioned treatment outcomes, 61% of the patients were able to



have their legs saved and there was a mortality rate of 27% among the patients. The

mortality rate will rise in the group with ulcerations and gangrene than in the group

with only rest pain. And when groups of diabetic and non-diabetic patients were

compared, it was found that 90% of the diabetic group presented with symptoms of

ulcerations and gangrene compared with 73% of non-diabetic group. And the diabetic

group will be treated by major amputation more than the non-diabetic group, which is

in similarity with the study of Mutirangura, et al. (2006) wherein it was found that

31.88% of the patients required major amputation due to limb ischemia and infections,

thus preventing them from being able to keep their legs. Of the total number of

patients coming to receive treatment, there was a mortality rate of 11.3%. The

common causes of death were sepsis and ischemic heart disease.

Additionally, some studies were found that patients who came to see

doctors at the stage II (Fontaine’s stages classification); intermittent claudication,

have amputation rates within the period of 5 years of only less than 1-2% (Dormandy

& Rutherford, 2000; Norgren, et al., 2007). Approximately 1 in 4 of these patients

with stage II will suffer leg pain. The symptoms will increase 7-9% within the first

year from symptom onset and these symptoms will increase at 2-3% in the next year

(Schmieder & Comerota, 2001).Treatment of patients with stage II can be done by

providing anticoagulants and supervised exercise therapy in order to increase blood

circulation to supply the leg area. Ten to twenty percent of patients require procedures

or revascularization (Dormandy & Rutherford, 2000) and 1-4% will require

amputation (Belch, Topol, Agnelli, Bertrand, Califf, et al., 2003; Schmieder &

Comerota, 2001).

The aforementioned data indicates that most of the patients with PAOD

who came to the hospital did so when the disease severity level was the stage IV

(ischemia ulcer and gangrene), which caused patients to receive late diagnosis and

initiation of treatment. Even in developed countries, such as the United States, it has

been found that this problem occurs in the group of PAOD patients (Hirsch, Gloviczki,

Drooz, Lovell, & Creager, 2004). The effects of late diagnosis and initiation of

treatment generally indicate that patients will limb loss and high mortality rates from

disease severity.



2. The first diagnosis time in PAOD patients

The duration from patients perceived that symptoms have occurred until

the time that receives diagnostic is significant toward the success of treatment in

patients with any disease; if this duration is short, the disease will progress less than

when patients extend the time period. When a long period has elapsed, diseases or

various conditions of illnesses will have increased severity and treatments when the

disease is severe require complex nursing care, treatments, and specialized, wherein

treatment outcomes may be less successful than for treatments beginning during a

period when the disease is not yet severe.

According to the literature review, it was found that various diseases, both

cardio vascular diseases or not, require a minimal amount of time for bringing patients

to receive appropriate treatment in order to yield good results. For example, in the

group of cardiovascular patient, there have been studies on the time period since

symptoms onset until the patients received treatment with impact on the success of

treatments and it has been found that mortality rates for patients with conditions of

acute myocardial infarction will be reduced by 50% if patients receive treatment with

anticoagulants within 1 hour since symptoms onset (National Heart Attack Alert,

Program Coordination Committee, 60 Minutes to Treatment Working Group, 1994).

Notwithstanding, the duration from the time when patients perceive

symptoms until they receive appropriate healthcare services is significant toward

treatment outcomes, and it was found in the literature review that treatment outcomes

were not as successful as they should have been in the group of PAOD patients who

received treatment when symptoms were severe as patients had complications,

disabilities and a high mortality rates due to disease severity (Bailey, Saha, Magee, &

Galland, 2003; Bonham & Kelechi, 2008), but no studies were found on the duration

of patients’ visiting in healthcare service or the duration before diagnostic were

received in this group of patients. Furthermore, no criteria was found for determining

the duration considered late treatment in this group of patients. The only studies found

was that of Bailey, Saha, Magee, & Galland (2003) in England, who studied a group

of 134 PAOD patients with CLI and found that the median duration of symptoms

before presentation of these patients was 8 weeks (range 2 weeks – 1.5 years).

Furthermore, 68% of the referrals of patients from general practitioners (GP) to



vascular surgeon were not urgent referrals while 24% were urgent. The median length

of wait for an outpatient appointment of these patients was 25 days (range 1-100

days). Only 30% of the patients were able to see specialist within 2 weeks of referral.

When compared with urgent referrals, patients will require 7-18 days less time in

waiting to meet a specialist, which also means that these patients will receive

treatment earlier.

When the treatment outcomes of patients at various levels of disease

severity were considered according to Fontaine’s stages classification, it was found

that the treatments were more successful and required fewer resources for treatments

with low disability rates if patients came to receive treatment at stage II; which is

when patients became aware of intermittent claudication, (Dormandy & Rutherford,

2000; Norgren, et al., 2007) because there is only partial occlusion at this stage and

the occlusion of the vessels of the periphery of the legs is still not complete. When

patients receive treatment by supervise exercise therapy to increase blood circulation

to the peripheral organs and take medication, the blood circulation to that area of the

peripheral organs will be sufficient without requiring revascularization procedures

(Mutirangura, 2002).

In cases where patients come to receive treatment when they have critical

limb ischemia (stage III and stage IV) with presenting symptoms of rest pain,

ischemic ulcer or gangrene due to ischemia, treatments will have little success with

more complications, greater chance of disability and higher mortality rates (Bailey,

Saha, Magee, & Galland, 2003; Bonham & Kelechi, 2008) because the peripheral

arteries have more complete occlusion according to the time period elapsing until

patients lose blood circulation in peripheral. Therefore, there is a chance that doctors

will be unable to achieved limb salvage by revascularization procedures and it may

become necessary to amputate the organs with no blood circulation, which will lead to

disability and possible mortality from potential complications (Bailey, Saha, Magee, &

Galland, 2003).

Although there are no specified duration of disease progression from one

stage to subsequent and more severe stages in the group of PAOD patients, but the

literature review found that better outcomes could be yielded if patients received

appropriate treatment as quickly as possible after the onset of symptoms than allowing



a delay after the onset of the symptoms without receiving appropriate treatment.

Therefore, the researcher was interested in studying in the topic of the duration in

visiting to healthcare service and the duration that receive diagnostic of PAOD

patients by implementing the conceptual framework of Cognitive Model of Delay in

Seeking Health Care (Noureddine, et al., 2006), which was developed from The

commonsense model of illness representation (Diefenbach & Leventhal, 1996), a

conceptual framework explaining the coping strategies of individuals when illness

occurs that was developed for use in research in the group of cardio vascular patients

to find predictive factors of delay in seeking health care. The commonsense model of

illness representation explains that people evaluate the presenting symptoms

connected to existing diseases or illnesses when they feel threatened, which refers to

the symptoms that occur. The coping process consists of cognitive response and

affective response, which occur together. And factors with impact on coping are

factors in the social-cultural, mental and clinical characteristic areas, which lead to

behaviors or activities performed by the patients. This conceptual framework is

illustrated in the diagram below:

Cognitive Model of Delay in Seeking Health Care (Noureddine, et al., 2006)

Nature of

symptoms

Cognitive response

Demographics

Symptom context

Response of others

Clinical history

Affective response

Delay time Behavioral

response:

Action taken



3. Factors related to PAOD patients’ visiting health care service lead to

diagnostic

3.1 Knowledge or information about PAOD

Information about the disease is an important factor in the healthcare

services received by patients. If patients and public with normal health perceive

correct information regarding PAOD, their decisions about receiving healthcare

services in an appropriate time will be affected. According to the literature review, it

was found that people public and patients who lack information about PAOD included

general information regarding PAOD, such as the name of the disease , the conditions

and the presenting symptoms of the disease . In a group of 1,048 people aged 18 years

an over with normal health, 15% had heard of “Peripheral Arterial Occlusive Disease”,

5% knew the words “intermittent claudication” and the majority (61%) understood

that PAD is a rather severe disease. A minority (5%) understood that PAOD is a very

severe disease.

As for another group of 219 PAOD patients aged 35 years and over, it was

found that 21% perceived PAOD as an arterial disease , 25% understood that PAOD is

a disease involving the arteries and veins, 11% understood that PAOD is a disease

involving the veins and 43% did not perceive PAD as occurring in the arteries or veins

(Willigendael, et al., 2004). Furthermore, in a group of regular patients with

intermittent claudication, 44% of these patients did not know they were affected by

PAOD (Brevetti, Oliva, Silvestro, Scopacasa, & Chiariello, 2004).

In addition to general information, specific information about the risk

factors of the disease is considered important and it has been found that people with

regular health continue to lack information on the risk factors of PAOD, as they fail to

perceive the resulting disease severity when left untreated. As for knowledge about

the risk factors associated with atherosclerosis, it was found in a group of 2,501

public population, > 50 years of age in U.S. that there was poorly imformed about the

disease or risk factors associated with PAD as compared to stroke and coronary artery

disease (CAD), this population reported a relatively high awareness of both stroke

(73.9%) and CAD (67.1%) while 25% were reported an awareness of PAOD even

though the three diseases share common risk factors. (Sieggreen, 2006) Forty four

percent of the respondents did not know that smoking, and fifty percent did not know



diabetes were significant cause of the disease. More than half of the respondents were

not aware that high blood cholesterol and high blood pressure serve as PAOD risk

factors. Another finding was that knowledge about risk factors tends to be lowest

among those who were older, male, and had lower education or income level, 14% of

the sample group perceived that PAOD may lead to loss of legs and potential mortality

(Hirsch, et al., 2007).

When knowledge on peripheral arterial occlusive disease and risk factors

of the disease was evaluated in female patients with normal health aged 40-85 years

who came to receive services at out-patient departments in tertiary hospitals by using

questionnaires, it was found that 46.9% had knowledge about PAOD at a high level,

but 53.6% had knowledge about the risk factors at a low level and more than 68% had

never discussed PAOD or risk reduction with their physician. (Bush, Kallen, Liles,

Bates, & Petersen, 2008)

In present study, the knowledge of patients was evaluated by using the

questionnaire on knowledge about PAOD, a questionnaire developed by the researcher

by reviewing documents and literature on PAOD (Willigendael, et al., 2004; Hirsch, et

al., 2007; Bush, Kallen, Liles, Bates, & Petersen, 2008) and consisting of questions

regarding common knowledge, risk factors, presenting symptoms, treatment and

severity of peripheral arterial occlusive disease.

