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      The reliability of the ankle brachial index: a systematic review

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          Abstract

          Background

          The ankle brachial index (ABI) is widely used in clinical practice as a non-invasive method to detect the presence and severity of peripheral arterial disease (PAD). Current guidelines suggest that it should be used to monitor potential progression of PAD in affected individuals. As such, it is important that the test is reliable when used for repeated measurements, by the same or different health practitioners. This systematic review aims to examine the literature to evaluate the inter- and intra-rater reliability of the ABI.

          Methods

          A systematic search of MEDLINE, EMBASE and CINAHL Complete was conducted to 20 January 2019. Two authors independently reviewed and selected relevant studies and extracted the data. Methodological quality was determined using the Quality Appraisal of Reliability (QAREL) Checklist.

          Results

          Fifteen studies of ABI reliability in a range of patient populations were identified as suitable for inclusion in the review: seven considered inter-rater reliability, four intra-rater reliability, and four studies evaluated both inter- and intra-rater reliability. Inter-rater reliability was found to be highly variable, with intraclass correlation coefficients (ICC’s) ranging from poor to excellent (ICC 0.42–1.00), while intra-rater also demonstrated considerable variation, with ICCs from 0.42–0.98. Meta-analysis was not possible due to the lack of statistical information reported.

          Conclusions

          Results of included studies suggest the inter- and intra-tester reliability of the ABI is acceptable. However, inconsistencies in obtaining systolic pressure measurements, calculating ABI values, and incomplete reporting of methodologies and statistical analysis make it difficult to determine the validity of the results of included studies. Further research, with more consistent reliability methodology, statistical analysis and reporting conducted in populations at risk of PAD is needed to conclusively determine the ABI reliability.

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          Peripheral arterial disease in diabetic and nondiabetic patients: a comparison of severity and outcome.

          S Oyibo, E. Jude, N Chalmers … (2001)
          The aim of this study was to quantify the distribution of peripheral arterial disease in the diabetic and nondiabetic population attending for angiography and to compare severity and outcome between both groups of patients. Randomly selected lower-extremity angiograms were examined according to the Bollinger system. Patient demographics and medical history were recorded and case notes were examined to determine which patients later underwent a revascularization procedure or amputation and which patients had died. A total of 136 arteriograms obtained between 1992 and 1996 were analyzed. The age (mean +/- SD) of the patients was 64.7 +/- 10.8 years. Diabetic patients (43%) and nondiabetic patients were of similar age (63.9 +/- 10.4 vs. 65.3 +/- 11.1 years, P = 0.43), with a similar history of smoking (81.0 vs. 76.9%, P = 0.26), ischemic heart disease (41.4 vs. 37.2%, P = 0.54), and hypercholesterolemia (24.4 vs. 30.8%, P = 0.48). However, there were a greater proportion of hypertensive patients in the diabetic group (63.8 vs. 39.7%, P = 0.006). Diabetic patients had greater severity of arterial disease in the profunda femoris and all arterial segments below the knee (P = 0.02). A greater number of amputations occurred in the diabetic group: diabetic patients were five times more likely to have an amputation (41.4 vs. 11.5%, odds ratio [OR] 5.4, P < 0.0001). Mortality was higher in the diabetic group (51.7 vs. 25.6%, OR 3.1, P = 0.002), and diabetic patients who died were younger at presentation than nondiabetic patients (64.7 +/- 11.4 vs. 71.1 +/- 8.7 years, P = 0.04). In patients with peripheral arterial disease, diabetic patients have worse arterial disease and a poorer outcome than nondiabetic patients.
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            The development of a quality appraisal tool for studies of diagnostic reliability (QAREL).

