Pulse Check: A Survey of Clinical Practice in Lower Extremity Vascular Assessment

Peripheral arterial disease (PAD) is a prevalent and progressive condition that significantly impacts lower extremity health, particularly among patients with diabetes, chronic wounds, or vascular insufficiency.¹ Early identification and ongoing assessment of PAD are critical to preventing complications such as ulceration, infection, and limb loss.¹ Despite the availability of diagnostic tools and clinical guidelines, the integration of vascular assessments into routine practice remains inconsistent, often influenced by clinician preference, resource availability, or perceived patient risk.

PAD assessment methods range from basic techniques, such as pulse palpation, to more advanced diagnostics like the ankle-brachial index (ABI), plethysmography (PPG), and near-infrared spectroscopy.² However, the frequency and context in which these tools are used vary widely. This variability may hinder timely diagnosis and appropriate intervention, particularly in at-risk populations.

To better understand current practices, a cross-sectional survey explored how healthcare professionals assess lower extremity vascular health, the tools and methods they employ, and how assessment results influence clinical decision-making. The survey also examined the timing and rationale for conducting vascular assessments, the prevalence of comorbid conditions among patients undergoing testing, and the educational resources clinicians rely on to stay informed.

This study aimed to establish a baseline understanding of PAD assessment practices, identify gaps in implementation, and highlight opportunities for standardization and education to improve vascular health outcomes in clinical settings.

Survey Methods

Data was collected via an online e-survey recruited from the Podiatry Today email database of healthcare practitioners and social media followers. No incentive was offered to complete the survey. Data were collected via online platform between August 5 and October 11, 2025. A total of 60 responses were collected for the PAD Assessment Trends 2025 survey. Of these, 18 (30%) were complete, and 42 (70%) were partially complete. No responses were disqualified.

A Review of the Results

Time allocation for vascular assessment methods. Respondents reported varied time spent on assessment for lower extremity vascular health. The most frequently used method was palpation of pulses (n = 17), followed by handheld Doppler (n = 15) and ankle-brachial index (ABI) testing (n = 15). Plethysmography (PPG) was used by 12 respondents, while 10 indicated use of other methods.

Timing of vascular assessments. When asked when vascular assessments are incorporated into practice, the most common responses were:

• When patients present with vascular symptoms (100%, n = 20)
• If the patient has a wound or ulcer (95%, n = 19)
• If history or exam indicates risk for PAD (90%, n = 18)
• Prior to surgery (60%, n = 12)

Routine assessments were less common, with 25% (n = 5) performing them annually for all patients and 30% (n = 6) doing so more than once annually. A smaller portion (15%, n = 3) selected “Other.”

Patient diagnoses associated with vascular testing. Respondents indicated that vascular testing was most often associated with patients who had:

• Open wounds or ulcers (n = 19)
• PAD (n = 18)
• Venous insufficiency with edema (n = 18)
• Diabetes (n = 16)
• Other diagnoses (n = 4)

Sources of continuing education. To stay current on best practices in vascular assessment, respondents reported engaging in:

• Live conferences (n = 19)
• Reading industry publications and journal articles (n = 16)
• Virtual webinars (n = 15)
• Word of mouth from colleagues (n = 14)
• Other resources (n = 3)

Influence of assessment results on treatment. The majority of respondents (70%, n = 14) indicated that vascular assessment results always influence their treatment plans. An additional 25% (n = 5) reported that results often influence treatment, while 5% (n = 1) said they sometimes do.

Care settings for vascular assessments. Respondents most frequently referred patients to external vascular labs or hospital departments (n = 17). Fourteen respondents reported that their practice owns vascular screening devices and performs assessments in-house. Eight selected “Other.”

Why Vascular Screening Is Essential in Wound Care

Medical Necessity Documentation Under WISeR. The WISeR (Wasteful and Inappropriate Services Reduction) Model, launching in January 2026 in six states (including Ohio), introduces AI-driven prior authorization for services deemed high-risk for overuse or fraud—including skin substitutes and cellular, acellular and matrix-like products (CAMPs).³ 

Under WISeR:

• Providers must demonstrate clinical appropriateness and necessity for advanced therapies.
• Claims lacking objective vascular assessment data (e.g., ABI, TBI, Doppler) may be flagged or denied.
• Pre-authorization will be required for many wound-related services in the impacted states, and vascular screening will be a key component of that justification. 