3.2 Reasons for not visiting a health care service

The reasons for not visiting a health care service when the symptoms

occurred is a factor that affect to the first visit time in health care service. These

reasons result from coping process of individual that comprise of both cognitive

process and emotional process to appraise and assign meaning to those illness

representation then cognitive-affective response consequent. Afterward the person will

have visited in health care service that one of the action taken to response their

symptoms. (Diefenbach, & Leventhal, 1996; Noureddine, et al., 2006) From previous

study in CAD patients found that the reasons for not visit in health care service of

participants were waiting for symptoms to go away (70.9%), not realizing their

importance (52.2%), the symptoms came and went (47.8%) and this study revealed

that longer delays in seeking healthcare related to intermittent symptoms and waiting



for symptoms to go away. (Noureddine, et al., 2006) From the aforementioned, coping

process is direct affect to the time elapse before the visiting health care service,

therefore this factor is affect to the first visit time in health care service lead to receive

diagnostic of PAOD.

In present study, the researcher evaluated the reasons for not visiting a

health care service by using the interview form of reasons for not visiting a health care

service, which developed by the researcher by partially modifying The Modified

Response to Symptoms Questionnaire developed by Dracup & Moser (1997) and used

to study the time elapsed before cardiovascular disease patients receive treatment.

Afterwards, this instrument was widely used in cardiovascular patients (Dracup, &

Moser, 1997; Noureddine, et al., 2006).

3.3 Personal Factors: Age

Age may be a factor affecting patients in visiting a health care services.

From the literature review, it was found that PAOD is mostly found in elderly and the

incidence continues to increase in population groups with increasing age and the

prevalence of the disease was found to be 4.3% in people aged over 40 years and

increased to 13% in people aged over 65 years (Newman, et al., 1999). In Japan, the

prevalence of PAOD in diabetic patients has been found at 7.6% and people aged over

65 years at 12.7%, while people aged less than 65 years have only 4%. (Maeda, et al.,

2008).

As for in the United States, the prevalence of PAOD in people aged 40

years and over was 4.3% (95% CI 3.1% - 5.5%), comprising approximately 5 million

patients (95% CI 4 to 7 million). As for people aged 70 years and over , the prevalence

of peripheral arterial occlusive disease was found to 14.5% (95% CI 10.8%-18.2%)

and there are approximately 4 million patients in this group (95% CI 3 to 5 million)

(Selvin & Erlinger, 2004). In Thailand, studies found that 414 hospitalization PAOD

patients have a mean of age 66.9% years (Mutirangura, et al., 2006). This could be

explained in that the inner arterial walls of senior adults will deteriorate and the tunica

intima; which is the innermost the wall will thicken due to increased connective

tissues and collection of smooth muscle cell. In addition to narrowing the arteries,

these factors also obstruct the absorption of nutrients from the area of the inner arterial



walls. Furthermore, there are also calcifications, causing the arteries to lose flexibility

(Lungstrom & Emerson, 2005; Sydenham & Medic, 2004).

Moreover, there have also been studies in groups of PAOD which found

that the level of knowledge regarding the disease both in terms of risk factors and

disease symptoms will reduce in groups of more elderly patients (Hirsch, et al., 2007).

Therefore, it may be possible that age also affects patients in visiting to healthcare

services.

Other findings show that PAOD will be encountered more often in males

than females (Cimminiello, 2002; Mutirangura, et al., 2006), because males have

greater risk for atherosclerosis than females, which could be explained in that males

have higher LDL levels in the blood and low HDL levels as compared to females,

because females have estrogen, which helps raise HDL levels while decreasing LDL

levels. As previously mentioned, LDL has a direct effect on the occurrence of

atherosclerosis. As a result of this factor, males will have greater risk for

atherosclerosis than females. Following menopause, however, females will lose

estrogen hormones and the occurrence of atherosclerosis will begin quickly and at no

different rate than males of the same age. In this study, the relationship between

gender and time elapsed before receiving treatment will not be studied.

3.4 Social factors: Response of others

The responses of others are another factor supporting patients in visiting to

healthcare service lead to receive the diagnostic and the appropriate treatment for

symptoms and disease severity. Some study found that 80% of 99 PAOD patients aged

less than 65 years with family members, friends or close individuals who provided

support at a high level will receive revascularization procedures after receiving

diagnosis, which can be considered as proper treatment. On the other hand, 45% of

patients with family members, friends or close individuals who provide support at a

low level will receive revascularization procedures (Aquarius, Denollet, Hamming, &

Vries, 2006). And this behavior of not receiving proper following diagnosis will

increase disease severity.

Furthermore, there was a study on socioeconomic factors with relationship

to the severity of PAOD that examined 691,833 patients who received treatment in the



hospital and were diagnosed with limb ischemia or gangrene by considering the

disease severity for received treatments; revascularization and leg amputation. These

findings show the rate of treatment by leg amputation to be higher in nonwhites

groups of people (1.91, 95% CI; 1.65, 2.20) in the low-income bracket (1.41, 95% CI,

1.18, 1.60) on Medicare & Medicaid (1.81, 95% CI, 1.66, 1.97) (Eslami, Zayaruzny, &

Fitzgerald, 2007).

In this study, the researcher evaluated the responses of others by using the

interview form of response of others to the symptoms of patients, which developed by

the researcher by partially modifying the Response to Symptoms Questionnaire

instrument developed by Burnett, Blumenthal, Mark, Leimberger, & Califf (1995) and

used to study the time elapsed before cardiovascular disease patients receive treatment.

Afterwards, this instrument was widely used in cardiovascular patients (Dracup, &

Moser, 1997; Noureddine, et al., 2006).

4. Summary

The first visit and first diagnosis time is extremely important toward the

success of treatment outcome in PAOD patients because prompt or delayed time

periods in visiting a health care service are related to the level of disease severity; if

patients receive treatment quickly, the severity level will be minimal. If the time

period is extended, the severity level or the symptoms of the disease will be more

severe as time passes. When symptoms are severe, medical treatment may be less

successful, because treatments increase in complexity according to the severity of the

symptoms. In addition to factors of patients in visiting to a health care services, factors

concerned with the health care service system also play a part in patients receiving

correct diagnosis and proper treatments for their disease, which will further impact

treatment success.

According to the literature review, no studies were found on topics

associated with the duration before PAOD patients in Thailand come to receive

healthcare services. Therefore, the researcher was interested in studying the

aforementioned issue with the expectation that the research findings will be feasible

for implementation as basic information in spreading knowledge for patients at risk for

the disease to receive treatment within an appropriate amount of time and the acquired



research findings will be useful as a database in developing the healthcare system so

PAOD patients will have earlier access to healthcare services.


Siriphorn Sawangphong Methodology / 42

CHAPTER III

METHODOLOGY

Research Design

This research was a descriptive study designed with the aim of study for

explained the associate between reasons for not visit in healthcare service, knowledge

of disease, age and response of others with duration from symptoms onset to

diagnosis in patients with peripheral arterial occlusive disease. The methodology in

this study was as follows:

Population

The population of the study comprised both male and female patients with

PAOD that received the diagnostic from their physician and visiting to the Vascular

surgery outpatient department or the Vascular surgery laboratory, Siriraj Hospital.

Sample

The sample of the study comprised both male and female patients with

PAOD that received the diagnostic from their physician and visiting to the Vascular

surgery outpatient department or the Vascular surgery laboratory, Siriraj Hospital.

Inclusion criteria

1. Symptomatic PAOD

2. Able to communicate by writing or speaking

Exclusion criteria

1. Acute peripheral arterial occlusive disease patients

2. PAOD patients who arterial occlusion from others causes include

embolism, inflammation or traumatic vascular



3. Dementia patients

Sample size

To estimate the sample size for this study, guidelines suggested by Power

Analysis (Polit, & Beck, 2008: p 605). Given a conventional level of power of test

0.80, the alpha level of significance for two-tailed hypothesis test 0.05 and a medium

effect size of 0.30, a sample size of 88 was necessary. Ninety participants were

approached to participate in this study.

Setting

1. The outpatient vascular clinic of Siriraj Hospital, 3rd floor of Outpatient

Building comprise of two clinics as follow:

A) The vascular clinic during business hour; this is open every

Friday from 8:00 a.m. to 4:00 p.m. and treats approximately 25 PAOD patients per

week. These patients included the follow up case, the new case of PAOD that may

visit by themselves, referral by other division, or referral by other healthcare service

setting.

B) The special vascular clinic, providing services outside of business

hours; open every Tuesday and Friday from 4:00 p.m. – 8:00 p.m. approximately 20

PAOD patients per week. These patients included the follow up case, the new case of

PAOD that may visit by themselves, referral by other division

2. The vascular surgery laboratory, first floor of Siamintra Building, Siriraj

Hospital is open Monday – Friday from 8:00 a.m. to 4:00 p.m. approximately 20

PAOD patients per week who receive the specific evaluation of peripheral vascular.

All of these patients were both in-patients and out-patients who had the appointment

from their vascular surgeon.



Instruments

The instruments in this study for data collection consist of 7 parts:

Part 1 The demographic characteristic questionnaire was developed by the

researcher. The questionnaire had 9 items and it was composed of the data of age,

gender, current province, marital status, education, occupation, income and source of

medical expense.

Part 2 Health and comorbidity record form comprised the data of

diagnosis, smoking history, and comorbid as evaluated by Charlson’s Co-morbidity

Index developed by Charlson, Pompei, Ales, & Mackenzie (1987) and use for

evaluate medical comorbidity in cardiology patients and other chronic illness patients.

