Despite evidence supporting the benefit of supervised exercise in intermittent claudication, there is a worldwide scarcity of funds for programmes. Experts were united in their frustration that there is a global lack of funding despite the rhetoric of the need to focus more on prevention.
Delegates heard that Cochrane reviews, the highest standard in evidence-based healthcare, suggest that the key to patients with intermittent claudication living longer is for them to stop smoking, begin a programme of supervised exercise and undergo best medical therapy. Yet, worldwide there is a shortage of financial support for studies examining the benefit of supervised exercise.
Ninety per cent of the CX audience voted that they would recommend Nordic walking (used as a surrogate term for supervised exercise), and only 10% said they would not. Jonathan Beard, Sheffield, UK, said: “Why on earth is there no funding for a supervised exercise programme for arterial disease? I think this would be something for the European Society [for Vascular Surgery] or the international societies to push for in terms of health advocacy. We are a bit too focused on technical interventions. The best thing for patients is for them to exercise, after stopping smoking.”
CX chairman Roger Greenhalgh made the point that it was only after the conditions of smoking cessation, best medical treatment and supervised exercise are met that technical interventions were to be undertaken. He said, of trials that compared one technical intervention against another, that “such comparisons are not entirely legitimate as they have the same basic slant. Supervised exercise is known to be beneficial yet this is not included in the trial designs.”
Greenhalgh referred to the MIMIC trials, two multicentre randomised controlled trials which investigated whether there is adjuvant benefit of percutaneous transluminal angioplasty over supervised exercise and best medical therapy in the treatment of intermittent claudication. Investigators found that angioplasty confers adjuvant benefit over supervised exercise and best medical therapy in terms of walking distances and ankle brachial pressure index 24 months after angioplasty in patients with stable mild to moderate intermittent claudication.
Describing the situation “across the pond”, Barry Katzen, Miami, USA, told CX Daily News that while there were plenty of data to suggest that supervised exercised conferred benefits in intermittent claudication, there were currently no initiatives, and certainly no funding to study and implement this. “There is now a push from the Government towards funding preventative or less invasive medicine. A small minority of medical practitioners in the USA question whether intermittent claudication is indeed a disease, it is seen more as a quality-of-life issue. There is no currently no funding to study supervised exercise within studies or trials and I do not see a change in the funding scenario in the future,” said Katzen.
Greenhalgh described the situation in Britain colloquially as “giving the money to the doctors and then incentivising them not to spend it. Intermittent claudication is not a disease, but a milder symptom of peripheral arterial disease. It is fair to say that there is currently no funding available for supervised exercise globally, and in Britain,” he said.
Plinio Rossi, one of the legends of interventional radiology, also told CX Daily News that “supervised exercise is very important, but seen as too expensive to be funded by the state. It is clear that supervised exercise is far more beneficial that exercise advice (unsupervised); the latter just does not hit the spot.”
Beard, speaking on the topic “Nordic walking: more effective than standard exercise programmes for claudicants?” told delegates that unsupervised exercise (ie. advice) does not work. “We do know that supervised exercise programmes are more effective than angioplasty and stents, but there are problems with compliance and funding, and many countries will not fund it. How do we ensure funding for exercise therapy for patients with peripheral arterial disease? What level and duration of support is required and which regime gives the best long-term compliance?” he asked.
Chairman Frans Moll, Utrecht, The Netherlands, told delegates at the session, “In the Netherlands, the healthcare insurance companies are reimbursing supervised exercise even beyond the six months, and specifically for claudication. Are there any other countries doing this?” On finding out from the audience that Switzerland was the only other country with this practice, he said that the situation was “certainly underdeveloped. Smoking cessation, supervised exercise and best medical practice are the key to healthcare,” he said.