LCD changes emphasize standard of care first. The proposed 2026 LCD updates for CTPs,4 which at time of this publishing are future effective for January 1, 2026, require:

• At least 4 weeks of standard wound care before CTP use.
• Documented failure to improve by ≥50% in wound size.
• Evidence of vascular assessment, especially for diabetic foot ulcers (DFUs) and venous leg ulcers (VLUs), to rule out ischemia as a barrier to healing.
• Use of the KX modifier for more than 4 applications, which must be backed by documentation of healing progress and continued medical necessity. 

Clinical relevance: PAD and healing outcomes. PAD is present in up to 29% of patients with chronic wounds, and delayed diagnosis can lead to⁵:

• Increased risk of major amputation.
• 70% 5-year mortality post-amputation.
• Poor outcomes with advanced therapies if perfusion is inadequate.

Vascular screening as a gatekeeper. Vascular assessments such as ABI, TBI, and Doppler ultrasound:

• Confirm perfusion adequacy before initiating advanced therapies.
• Help triage patients to revascularization or conservative care.
• Provide objective data to support medical necessity in audits and pre-authorizations.

Concluding Thoughts

The findings from the PAD Assessment Trends 2025 survey reveal a diverse landscape of clinical practice in the assessment and management of peripheral arterial disease. While many clinicians incorporate vascular assessments in response to specific clinical indicators—such as wounds, symptoms, or surgical planning—routine screening remains underutilized. The variability in tools used, timing of assessments, and educational resources accessed suggests a need for greater standardization and support.
Importantly, many respondents reported that vascular assessment results significantly influence treatment decisions, underscoring their clinical value. However, reliance on basic tools and inconsistent access to advanced diagnostics may limit the effectiveness of PAD management in some settings.

Call to Action

To improve outcomes and ensure timely, evidence-based care for patients at risk of PAD, the following actions are recommended:

• Audit current workflows to ensure alignment with upcoming CMS requirements.
• Standardize protocols for when and how vascular assessments should be conducted, especially for at-risk populations.
• Promote routine screening for PAD in patients with diabetes, chronic wounds, or other vascular risk factors—not just in response to symptoms.
• Expand access to diagnostic tools such as ABI and PPG devices in outpatient and community settings.
• Document vascular status clearly in the medical record before initiating CTPs.
• Invest in clinician education through targeted training, webinars, and access to current literature on PAD assessment and management.
• Encourage interdisciplinary collaboration between wound specialists, vascular teams, and primary care providers to ensure comprehensive care.
• Support data collection and benchmarking to track assessment practices and outcomes over time, enabling continuous improvement. 

Dr. Cole is the Director of Wound Care Research at Kent State University School of Podiatric Medicine and a member of the Podiatry Today Editorial Board.  

References
1.    Zemaitis MR, Boll JM, Dreyer MA. Peripheral arterial disease. In: StatPearls [Internet]. StatPearls Publishing; 2025. Updated May 23, 2023. Available at: https://www.ncbi.nlm.nih.gov/books/NBK430745/
2.    National Institute for Health and Care Excellence (NICE). Peripheral Arterial Disease: Diagnosis and Management: Evidence Review for Determining Diagnosis and Severity of PAD in People with Diabetes. NICE; 2018. (NICE Guideline No. 147.) Available at: https://www.ncbi.nlm.nih.gov/books/NBK550332/
3.    Centers for Medicare & Medicaid Services. WISeR Innovation Model. Available at: https://www.cms.gov/priorities/innovation/innovation-models/wiser. Accessed November 12, 2025.
4.    Centers for Medicare & Medicaid Services. Medicare Coverage Database: LCD ID 39823 (Version 11). Available from: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=39823&ver=11
5.    Li WW, Carter MJ, Mashiach E, Guthrie SD. Vascular assessment of wound healing: a clinical review. Int Wound J. 2017;14(3):460–9.