The score is calculated for nineteen domains, and scores for each domain can range

from 0 (no risk factors) to 6 (severe risk factors). The condition to weighting the

comorbid as follow:

weight = 1 included Myocardial infarction, Congestive heart failure,

Peripheral vascular disease, Cerebro vascular accident, Dementia, Chronic pulmonary

disease, Connective tissue disease, Gastrointestinal ulcer disease, Mild liver disease,

and Diabetes mellitus.

weight = 2 included Hemiplegia, Moderate or severe renal disease,

Diabetes with end-organ damage, Any tumor, Leukemia, and Lymphoma.

weight = 3 included only moderate or severe liver disease.

weight = 6 included Autoimmune deficiency syndrome (AIDS) and

Metastatic solid tumor.

In present study the researcher got permission to use this instrument from

the owner of copyright. (Appendix D)

Part 3 The symptoms interview form was developed by the researcher.

This instruments comprise of the onset symptoms and chief complain as evaluated by

interview the participants.



Part 4 The sequence of visiting health care services interview form was

developed by the researcher comprise of the data of the healthcare service setting that

participants visited and the duration from their symptom onset to receive the

healthcare service in each setting.

Part 5 Reasons for not visiting a health care service interview form

developed by the researcher by partially modifying The Modified Response to

Symptoms Questionnaire developed by Dracup & Moser (1997). Then the researcher

translate to Thai and back translate to English by one expert in bilingualism. This

instrument comprise of 8 reasons that shown the reasons of participants for not visit in

the healthcare service setting immediately their symptoms was presented. The answers

consist in 2 choices as “yes” and “no”;

yes (1 score) mean that reason affected to non first visit

no (0 score) mean that reason did not affected to non first visit.

This instrument was evaluated by each item not by a total score that

comprise of 3 domains as follow:

1) The emotional related reasons for did not visiting a health care service

comprise of item 1, 2, 3, and 6.

2) The cognitive related reasons for did not visiting a health care service

comprise of item 5, 7, and 8.

3) The symptom related reasons for did not visiting a health care service is

item 4.

If the participants had at least one item in each domains interpret as they

have that factors.

Part 6 Knowledge about PAOD interview form as developed by the

researcher from reviews of related documents and literature (Bush, Kallen, Liles,

Bates, & Petersen, 2008; Hirsch, et al., 2007; Willigendael, et al., 2004) consisting of

general knowledge, presenting symptoms, treatment and severity about PAOD that

comprise of 18 items as follow:

1) The general knowledge comprise of general knowledge of PAOD and

risk factor of disease: item 1-9



2) The knowledge related to patient’s experience comprise of knowledge

about symptoms, treatment and severity of disease: item 9 - 18

The answers consist of 3 choices that “yes” “no” “not sure” the score

between 0 – 18 scores (18 means the high level of PAOD)

“yes” 1 score

“no” / “not sure” 0 score

Part 7 Response of others interview form developed by the researcher by

partially modifying the modified Response to Symptoms Questionnaire instrument

developed by Dracup & Moser (1997). This instrument comprise of 10 items that

shown the response of others individual. The answer consist in 2 choices as “yes” and

“no” and this instrument was evaluated by each item not by a total score that

comprise of 3 sections as follow:

“yes” (1 score) mean the patient received that response from other person

“no” (0 score) mean the patient don’t received that response from other

person

This instrument is divide in two groups as follows:

1) Response of others did not induce first visit comprise of item 1 – 8.

2) Response of others induce first visit comprise of item 9 – 10.

If patient not told to someone about their symptoms = 0 score in all items.

If the participants had at least one item in each domains interpret as they

have that factors.

In part of the instrument that the researcher developed by partially

modified from the Response to Symptoms Questionnaire (part 4 and part 6), the

researcher got permission to use these instrument already. (Appendix D)

Instrument quality testing

Translate-back translate

In current study, the translate-back translate was utilize for the

Reasons for not visit in healthcare service interview form, by the researcher translate

to Thai and then the thesis advisor was examined. Afterward the back translation to



English was done by one expert in bilingualism. Then the back translation was sent

back to the owner to compared with the original version.

Validity

In this study, content validity of the instruments were confirmed as follow:

As for content validity, Knowledge About PAOD interview form, Reason for not

Visiting a Health Care Service interview form, and Response of Others interview form

were validated by five experts consisting of two vascular physician instructors, two

nurse specialist in care of peripheral vascular patients, and one nursing instructor

(Appendix A).The content validity index (CVI) of these instruments were 0.8, 0.8 and

0.9 respectively. The instruments were the revised and rewritten according to the

comments and suggestions of these experts to ensure clarity and comprehensiveness of

the content.

Reliability

The reliability of the Knowledge About PAOD was checked by assessing

30 patients with PAOD, who had the same characteristics as the eligible population.

The Kuder – Richarson; KR-20 was used to test reliability and was found to be 0.87.

Objectivity

The objectivity was conducted to the Reason for not Visiting a Health Care

service interview form, and the Response of Others interview form by assessing 30

patients with PAOD who had the same characteristics as the eligible population. It was

found that all of patients were understandable the meaning of questions correctly.

Data Collection

The researcher collected the data by herself following these procedures;

1.The researcher sent an introduction letter issued by The Graduate school,

Mahidol University to the Director and the committee of Siriraj Institutional Review

Board (SIRB), and requested permission to conduct data collection at the Surgery

Outpatient Department, Siriraj hospital and requesting Outpatient history record from

the Director of Siriraj Hospital.

2. After receiving the permission, the researcher met the head of Division

of Vascular Surgery, and head nurse of Outpatient department to introduce herself,

explain the details of study, and ask for corporation in data collection.



3. Data collection was conducted as the following procedure;

3.1 Reviewing the PAOD patients who visited in the Vascular clinic at the

out-patient department and the Vascular laboratory according to inclusion criteria and

recruited patients to the study.

3.2 The researcher introduced herself and built relationships with the

samples, advising them of the objectives of the research and asking for compliance

with participation in the research while patients were waiting outside the examination

room or completely to see their physician. However, the research was realized the

patients’ rights at all times.

3.3 The researcher distributed the research instruments after the

participants signed the consent form and started the interview in the following order:

1) The demographic data interview form

2) The health and comorbidity record

3) The symptom characteristic interview form

4) The sequence of visiting health care services interview form

5) The reasons for not visiting a health care service interview

form

6) The knowledge about PAOD interview form

7) The response of others interview form



Table 3 Summery of procedures

No. Instruments Activities included Time required

1 The demographic data interview form Interview the participants 3 mins

2 The health and comorbidity record Interview the participants and

collected data from the

patients’ medical record

3 mins

3 The symptoms characteristic

interview form

Interview the participants 5 mins

4 The sequence of visiting health care

services interview form

Interview the participants and

collected data from the

patients’ medical record

30 mins

5 The reasons for not visiting a health

care service interview form


6 The knowledge about PAOD

interview form


7 The response of others interview form Interview the participants 5 mins

3.4 At the close of the interview, the researcher allowed time for any

inquiry made by the participants and corrected of any incomplete items. This process

took approximately 60 minutes each with the data collecting steps as shown in the

following table 3.

4. The researcher submitted the data collected from the questionnaires to

statistical analysis.

Protection of human rights of the subjects

The researcher requested permission to conduct research in human

subjects from Siriraj Institutional Review Board (SIRB) (Appendix B). Once the

permission was granted, the researcher introduced herself to the samples, advised them

of the objective of the research, procedures, and timing in data collection and

eventually asked the patients for participation in the study. The protection of human

subjects was concerned with 3 aspects as follows:

1. Benefit from research; the results of the research will be beneficial for

PAOD patients from an overall point of view that the healthcare professional will able

to utilize the findings as fundamental data in educating patients at risk for the disease



to receive treatment within an appropriate amount of time. Moreover, the healthcare

professional will have the ability to implement research findings as a database in

improving the healthcare system, so PAOD patients will be able to increase access the

health care system.

2. Risk from research; this data collection was collected by interview to

participants and investigated from the medical record of participants, so no physical

risk or side effect arose out of the research. However, the participants had to take

approximately 60 minutes in responding to the questionnaire and some questions may

have irritated feelings and emotions of them so they were able to deny answering the

questions in the questionnaire or quit answering anytime they wished with no effects

whatsoever on their treatment or care provided by the healthcare professional. The

data collection was carried out while patients were waiting outside the examination

room to see the physician; if the patients’queue was reached before the interview had

been complete, the patient went to see their physician and came back to continue. The

researcher did not interrupt any intervention done by the healthcare professionals.

This research was voluntary and no wage payment was made to samples

and no reimbursement of expenses incurred to patients. If any additional information

whether beneficial or problematical related to this research was acquired, the

researcher would have informed participants without delay or concealment.

3. Confidentiality of data; All data collected from samples were stored

separately and number in place of name identified the data, and only the researcher

was able to access the computer database by using password. Research results, which

may be published in related journals or presented in related seminars, will be treated in

overall as general data without any personal data. When all samples were informed of

the objectives of research and other relevant issues, they signed the consent form for

research participation.



Data Analysis

The computer program was used in the analysis, which was conducted in

the following sequence:

1. Demographic data include gender, age, current address, living

environment, marital status, education, occupation, income and source of medical

expense were analyzed by using frequencies and percentage.

2. Health and comorbidities were analyzed by using frequencies and

percentage.

3. The first visit and first diagnosis time were analyzed by using

frequencies, percentage, median, mode and range.

4. Knowledge about PAOD, the reasons for not visiting a health care

service, the response of others were analyzed by using frequencies and percentage.

5. Spearman rank-order correlation coefficient was employed to analyze

the relationships between Knowledge about PAOD, the reasons for not visiting a

health care service, the response of others and the first diagnosis time.