            Nicholas Lucas, Petra Macaskill, Les Irwig … (2010)
            In systematic reviews of the reliability of diagnostic tests, no quality assessment tool has been used consistently. The aim of this study was to develop a specific quality appraisal tool for studies of diagnostic reliability. Key principles for the quality of studies of diagnostic reliability were identified with reference to epidemiologic principles, existing quality appraisal checklists, and the Standards for Reporting of Diagnostic Accuracy (STARD) and Quality Assessment of Diagnostic Accuracy Studies (QUADAS) resources. Specific items that encompassed each of the principles were developed. Experts in diagnostic research provided feedback on the items that were to form the appraisal tool. This process was iterative and continued until consensus among experts was reached. The Quality Appraisal of Reliability Studies (QAREL) checklist includes 11 items that explore seven principles. Items cover the spectrum of subjects, spectrum of examiners, examiner blinding, order effects of examination, suitability of the time interval among repeated measurements, appropriate test application and interpretation, and appropriate statistical analysis. QAREL has been developed as a specific quality appraisal tool for studies of diagnostic reliability. The reliability of this tool in different contexts needs to be evaluated. Copyright (c) 2010 Elsevier Inc. All rights reserved.
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              Ankle Brachial Pressure Index (ABPI): An update for practitioners

              Mo Al-Qaisi, David M Nott, David King … (2009)
              Peripheral vascular disease affects some 12%–14% of the general population, and the majority of people with the disease are asymptomatic. The Ankle Brachial Pressure Index (ABPI) test is widely used by a diverse range of practitioners (in the community and hospital setting) in order to screen asymptomatic patients, diagnose patients with clinical symptoms, and to monitor patients who have had radiological or surgical intervention. This paper explains the theoretical basis of the ABPI test, as well as the relevance of the common modifications of the test. It explores the background to the quoted normal ranges for the ABPI test. It reviews the large body of literature that has developed on the association between ABPI and cardiovascular risk, as well as ABPI as a predictor for cardiovascular morbidity and mortality, highlighting the evidence that can inform practice. The review looks critically at the limitations of the ABPI test, providing practitioners with an evidence-based update on the importance and challenges of standardizing ABPI methodology. This paper highlights the influence of the key technical aspects of the ABPI test that all practitioners need to consider in order to be able to make more reliable and informed management decisions based on ABPI findings.
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                Author and article information

                Contributors
                Sarah Casey:
                ORCID: http://orcid.org/0000-0003-4024-1012
                Sarah.Casey@newcastle.edu.au
                Sean Lanting: Sean.Lanting@newcastle.edu.au
                Christopher Oldmeadow: Christopher.Oldmeadow@hmri.org.au
                Vivienne Chuter: Vivienne.Chuter@newcastle.edu.au
                Journal
                Journal ID (nlm-ta): J Foot Ankle Res
                Journal ID (iso-abbrev): J Foot Ankle Res
                Title: Journal of Foot and Ankle Research
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1757-1146
                Publication date (Electronic): 2 August 2019
                Publication date PMC-release: 2 August 2019
                Publication date Collection: 2019
                Volume: 12
                Electronic Location Identifier: 39
                Affiliations
                [1 ]PO Box 127, Ourimbah, NSW 2258 Australia
                [2 ]GRID grid.413648.c, CReDITSS – HMRI, School of Medicine and Public Health, ; Newcastle, Australia
                Author information
                http://orcid.org/0000-0003-4024-1012
                Article
                Publisher ID: 350
                DOI: 10.1186/s13047-019-0350-1
                PMC ID: 6679535
                PubMed ID: 30809275
                SO-VID: 53cef981-c5a7-47b2-b0dd-cb1b4e6f90c8
                Copyright © © The Author(s). 2019
                License:

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 30 May 2019
                Date accepted : 29 July 2019
                Categories
                Subject: Review
                Custom metadata
                issue-copyright-statement © The Author(s) 2019

                ScienceOpen disciplines: Orthopedics
                Keywords: ankle brachial index,peripheral arterial disease,lower extremity artery disease,repeatability,reproducibility,reliability
                Data availability:
                ScienceOpen disciplines: Orthopedics
                Keywords: ankle brachial index, peripheral arterial disease, lower extremity artery disease, repeatability, reproducibility, reliability

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