The researcher checked the data were met the assumption of Spearman

rank-order correlation coefficient as follow (Munro,2005; Srisathitnarakul, 2004):

5.1 Both independent and dependent variables were ordinal scale

5.2 Both independent and dependent variables were non inear

relationship

5.3 The variables unnecessary have a normal distribution.

In this study, the first diagnosis time was positive skewness and age was

negative skewness (Appendix F) so the researcher ranked all variables in ordinal scale

and then analyzed by Spearman rank-order correlation coefficient in the statistical

computer program


Siriphorn Sawangphong Results / 52

CHAPTER IV

RESULTS

The purpose of this study was to examine the factors associated with the

duration from symptom onset to diagnosis in patients with PAOD. The participants of

this study were PAOD patients who visit to the Vascular surgery outpatient

department and at the Vascular surgery laboratory, Siriraj Hospital. One-hundred

patients who met the inclusion criteria were approached. Ten patients were excluded

from the study due to disable to communicate by writing or speaking (3 patients) and

asymptomatic PAOD (7 patients) so, the participants remained in this study was 90

patients.

In this chapter, the results were presented in 7 sections as follow :

Section 1 : General characteristic and the illness of the participants

Section 2 : The symptoms of the participants

Section 3 : The first visit and the first diagnosis time of the participants

Section 4 : Reasons for not visiting a health care service of the participants

Section 5 : Knowledge about PAOD of the participants

Section 6 : Response of others of the participants

Section 7: The association of variables with the first diagnosis time


Fac. of Grad. Studies, Mahidol Univ.

M.N.S. (Adult Nursing) / 53

Section 1 General characteristic and the illness of the participants

1.1 in PAOD patients.

Table 4 Frequency and percentage of PAOD patients classified by demographic

characteristics (n = 90)

Characteristics Frequency Percentage (%)

Gender

Male 58 64.4

Female 32 35.6

Age

36 – 65 years (Adult) 25 27.8

65 – 74 years (Young old) 34 37.8

75 – 84 years (Middle old) 24 26.7

> 85 years (Oldest old) 7 7.7

Mean = 68.68, S.D. = 11.31, Range = 36 – 90 years

Current address

Bangkok / perimeter 52 57.8

Middle 16 17.8

East 7 7.8

Northeast 3 3.3

West 8 8.9

South 4 4.4

Living environment

Urban 63 70.0

Rural 27 30.0

Marital status

Single 3 3.3

Married 61 67.8

Widow 21 23.3

Separate 5 5.6




characteristics (n = 90) (Continued)


Level of Education

No schooling 7 7.8

Elementary 47 52.2

Secondary 18 20.0

Diploma or equivalent 7 7.8

Bachelor 11 12.2

Occupation

No occupation 55 61.1

Retirement 15 16.7

Agriculture 1 1.1

Employee 6 6.7

Officer 2 2.2

Government officer 4 4.4

Business owner 1 1.1

Trade 5 5.6

Priest 1 1.1

Income per month

None 54 60.0

< 5,000 6 6.7

5,000 -10,000 10 11.0

10,001-20,000 9 10.0

20,001-30,000 6 6.7

> 30,000 5 5.6





characteristics (n = 90) (Continued)


Income and enough for use

Not enough 2 2.2

Enough but not to save 80 88.9

Enough and to save 8 8.9

Source of medical expense

Reimbursement 57 63.3

Universal coverage 20 22.2

Self payment 11 12.2

Social security 2 2.2

As shown in Table 4, the majority of the patients were males (64.4%).

Ages ranged between 36 – 90 years, with the mean age of 68.68 years (S.D. = 11.31),

the majority of age were aged > 65 years (72.2%). The majority of participants lived

in Bangkok or perimeter (57.8%) and in the urban (70%). Sixty seven percent of

patients had married status, most of them had elementay level of education (52.2%).

Most of the patients were no occupation (61.1%) and did not have their own income

(60%), 88.9% of the participants reported that the income enough to use but not to

save, the main source of medical expense payment of samples was reimbursement

(63.3%).



1.2 Health and comorbidities of PAOD patients

1.2.1 The diagnostic classified by sites of arterial occlusion

Table 5 Frequency and percentage of sites of arterial occlusion in PAOD patients

(n = 90)

Sites of arterial occlusion Frequency Percentage

Femoropopliteal 41 45.6

Tibioperoneal 31 34.4

Aortoiliac 9 10.0

Iliofemoral 6 6.7

Aortofemoral 1 1.1

Iliofemoral+Femoropopliteal 1 1.1

Popliteal 1 1.1

total 90 100.0

As shown in table 5, sites of arterial occlusion in PAOD patients; the result

revealed that most of participants were femoropopliteal artery occlusion (45.6%),

following by tibio-peroneal artery (34.4%).




1.2.2 Smoking history of PAOD patients

Table 6 Frequency and percentage of PAOD patients classified by smoking history

(n=90)

Smoking history Frequency Percentage Range Mean (S.D.)

Never smoking 38 42.2 - -

Former smoking 43 47.8 - -

Time to quit smoking (years) - - .08-48 9.41

(11.49)

Number of smoking per day - - 6-60 22.00 (12.41)

Current smoking 9 10.0

Number of smoking per day

(current) - - 2-20

8.22 (5.40)

Table 6 shown the smoking history of participants, the data indicated that

47.8% was former smoking as the mean of time that they had quitted smoking was

9.41 years (S.D. = 11.49) and the mean of cigarette that ever smoked was 22 per day

(S.D. = 12.41). Only ten percent of participants were the current smoking, an average

smoking amount of 8.22 cigarettes/day (S.D. = 5.40).



1.2.3 The comorbidity of PAOD patients

Table 7 Frequency and percentage of Charlson Comorbidity Index (CCI) of PAOD

patients (n = 90)

Condition* Frequency Percentage (%)

Hypertension** 75 83.3

Diabetes mellitus 59 65.6

Dyslipidemia** 46 51.1

Myocardial infarction 26 28.9

Cerebro vascular accident 11 12.2

Hemiplegia 3 3.3

Chronic pulmonary disease 2 2.2

Connective tissue disease 1 1.1

Moderate or severe renal disease 1 1.1

Diabetes with end-organ damage*** 1 1.1

summary of the number of comorbidity

none comorbidity 7 7.8

one comorbidity 9 10.0

two comorbidities 28 31.1

three comorbidities 29 32.2

four comorbidities 15 16.7

five comorbidities 2 2.2

CCI : Mean = 2.21, S.D. = 0. 83, Range = 1 – 4

* one patient reported more than one answer

** the additional from CCI

*** patient with retinopathy, neuropathy or nephropathy




Table 7 shown the evaluation of participants’ comorbidity by the Charlson

Comorbidity Index (CCI) found that the mean score was 2.21 (S.D. = 0.83), range

between 1- 4 scores. The result revealed that the most of comorbidity were

Hypertension (HT), Diabetes mellitus (DM) and Dyslipidemia (DLP) (83.3%, 65.6%

and 51.1%). Furthermore, ninety percents of participant were HT or DM, sixty

percents were both HT and DM. Only 7.8% were none comorbidity patients, most

of the participants had three comorbidities (32.2%), forty percent of participants had

coronary artery disease or cerebrovascular disease and 4.4% had coronary artery with

cerebrovascular disease.



Section 2 The symptoms of the participants 2.1 The perceived onset symptom of the participants

Table 8 Frequency and percentage of perceived onset symptom (n = 90)

Symptoms* Frequency Percentage

Intermittent claudication (IC) 39 43.3

sites of IC (n = 39)

both legs 11 28.2

both calves 9 23.1

single calf 9 23.1

single leg 7 17.9

single thigh 2 5.1

both thighs 1 2.6

Rest pain 9 10.0

sites of rest pain (n = 9)

feet 5

both legs 1

single leg 1

below knees 1

toes 1

pain score of the rest pain Mean = 9.44, S.D. = 1.67, Range = 5 - 10

Ulceration 32 35.6

sites of ulcer (n =32)

toes 23 71.9

top of feet 5 15.6

malleolus 2 6.3

heels 1 3.1

sole of feet 1 3.1

other perceived onset symptoms

Paresthesia 16 17.8

Poikilothermia 6 6.7

Blebs 4 4.4

Swelling 3 3.3

Localized cyanosis 2 2.2

Pallor 1 1.1

Gangrene 1 1.1

* One patient have at least one symptom




As shown in table 8, the perceive onset symptom of PAOD patients, it was

found that the most of participants perceived intermittent claudication as the onset

(43.3%); of this number most site of the IC was both legs (28%). The following onset

symptom percept was ulceration (35.6%); of these was found that the most of

ulceration site was toes (71.9%). Only ten percent of participants perceived the rest

pain at the onset. Besides, the participants had the other perceive onset symptoms such

as paresthesia (17.8%), Poikilothermia (6.7%), etc.



2.2 The chief complaint of participants

Table 9 Frequency and percentage of chief complaint at the first visit in healthcare

service (n = 90)

Symptom* Frequency Percentage (%)

Intermittent claudication (IC) 27 30.0

sites of IC (n = 27)

both legs 8 29.6

both calves 6 22.2

single leg 5 18.5

single calf 5 18.5

single thigh 2 7.4

both thighs 1 3.7

Rest pain 13 14.4

sites of rest pain (n = 13)

feet 8

both legs 1

single leg 1

below both knees 1

below single knee 1

toes 1

pain score of the rest pain Mean = 9.77, S.D. = 0.60, Range = 8-10

Ulceration 47 52.2

sites of ulcer (n = 47)

toes 31 66.0

top of feet 8 17.0

malleolus 5 10.6

heels 3 6.4

other chief complain

Paresthesia 14 15.6

Poikilothermia 6 6.7

Localized cyanosis 5 5.6

Gangrene 5 5.6

Swelling 4 4.4

Blebs 3 3.3

* One patient have at least one symptom




As shown in table 9, the most chief complaint of participants was

ulceration (52.2) wherein the site of ulcers were most frequently encountered was the

toes (66%), follow by the chief complaint of IC (30%); of this number it was found

that the most site of IC was both legs 29.6%. As for the chief complaint of rest pain at

first visit, it was found that only that 14.4% of participants had experienced. Furthermore, there were other chief complaint that caused the participants visit to the

healthcare service facilities wherein the symptom most frequently encountered was

paresthesia (15.6%) follow by poikilothermia (6.7%).



Section 3 The first visit and first diagnosis time of the participants Table 10 Frequency and percentage of PAOD patients classified by the first visit and

first diagnosis time (n = 90)

Duration (days) Frequency Percentage

First visit time

< 30 days 35 38.9

31 – 59 days 17 18.9

60 – 89 days 4 4.4

> 90 days 34 37.8

Median = 30.00, Mode = 7, Range = 1-1825

First diagnosis time

< 30 days 16 17.8

31 – 59 days 17 18.9

60 – 89 days 10 11.1

> 90 days 47 52.2

Median = 90.00, Mode = 30, Range = 2-1825

As shown in Table 10, the median of first visit time was 30 days. The most

of participants had first visit time less than 30 days (38.9%) follow by, 90 days and

over (37.8%).

The median of first diagnosis time was 90 days. The most of participants

experienced was 90 days and over (52.2%) follow by, 31 – 59 days (18.9%).




Table 11 Frequency and percentage of PAOD patients classified by first visit setting,

diagnosis setting and first visit to diagnosis time (n =90)

First visit to diagnosis time

1 day 2 -14 days 15-29 days 30 - 89 days > 90 days First visit setting (n) %

n n n n n

University hospital (n = 31) 34.4

Diagnosis settting

University hospital (n = 31) 27 2 1 1 -

Private hospital (n = 14) 15.6

Diagnosis settting

University hospital (n = 9) - 2 1 4 2

Private hospital (n = 5) 1 - 1 2 1

Tertiary care (n = 5) 5.6

Diagnosis settting

University hospital (n = 1) - - - 1 -

Private hospital (n = 1) - - - 1 -

Tertiary care (n = 3) 3 - - - -

Secondary care (n = 20) 22.2

Diagnosis settting


Private hospital (n = 1) - - - 1 -

Tertiary care (n = 1) - - - 1 -

Secondary care (n = 3) 2 - - 1 -

Primary care (n = 20) 22.2

Diagnosis settting


Private hospital (n = 2) - 1 - 1 -

Tertiary care (n = 1) - 1 - - -

Secondary care (n = 3) - 1 - 2 -

Primary care (n = 1) 1 - - - -

Total 100.0 34

(37.8%)

12

(13.3%)

7

(7.8%)

24

(26.7%)

13

(14.4%)

Table 11 shown the number of participants classified by the first visit

health care setting, the diagnosis setting and the first visit to diagnosis time. The result

revealed that 34.4% of the samples received services for the first time at university

hospitals which was the only setting all patients who received diagnosed with PAOD.



Of this number the most of samples received diagnosis on the day services were

received (87.1%). Furthermore, it was found that half of the samples were first visiting

in other government setting which lower levels than university hospitals. The majority

of participants received diagnosis at university hospitals (69 of 90 patients; 76.7%);

more than half of these were patients referred by other health care setting (55.1%).




Section 4 Reasons for not visiting a health care service of the

participants The reasons for not visiting a health care service in this study were

comprise of 8 reasons and distribute to 3 domains as followed: 1) emotion related the

reasons, 2) cognitive related the reasons, and 3) symptom related the reason.

The result revealed that all of participants had at least one item of the

cognitive related the reasons and 53.3% of participants had the emotional related the

reasons at least one item. (Table A; Appendix E)

Table 12 : Frequency, percentage and the median of time of PAOD patients classified

by the items of reason for not visiting a health care service (n = 90)

Reasons* n % First visit time(days)

Mdn (range)

First diagnosis time (days)

Mdn (range)

Reasons in emotion Waiting to see symptoms go

away 21 23.3 30

(7-1825) 67

(10-1825)

Embarrassed to get help 10 11.1 22.5 (7-1050)

261.50 (11-1050)

Did not want to trouble anyone 34 37.8 30 (1-1050)

123.50 (21-1050)

Feared the consequences 8 8.9 30 (7-365)

63.50 (7-730)

Reasons in cognitive Did not recognize symptoms as

PAOD 88 97.8 30

(1-1825) 90

(2-1825)

Did not know the symptoms of

PAOD 88 97.8 30

(1-1825) 90

(2-1825)

Did not realize the importance of

symptoms 79 87.8 30

(1-1825) 90

(2-1825)

Reasons in symptoms

Symptoms came and went 28 31.1 120 (2-1050)

261.50 (2-1050)




As shown in Table 12, the participants who did not receive health care

services because symptoms were intermittent had the longest first visit time and first

diagnosis time (the median was 120 days and 261 days, respectively). The majority of

participants did not visiting a health care service immediately symptoms onset because

they were equally not recognize that the symptoms as PAOD symptoms as the reason

that they did not know with the symptoms of PAOD (97.8%). Follow by, the

participants had the reason with they did not realize the importance of those symptoms

(87.8%).




Section 5 Knowledge about PAOD of the participants Table 13 Frequency and Percentage of PAOD patients classified by Knowledge about

PAOD and time (n = 90)

As shown in Table 13, the level of knowledge about PAOD was analyzed,

it was found that the mean scores was 9.71 + 4.09 from a total possible score of 18

points. Fifty-one percent of the sample had higher than half of possible score regarding

PAOD. When considering in terms of area, it was found that 55.6% of the sample had

scores in the area of general knowledge and risk factors of PAOD at lower than half,

while 72.2% of patients had scores higher than half in the area of knowledge related to

patients’ experience.

Moreover, the majority (84.4%) of participants were aware that their

illness has association with cardiovascular disease while 33.3% were aware PAOD

concern the arteries, 46.7% were aware that DM contributes to PAOD and 38.9% were

aware that HT contributes to PAOD. As knowledge related to patients’ experience, 42.2% were aware that

intermittent claudication was the initial symptom of PAOD, 34.4% were aware that

rest pain was occurred when the disease became severely, and 62.2% were realize that

First visit time First diagnosis time

< 90 days > 90 days < 90 days > 90 days

Knowledge

scores

(total)

n %

n n n n

0-9 44 48.9 29 15 21 23

10-18 46 51.1 27 19 22 24

Total 90 100 56 (62.2%)

34

(37.8%) 43

(47.8%) 47

(52.2%)

Mean scores = 9.71 , S.D. = 4.09, Range = 2-18

Knowledge about general & risk factors of PAOD (9 items)

0 – 4 50 55.6 34 16 24 26

5 – 9 40 44.4 22 18 19 21

Knowledge related to patient’s experience (9 items)

0 – 4 25 27.8 18 7 13 12

5 – 9 65 72.2 38 27 30 35



ischemic ulceration was sign of critical limb ischemia. The majority (71.1%)

associated PAOD with a risk of amputation while less than half of participants

(47.8%) were aware that PAOD with a risk of death.




Section 6 Response of others of the participants

Regarding response of others to the participants’ symptoms, it was found

that the majority (63.3%) told someone about their symptoms that occurred while 60%

received at least one response that did not induce the first visit and most of them

(56.7%) received responses telling them to rest, followed by response that were

attempts to make patients more comfortable (23.3%) and 61.1% received at least one

response that induced the first visit. More than one third (37%) were escorted by

others to a health care service setting within 90 days or more after telling someone

about their symptoms, followed by another group of patients (33.3%) who were

brought to health care service setting less than 30 days after telling someone about

their symptoms. (Table 14)

Table 14 Frequency and percentage of PAOD patients classified by response of

others and time (n=90)


< 90 days > 90 days < 90 days > 90 days Condition (n = 90) n %

n n n n

Not telling anyone about

symptoms 33 36.7 20 13 15 18

Told someone about

symptoms 57 63.3 36 21 28 29

Response of others *

Response that did not

induce the first visit* 54 60 34 20 26 28

Response induce first

visit* 55 61.1 35 20 27 28

duration from telling

others to escort 1st visit

(n = 54)

< 30 days 18 33.3

30 – 59 days 13 24.1

60 – 89 days 3 5.6

> 90 days 20 37




Section 7 The association of variables with the first diagnosis time Spearman rank-order correlation coefficient was use for data analysis. The

result indicated that age was negative significantly associated with first diagnosis time

(ρ = - .251; p < .05), while duration from telling others to escort first visit was positive

significantly associated with first diagnosis time (ρ = .712; p < .01).

There was no statistical significance between knowledge about PAOD,

reasons for not visiting a health care service and the first diagnosis time (p > .05).

(Table 15)

Furthermore, the finding revealed that general knowledge of PAOD was a

negative relationship with age (ρ = -.406; p < .01), response of others induce first

visit was negative significantly associated with emotional related reasons for did not

visiting health care service (ρ = -.279; p < .01), response of others did not induce first

visit was negative significantly associated with emotional related reasons for did not

visiting health care service (ρ = -.271; p < .01) and positive significantly associated

with response of others induce first visit (ρ = .884; p < .01). Finally, duration from

telling others to escort first visit was positive significantly associated with symptom

related reasons for did not visiting health care service (ρ = .275; p < .05).


Fac. of Grad. studies, Mahidol Univ. M.N.S. (Adult Nursing) / 73

Tab

le 1

5 F

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4 5

6 7

8 9

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Siriphorn Sawangphong Discussion / 74

CHAPTER V

DISCUSSION

The aim of this study was to examine the correlation of age, knowledge

about PAOD, the reasons for not visiting a health care service, the response of others

and the first diagnosis time of PAOD patients, the research findings can be discussed

in terms of the following issues: 1) symptoms and co-morbidities of PAOD patients, 2)

the first diagnosis time and 3) the factors associated with first diagnosis time of PAOD

patients.

1. Symptoms and co-morbidities of PAOD patients

According to the research findings, it was indicated that most of the

sample (32.2%) had a total of three comorbidities and only 7.8% had no comorbidity.

The co-morbidities most frequently encountered consisted of hypertension (83.3%),

followed by DM Dyslipidemia, MI and CVA (66.7%, 51.1%, 28.9% and 12.2%,

respectively) (Table 5). This finding concurred with the findings of previous studies

which found that 95% of PAOD patients had more than one cardiovascular risk factor

(Selvin & Erlinger, 2004). It was further observed in this research that 40% of

participants had cardiovascular or cerebro-vascular co-morbidities and 4.4% of

patients had coronary artery and cerebro-vascular disease as co-morbidities because

the occurrence of atherosclerosis is a condition of systematic atherosclerosis.

Therefore, when atherosclerosis occurs in the peripheral arteries, there is a chance that

it may also occur in other arteries of the body (Lungstrom & Emerson, 2005; Smeltzer,

Bare, Hinkle, & Cheever, 2008). This finding concurred with the findings of a

previous study by Diehm, et al. (2004) which found that 15% of PAOD patients had

cerebro-vascular disease and 28.9% had cardiovascular disease. The findings also

concurred with the study of Bertomeu, et al., (2008) which found the prevalence of

PAOD in patients with acute coronary syndrome (ACS) to be nearly 40%. Other than

the aforementioned comorbidities, it was also found in the present study that most



patients were former smokers (47.8%) wherein the average time period of not smoking

was 9.41 years (S.D. = 11.49) while 10% were still smoking at the time of the study

(Table 6). The aforementioned comorbidities, including smoking, are all

cardiovascular risk factors (Smeltzer, et al., 2008; Sydenham, & Medic, 2004) that

will also be risk factors in the occurrence of occlusion of the peripheral arteries.

In terms of perceive onset symptoms of the disease, the research findings

indicated that 43.3% of patients peceived intermittent claudication as the onset

symptom, of this number, 28.2% had pain in both legs. (Table 8) The most of

participants were femoropopliteal artery occlusion (45.6%), following by tibio-

peroneal artery (34.4%) (Table 7), a finding that concurred with previous studies

(Mutirangura, et al., 2006; Panchoowong, et al., 2008) indicating that most of the

sample also had occluded arteries in this area. The perceived onset symptom found to

follow this was ulceration (35.6%). Ulceration can be considered as one of the

symptoms indicating critical limb ischemia (Hirsch, et al., 2006; Norgren, et al.,

2007). The reason this group of patients perceived ulceration as first symptom may be

due to these patients were asymptomatic PAOD before ulceration occurred, a finding

that agreed with previous study which found that only 12% of patients with ABI < 0.9

were preceding intermittent claudication. (McDermott, et al, 2001).

Furthermore, according to the research findings, most of the sample visit

health care services due to chief complaint of ischemic ulcers, followed by intermittent

claudication (52.2% and 30%, respectively) (Table 9), which was in agreement with

the research of Mutirangura, et al (2006) who found that most PAOD patients receive

treatment for ischemic ulcers.



2. The first diagnosis time of PAOD patients

According to the research findings, it was indicated that most of the

sample group (62.2%) were not received diagnosed immediately upon visit health care

services (Table 11). The median of first visit time was 30 days while the median of

first diagnosis time was 90 days (Table 10). Eventually, 76.7% received diagnosis at

university hospitals and more than half were patients referred by other health care

service setting. (Table 11) This finding shown the health care provider; especially in

primary care setting through to tertiary care setting could not PAOD diagnosed to

patients who visiting.

This finding may be explained in that the health care service setting that

were not university hospitals did not have specialist; vascular surgeon who were able

to perceive the problems of peripheral arteries. From data of the Vascular Surgery

Association, Thailand indicated that most of vascular surgeon were in university

hospital (Vascular Surgery Association, Thailand, 2005). As a result, patients were

incorrectly diagnosed. According to this research, it was found that 52.2% of patients

received other diagnoses than PAOD from the first service provision facility where

they received services, which may be because the symptoms of intermittent

claudication of PAOD were similar to leg pains from other causes such as nerve root

compression, arthritis or spinal stenosis (Norgren, et al., 2007) and other research that

found that more than half of PAOD patients had to endure pain for more than 2 years

before receiving correct diagnosis by specific arterial tests. This characteristic of

symptoms constitute a condition usually found to cause patients to receive late

diagnosis (Picquet, Jaquinandi, Saumet, Leftheriotis, Enon, et al.,2005).

Bailey et al (2003) found that another reason affecting the time elapsed

before reaching a vascular surgeon was that general practitioners (GPs), the people

who referred the patients for further treatment, gave no importance to the urgency of

the problems of PAOD patients, which lengthened the duration from symptoms onset

to diagnosis. The study found that only a quarter of critical limb ischemia (CLI)

patients referral from general practitioner (GPs) to vascular surgeons were marked

urgent, while the review of referral letters of these patients by vascular consultants

revealed a significant increase in the number prioritised as urgent. Moreover, this

study found that the length of waiting for an outpatient appointment by patients



prioritized as urgent by their GPs or vascular consultants was reduced by at least 7

days.

3. Factors associated with first diagnosis time of PAOD patients

According to the research findings, it was indicated that age was negative

significantly associated with the first diagnosis time (ρ = - .251; p < .05), duration

from telling others to escort first visit was positive significantly associated with the

first diagnosis time (ρ = .712; p < .01). There was no statistically significance,

however, between knowledge about PAOD (both general knowledge and knowledge

related to patients’ experience), reasons for not visiting a health care services

(emotional, cognitive and symptomatic) and the first diagnosis time with relationship

values as follows: general knowledge (ρ = .005; p > .05), knowledge related to

patient's experience (ρ = .052; p > .05), emotional related reasons for not visiting

health care service (ρ = .112; p > .05), cognitive related reasons for not visiting health

care service (ρ = .007; p > .05), symptom related reasons for not visiting health care

service (ρ = .066; p > .05), responses of others induce first visits (ρ = -.033; p > .05),

responses of others did not induce first visits (ρ = -.009; p > .05) (Table 15). The

researcher has presented the discussion of the findings according to the hypotheses as

follows:

Hypothesis 1

Knowledge about PAOD is related to the first diagnosis time of PAOD

patients.

According to the research findings, it was indicated that knowledge about

PAOD were not significantly associated with the duration from the onset of PAOD

symptoms to diagnosis (ρ = .060; p >.05). Even though, from literlature review, the

researcher did not found studies which revealed about the correlation between these

factors, however, previous study found that PAOD patients had low awareness of

symptoms, risk factors, and treatment options (Willigendael et al., 2004). Another

study was found that the public is poorly informed regarding PAOD as the definition

of PAOD, risk factors, and associated limb symptoms and amputation risk (Hirsch et



al., 2007). Similarly, in current study found that more than half of the participants

(55.6%) had lower scores of general knowledge about and risk factors of PAOD

(Table 13). According to aforementioned, it presented the homogeneous of the sample

therefore it possibly result in non statistic significant between these variables. In

addition, these variables were abnormality distribution. (Appendix F)

Besides, in current study the researcher was evaluated the knowledge

about PAOD in known case, therefore the level of knowledge that presented may

higher than when the participant had been visiting healthcare service at first time that

leading to current diagnosis. Other possible explanation is that most of the sample

had non healing ulceration as the chief complaint when they visited in healthcare

service at first time (Table 9) and from the interviewing by researcher while collected

data in this study, it was found that participants were suffer from their symptom, these

result in they were determined visit health care service. Hence, the knowledge may

disaffected to the first visit or the diagnosis time. Additionally, the first diagnosis time

may caused by other factors regarding the health care system, owing to , even though

the participants had visited health care service but some cases can’t access to

diagnosis. (Table 11)

Hypothesis 2

The reasons for not visiting health care service are related to the first

diagnosis time of PAOD patients.

According to the research findings, it was indicated that the reasons for not

visiting health care services immediately after perceived onset symptoms i.e. emotion-

related reasons, cognitive-related reasons, and symptom-related reasons were not

significantly associated to the first diagnosis time (ρ = .112; p > .05, ρ = .007; p > .05

and ρ = .006; p >.05) (Table 15).

However, it was found that patients who did not receive health care

services due to intermittent symptoms had tendencies toward longer durations in

entering the healthcare system than other reasons (The median of the first visit time

was 120 days) (Table 12). The aforementioned research findings can explain that

patients who begin to experience abnormal symptoms will use the coping process to



manage the onset of abnormal symptoms consisting of both cognitive and emotional

processes and will have both cognitive responses and affective responses until there is

an action to manage symptoms onset (Diefenbach, & Leventhal, 1996; Noureddine, et

al., 2006). In this study, the reasons provided for not receiving health care services

were categorized by coping process, which will have both cognitive and affective

reasons i.e. when the symptoms onset has passed, patients will feel better from the

symptoms they have and they have learned from experience with past symptoms so

that they decide to not receive healthcare services result in the duration which received

diagnosis was elapsed.

Which was in agreement with the research of Noureddine, et al., (2006)

who found that cardiovascular disease patients with causes and risk factors in the

occurrence of diseases similar to PAOD had longer durations in accessing health care

services if the patients gave the reason that the characteristics of symptoms that

occurred were intermittent.

Furthermore, the research findings also indicated that there were other

reasons for tendencies leading to longer duration for patients in receiving services in

the health care system i.e. the fact that patients were unaware that the symptoms were

PAOD symptoms or patients were unaware that the symptoms were significant. Most

of the sample group (97.8%) did not receive health care services immediately upon

symptoms onset because they were unaware that the symptoms were symptoms of

PAOD (APPENDIX E), a finding that concurred with the study of Brevetti, et al.,

(2004) which found that 44% of patients with intermittent claudication were equally

unaware that the symptoms were symptoms of PAOD as they were unaware of the

nature of symptoms of PAOD, followed by the fact that patients did not receive

healthcare services because patients were unaware that the symptoms they had were

important (87.8%).

According to the aforementioned discussion, it is evident that the reasoning

of patients in not visiting health care services is coping strategies prior to receiving

services. Therefore, the longer patients delay during this period, the longer the

duration from symptom onset to visiting healthcare services, because this duration

depends upon the duration patients used in coping by the cognitive and affective

processes (Figure 2). As for first diagnosis time, there may be other variables other



that the process of patients’ coping; therefore, there were no relationships between

these two variables.

Hypothesis 3

Age is related to the first diagnosis time of PAOD patients.

This study found that age was negative significantly associated to the first

diagnosis time of PAOD patients (ρ = -.251; p < .05) (Table 15), a finding that did not

concur with the study of Noureddine, et al., (2006) which found that age was not

related to delay in receiving treatment among the group of cardiovascular disease

patients, possibly because although cardiovascular disease and peripheral arterial

disease are associated with the same causes and risk factors, but there are differences

in the impact organs of the disease and different characteristics of symptoms.

In addition most of the sample group in the present study had

comorbidities i.e. hypertension (83.3%), DM (65.6%) and most patients (32.2%) had 3

comorbidities. Furthermore, 40% had cardiovascular or cerebrovascular diseases

(Table 5). This finding concurred with previous studies (Piccirillo, et al., 2008) which

found that hypertension, myocardial infarction and DM will be found in groups with

higher ages. These comorbidities are chronic diseases requiring continual treatment;

therefore, it is possible that these patients are already in the health care system due to

other problems. Thus, individuals with older will have greater accessibility to the

health care system with problems of PAOD as a result of higher levels of interaction

with the health care team, so they receive health care services for the problem of

PAOD than younger individuals with less tendencies for comorbidities. Therefore,

patients with older will have shorter first diagnosis time than younger patients.



Hypothesis 4

The response of others is related to the first diagnosis time of PAOD

patients.

According to this research, it was found that the responses of others, both

in terms of responses of others induce first visit and responses of others did not induce

first visit were not significantly associated with the first diagnosis time of PAOD

patients (ρ = - .033; p > .05 and ρ = -.009; p > .05). However, it was also found that

the duration from telling others to escort first visit was positive significantly associated

with the first diagnosis time of PAOD patients (ρ = .712; p < .01) (Table 15).

Possible explanation is that all of participants who told about their

symptom to close person had received both the response that did not induce first visit

and response induce first visit from their close person and these response were similar

numbers (Table 14). From the interviewing participants by the researcher found that

before individuals were taken to hospital by other, most of them were received at least

one response that did not induce first visit from their close person. (APPENDIX E)

However, the participants have various durations from telling others to escort them the

first visit that result in their first diagnosis time were various too, because if the close

person bring patients visit health care services quickly, the patients will have better

chances of receiving early diagnosis.

Furthermore, it was also found that more than half of the patients (63.3%)

immediately told nearby individuals about their symptoms when perceived abnormal

symptoms. In this group, it was found that the first diagnosis time was a shorter than

the group that did not teld their symptoms to others, which may be explained in that,

while the majority of the patients were elderly and lived with family members

(95.5%),Therefore, when abnormal symptoms occur and patients tell family members,

family members will find methods to manage symptoms that occur before entering the

health care system. Furthermore, when these methods are found to fail at reducing the

symptoms for patients, the patients will be brought to receive services in the health

care system. This finding concurs with the setting of Thai society where family

members, especially children or grandchildren, will perform the duty of providing care

for elderly in the family during sickness. This finding agreed with the study of

Panchoowong, et al., (2008) which found that patients and family members will find



pain management methods when PAOD patients have leg pains but the symptoms will

not completely disappear because the cause of the arterial occlusion has not yet been

resolved (Mutirangura, 2002). Therefore, when symptoms fail to improve, relatives are

compelled to take patients to seek services in the healthcare system. When relatives

bring patients to receive health care services without delay, the patients will have

better chances of receiving early diagnosis.

This finding concurred with the research of Noureddine, et al., (2006),

which found that patients who received responses from others in the form of taking the

patients to hospital had shorter durations for entering the health care services system.



CHAPTER VI

CONCLUSION

The present study comprised descriptive research to examine the

correlation between knowledge about PAOD, reasons for not visiting a health care

services, age, and response of others with the first diagnosis time of PAOD patients.

The sample comprised 90 patients with PAOD occurring who visited the Outpatient

Department of Siriraj Hospital. The period of data collection was from June to

September of 2009 and the instrumentation employed in the study included seven sets

of questionnaires as follows: 1) Demographic data interview form; 2) Health and

comorbidity record; 3) Symptom characteristic interview form; 4) Sequence of visiting

health care service interview form; 5) Reasons for not visiting a health care service

interview form; 6) Knowledge about PAOD interview form and, 7) Responses of

others to interview form.

Data analysis was performed by using a ready-made computer program to

analyze descriptive statistics and relationships between knowledge about PAOD,

reasons for not visiting a health care services, age, response of others and the first

diagnosis time by the Spearman rank correlation coefficient. The research findings

were as follows:

1. General and illness information

The majority of the sample was male (64.4%) aged between 36-90 years

with an average age of 68.68 years. The majority of age were aged > 65 years

(72.2%). Most lived in Bangkok / perimeter (57.8%) and lived in urban areas (70%).

Most had marital status (67.8%) and most had elementary levels of education (52.2%).

Most of the sample group were unemployed (61.1%) and did not have their own

income (60%) and most were eligible for reimbursement for medical expense

payment. (63.3%).


Siriphorn Sawangphong Conclusion / 84

The most frequently of the sample had 3 comorbidities (32.2%). It was

found that forty percent of patients had diseases involving cardiovascular disease or

cerebrovascular disease. The comorbidities most frequently encountered were

hypertension (83.3%), follow by diabetes mellitus and dyslipidemia (65.6% and

51.1%, respectively) and 7.8% of the sample was free of comorbidities. Most of the

sample was former smoking (47.8%) with the average time period of not smoking

being 9.41 years.

Most of participants were femoropopliteal artery occlusion (45.6%)

followed by occlusion in the tibio-peroneal artery (34.4%).

Forty-three percent of the sample had onset symptom as intermittent

claudication. Of this number, the site with the most symptoms was in both legs

(29.6%) while chief complaint that caused most of the sample to visit in healthcare

service facilities were ulceration (52.2%) wherein the site were most frequently

encountered was the toes (66%). (15.6%).

2. The first visit and first diagnosis time

The median of first visit time was 30 days wherein most of the samples

(38.9%) had first visit time less than 30 days, follow by 90 days and over (37.8%).

The median of first diagnosis time was 90 days and most patients (52.2%)

had first diagnosis time 90 days and over, followed by 18.9% of the patients who had

first diagnosis time from 31 to 59 days (Table 10).

Approximately 34.4% of the samples had first visit setting at university

hospitals which was the only setting all patients who received diagnosed with PAOD;

most of them received diagnosis on the day services were received (87.1%).

Furthermore, it was found that half of the sample were first visiting in other

government setting which lower level than university hospitals, in this number, most

received the diagnosis after first visiting for 30-89 days (17 of 45 patients; 37.8%).

The majority of participants received diagnosis at university hospitals (69 of 90

patients; 76.7%); more than half of these were patients referred by other healthcare

setting (55.1%).



3. Reasons for not visiting a health care service, knowledge about

PAOD, and responses of others

All of the sample did not visiting a health care system because of at least

one cognitive-related reason, followed by 53.3% of the sample group who had at least

one emotion-related reason. The participants who did not visiting health care services

because symptoms were intermittent had the longest first visit time and first diagnosis

time (the median was 120 and 261 days, respectively). And most of participants did

not visiting a health care services immediately symptoms onset because they were

equally not recognize that the symptoms as PAOD symptoms as the reason that they

did not know with the symptoms of PAOD (97.8%).

Fifty-one percent of the sample had higher than half of possible score

regarding knowledge about PAOD. When considering in terms of area, it was found

that 55.6% of the sample had scores in the area of general knowledge about and risk

factors of PAOD at lower than half, while patients 72.2% had scores higher than half

in the area of knowledge related to patients’ experience.

Most of the sample (63.3%) told others about the abnormal symptoms that

occurred while 60% received at least one response that did not induce the first visit

and most of them (56.7%) received responses telling them to rest, followed by

response that were attempts to make patients more comfortable (23.3%) and 61.1%

received at least one response that induced the first visit. Moreover, most of the

sample were escorted by others to a health care service setting 90 days or more after

telling someone about their symptoms (37%).

4. The association of variables with the first diagnosis time

According to the research findings, it was indicated that age was negative

significantly associated with first diagnosis time (ρ = - .251; p < .05), while duration

from telling others to escort first visit was positive significantly associated with first

diagnosis time (ρ = .712; p < .01).

There was no statistically significance between knowledge about PAOD

(both general knowledge and knowledge related to patients’ experience), reasons for


Siriphorn Sawangphong Conclusion / 86

not visiting a health care services (emotional, cognitive and symptomatic) and the first

diagnosis time with relationship values as follows: general knowledge

(ρ = .005; p > .05), knowledge related to patient's experience (ρ = .052; p > .05),

emotional related reasons for did not visiting health care service (ρ = .112; p > .05),

cognitive related reasons for did not visiting health care service (ρ = .007; p > .05),

symptom related reasons for did not visiting health care service (ρ = .066; p > .05),

responses of others induce first visit (ρ = -.033; p > .05), responses of others did not

induce first visits (ρ = -.009; p > .05).

Implications and recommendations

Implications and application of the research findings

1. According to the research findings, it was indicated that most patients

did not receive diagnosis immediately first visit in the health care system, especially in

service setting at lower levels than university hospitals. Therefore, the health care

providers at primary care setting through to tertiary care settings should be trained

about screening for PAOD and a referral and network service set up to allow the

patients to access PAOD diagnosis as soon as possible.


continued to have knowledge regarding the risk factors of the disease at a low level,

even though patients had received diagnosis and treatment. Therefore, the health care

providers who provide care for patients should disseminate knowledge regarding the

risk factors of the disease and monitoring for abnormal symptoms so patients will be

aware of information regarding their disease and engage in practice to accurately

control the risk factors of the disease.


had comorbidities. Therefore, patients with hypertension and diabetes should have

enough information to recognize PAOD symptoms, to be aware the symptoms and

know how to prevent PAOD in order to reduce the number and severity of the patients.



Recommendations for further studies

1. Studies should be conducted on PAOD screening in medicine patients,

especially in hypertensive and diabetes patients.

2. Practice guidelines should be developed for early detection of PAOD

patients. Furthermore studies should be conducted on trial implementation of the

practice guidelines with patients in the risk group for development into standards for

providing further care of PAOD patients in the future.


Siriphorn Sawangphong References / 88

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APPENDICES


Siriphorn Sawangphong Appendices / 100

APPENDIX A

LIST OF EXPERTS

The validity of research instrument was assessed by five consulting experts:

1. Assist. Prof. Chumpol Wongwanit, M.D.

Division of Vascular Surgery

Department of Surgery

Faculty of Medicine Siriraj Hospital, Mahidol University

2. Wasupong Sridermma, M.D.

Division of Vascular Surgery

Department of Surgery


3. Assist. Prof. Napaporn Wanitkun

Department of Surgical Nursing

Faculty of Nursing, Mahidol University

4. Miss Sadudee Rojanapirom

Supervisor of Surgical Nursing Director

Department of Nursing


5. Miss Chulaporn Prasungsit, APN

Division of Surgical Nursing

Department of Nursing




APPENDIX B

ETHICAL CLEARANCE



APPENDIX C

CONTENT FORM

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APPENDIX D

RESEARCH INSTRUMENT

ลาดบท...........

วนท............................

สวนท 1 แบบบนทกขอมลทวไป 1.1 แบบสมภาษณขอมลสวนบคคล คาชแจง ใหผวจยสมภาษณกลมตวอยางแลวบนทกขอมลโดยทาเครองหมายถก ) (ลงใน

หนาขอความทตรงกบคาตอบของกลมตวอยาง หรอเตมขอความลงในชองวางทกาหนด

1. เพศ

ชาย หญง 2. อาย ....................ป 3. จงหวดทอาศยอยในปจจบน........................................................ 4. สถานภาพสมรส .................................. .................................. 5. ระดบการศกษา ........................................... ........................................... 6................................... 7. ................................. 8. ................................. 9. คาใชจายในการรกษาพยาบาล .....................................



Appendices / 110

1.2 แบบบนทกขอมลเกยวกบสขภาพและ โรครวม คาชแจง ใหผวจยสมภาษณกลมตวอยาง หรอ ดขอมลจากเวชระเบยนผปวย แลวเตมขอความลงในชองวางทกาหนด 1. การวนจฉยโรคในปจจบน.............................................................................. 2. ประวตการสบบหร ........................................................................ 3. แบบบนทกการมโรครวม

คาชแจง ใหผวจยนาขอมลการมโรครวมทไดจากการสมภาษณ หรอขอมลจากแฟมประวตของผปวยมารวมใหคะแนน ดงรายละเอยดตอไปน ให 1 คะแนน ถาผปวยมอาการตอไปน (อยางนอย 1 อาการ) คะแนน โรคกลามเนอหวใจขาดเลอด (MI) ___________

-ไดรบการวนจฉยหรอสนนษฐานวามภาวะกลามเนอหวใจขาดเลอดไปเลยงอยางนอย 1 ครง (โปรดระบถามากกวา 1 ครง: _____________ครง)

-พบความผดปกตของ ECG ขณะเขารบการรกษาในโรงพยาบาล และ / หรอมการเปลยนแปลงในระดบเอนไซมของหวใจ ( cardiac enzyme) ถาตรวจพบการเปลยนแปลงของ ECG

เพยงอยางเดยวไมถอวามภาวะกลามเนอหวใจขาดเลอดไปเลยง ภาวะหวใจลมเหลว )CHF( ___________

ให 2 คะแนน ถาผปวยมอาการตอไปน อยางนอย 1 อาการ ไดแก โรคอมพาตครงซก (Hemiplegia) ___________

ผปวยอมพาตครงซก หรออมพาตสวนลางของรางกาย (Paraplegia ) ซงเกดจากโรคอบตเหตของหลอดเลอดมอง หรอจากสาเหตอน ๆ



ให 3 คะแนน ถาผปวยมอาการตอไปนอยางนอย 1 อาการ โรคตบ (Liver disease) ___________

ให 6 คะแนน ถาผปวยมอาการตอไปนอยางนอย 1 อาการ โรคเอดส (AIDS) ___________

คะแนนรวม___________________คะแนน



Appendices / 112



สวนท 2 แบบสมภาษณอาการของโรค

คาชแจง ใหผวจยสมภาษณกลมตวอยางแลวบนทกขอมลโดยทาเครองหมายถก ) (ลงใน

หนาขอความทตรงกบคาตอบของกลมตวอยาง หรอเตมขอความลงในชองวางทกาหนด 1. อาการทเรมรบรครงแรก

1.1 อาการปวด 1.2................................. 1.3.................................

2. ............................................... 2.1.................................. 2.2.................................. 2.3..................................


Siriphornn Sawangphong Appendix / 114

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Fac. of Grad. Studies, Mahidol Univ. M.N.S. (Adult Nursing) /

115

สวนท 4 แบบสมภาษณเหตผลของการไมเขารบการรกษา คาชแจง ใหผวจยสมภาษณกลมตวอยางแลวบนทกขอมลโดยทาเครองหมายถก ( ) ลงในตาราง ปจจยตาง ๆ ตอไปมผลตอการททาใหคณไมเขารบการรกษาทนททมอาการ

ใช หมายถง ปจจยดงกลาว มผล ตอการไมเขารบการรกษาทนททมอาการ

ไมใช หมายถง ปจจยดงกลาว ไมมผล ตอการไมเขารบการรกษาทนททมอาการ

เหตผลของการไมเขารบการรกษา ใช ไมใช

1. คณไมเขารบการรกษาเพราะรอดเพอใหอาการหายไปเอง 2. ............................................................................... 3. .............................................................................. 4. ..............................................................................

5. ...............................................................................

6. ...............................................................................

7. ...............................................................................

8. ............................................................................... สวนท 5 แบบสมภาษณความรเกยวกบโรคหลอดเลอดแดงสวนปลายอดตน สาหรบผปวย

คาชแจง ใหผวจยสมภาษณกลมตวอยางแลวบนทกขอมลโดยทาเครองหมายถก) (ลงในตาราง

ขอคาถาม ใช ไมใช ไมแนใจ1. โรคทคณเปน เกดจากความผดปกตของระบบหวใจและหลอดเลอด 2. โรคทคณเปน เกยวของกบหลอดเลอดแดง 3. .............................................................................

.

.

18



Appendices / 116

สวนท 6 แบบสมภาษณการตอบสนองของบคคลอนตออาการของผปวย

คาชแจง ใหผวจยสมภาษณกลมตวอยางแลวบนทกขอมลโดยทาเครองหมายถก ( ) ลงในตาราง เมอคณมอาการครงแรก คณไดบอกเลาอาการของคณกบบคคลอนหรอไม ถาคณบอกบคคลทคณบอกเลาถงอาการทาอยางไรเมอทราบอาการของคณ

ไมไดบอกอาการทเกดขนใหบคคลอนทราบ (ไมตองตอบคาถามในตาราง) บอกอาการทเกดขนใหบคคลอนทราบ (ตอบคาถามในตารางตอไปน)

ใช หมายถง บคคลทคณบอกเลาอาการของคณกระทา ไมใช หมายถง บคคลทคณบอกเลาอาการของคณไมไดกระทา

ปฏกรยาของบคคลอนเมอทราบอาการ ใช ไมใช

1. ไมทาอะไร (เฉย ๆ)

2. แสดงทาทางราคาญ

.

. 10................................................................



117



Appendices / 118

APPENDIX E

Table A Frequency and percentage of PAOD patients classified by the reasons for not visiting a health care service and durations in health care service (n=90)


< 90 days > 90 days < 90 days > 90 days Reasons for not visit in

healthcare service * n %

n n n n

Cognitive related the reasons 90 100 56 34 43 47

Emotion related the reasons 48 53.3 29 19 22 26

Symptoms related the reasons 28 31.1 14 14 12 16




119

Table B: Frequency and percentage of PAOD patients classified by the items of

response of others to participants’ symptoms

Condition * n %

Response not induce first visit*

suggested to rest 51 56.7

tried to comfort 21 23.3

suggested wearing sock or blanket

10 11.1

take medicine to patient 7 7.8 told not to worry 6 6.7

did nothing 4 4.4

suggested take medicine 4 4.4

got upset 1 1.1

Response induce first visit*

suggested go to hospital 55 61.1

took to the hospital 54 60.0




Appendices / 120

APPENDIX F

Normality tesing

1800.0

1700.0

1600.0

1500.0

1400.0

1300.0

1200.0

1100.0

1000.0

900.0

800.0

700.0

600.0

500.0

400.0

300.0

200.0

100.0

0.0

frequency

diagnosis time (day)

40

30

20

10

0

Std. Dev = 344.49

Mean = 240.3

N = 90.00

Figure A The distribution of the first diagnosis of the sample

knowledge score

18.016.014.012.010.08.06.04.02.0

20

10

0

Std. Dev = 4.09

Mean = 9.7

N = 90.00

Figure B The distribution of knowledge about PAOD of the sample



121

age

90.085.080.075.070.065.060.055.050.045.040.035.0

20

10

0

Std. Dev = 11.31

Mean = 68.7

N = 90.00

Figure B The distribution of age of the sample


Siriphorn Sawangphong Biography / 122

BIOGRAPHY

NAME Miss Siriphorn Sawangphong

DATE OF BIRTH 5 December 1974

PLACE OF BIRTH Pathumthani, Thailand

INSTITUTIONS ATTENDED Mahidol University, 1992 – 1996

Bachelor of Nursing Science

Mahidol University, 2007 – 2009

Master of Nursing Science (Adult Nursing)

RESEARCH GRANT -

POSITION & OFFICE 1996 – Present, Register Nurse, Division of

Surgical Nursing, Department of Nursing,

Siriraj Hospital Tel. 02-4197116, 02-4199203

HOME ADDRESS 9/1 M. 4 Bangpood

Mueng Pathumthani District

Pathumthani, Thailand

E-mail: [email protected]

[email protected]

Mobile: 084-6811053


factors related to first diagnosis time in patients...

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