In a recently published study in the Journal of the American Heart Association (JAHA), researchers assessed nearly 189,000 Medicare fee-for-service patients in over 31,000 different zip codes (with greater than or equal to 100 beneficiaries) who had a major lower extremity amputation between 2010-2018.1 Over 78 percent of patients who had a major lower extremity amputation lived in metropolitan areas, according to the study. Researchers also found higher rates of these amputations among African Americans and those with lower socioeconomic status.
In their study, Fanaroff and colleagues suggest that geographic proximity to subspecialty peripheral arterial disease (PAD) care in metropolitan areas may not be adequate to ensure access to high-quality care.1 Foluso A. Fakorede, MD and Alton R. Johnson, Jr., DPM, concur that geographic proximity is not equivalent to access.
“There can be a PAD care center within the patient’s zip code but how does the patient get transportation to the facility?” questions Dr. Johnson, an Assistant Professor of Internal Medicine in the Division of Metabolism, Endocrinology and Diabetes-Podiatry at the University of Michigan Medical School. “Secondly, if the patient does have transportation to the facility, can the patient afford the copay for the appointment or procedure that is needed? Third, if the patient has the transportation and can afford the copayment, how long will it take for the patient to be seen by a provider due to the high demand for care within that zip code?”
Dr. Fakorede says there are multiple factors that contribute to preventable amputations in high-risk patient populations.
“The roots of unnecessary preventable amputations lie in the failure of our health-care system to raise PAD awareness; address structural racism (generational mistrust) and social determinants of health; failure to provide early screening and treatment of at-risk patients; and the lack of a multidisciplinary team-based approach, resulting in the delivery of variable and inconsistent care,” maintains Dr. Fakorede, an interventional cardiologist and Chief Executive Officer of Cardiovascular Solutions of Central Mississippi in Cleveland, Miss.
Dr. Johnson suggests increasing the knowledge of initial vascular screening among members of the multidisciplinary team and providing more access to technological advances in this arena.
“I believe that every primary care provider (PCP) and podiatry office should have point-of-care units that can test lower extremity thermography and ankle-brachial index (ABI)/toe brachial index (TBI) within a few minutes for vulnerable patients,” maintains Dr. Johnson. “These types of screenings provide early detection, facilitate better coordination of referrals and allow prioritizing of visits for the PAD care providers.”
The study authors suggest the development of targeted community-based tools to facilitate earlier intervention in high-risk populations in metropolitan areas.1
“Understanding of social determinants of health is the bedrock to which societies should modify care delivery models, focus research, and disseminate equal quality care,” emphasizes Dr. Fakorede. “Fund community and faith-based, health-driven initiatives within marginalized communities and establish partnerships between local respected leaders of underserved and vulnerable populations and health-care providers dedicated to PAD/CLI care. These (measures) should help address some of the generational mistrust that exists in our health-care system and eventually aid in the recruitment and retention of minority patients in cardiovascular trials in which underrepresentation of minorities has been historically less than 5 percent.”2
Dr. Johnson concurs that free lower extremity screenings and seminars affiliated with local churches, mosques, and temples are always “high yield.” He also advocates for the use of low-cost technology which can help patients understand PAD progression, whether it is in the form of a user-friendly, low-cost or free smartphone app or hardware that scans the lower extremity for vulnerabilities.
What Other Studies Have Revealed About Treatment Gaps in Patients with PAD
One 2017 study referenced in the JAHA study noted that only 36 percent of outpatients with PAD received antiplatelet therapy, 33 percent received statin therapy and 36 percent of smokers received smoking cessation counseling.1,3 In a separate multi-country registry of patients followed at PAD subspeciality clinics, only two percent of U.S. patients received referrals for supervised exercise therapy.4
“Unfortunately, lack of awareness of PAD on the patient and provider levels plays a significant role in these poor statistics,” laments Dr. Fakorede. “Patient-, society -, and provider-directed educational efforts are needed to address and close these treatment gaps. We need to readdress our curriculums across the training spectrum to include robust PAD content and allow for more cross-training early on in the training curriculum of our multidisciplinary teammates.”
Dr. Fakorede also calls for the development of sponsored fellowships/rotations in underserved communities.
“These educational venues would provide trainees not only the opportunity to learn evidence-based, protocol-driven care, but do so in a partnership with trainers from various specialties with an overarching emphasis on PAD/CLI care for vulnerable populations,” explains Dr. Fakorede.
On a patient-community level, Dr. Fakorede says there are multifactorial issues including a lack of awareness of necessary medications to treat disease as well as affordability/adherence issues due to social determinants that play a significant role in hampering the use of multiple supervised exercise therapy (SET) sessions.”
Dr. Johnson says he has seen these kind of treatment gaps across the various health systems in the United States. However, he believes clinicians all do their best given the circumstances and resources of their respective health-care systems. Dr. Johnson also notes that a multitude of comorbidities may prevent these patients from being candidates for the aforementioned therapies. In regard to SET sessions, Dr. Johnson says there may be a variety of issues that prevent the use of this modality for high-risk patients, including transportation challenges, issues with insurance authorization and co-pays, and lastly, getting patients to accept they need this modality to reduce long-term severity of their disease.
Can Social History Have an Impact?
Drs. Fakorede and Johnson believe more diligence and consistency in ascertaining a patient’s social history can help improve preventive efforts in high-risk patients with diabetes and PAD.
“We currently exist in an anemic public health infrastructure in which screening for diabetes is endorsed but screening for its major complications (PAD and chronic limb-threatening ischemia (CLTI)) are not endorsed by our preventative service task force (the U.S. Preventive Services Taskforce) that has a due diligence to focus on preventative limb-life saving measures,” points out Dr. Fakorede.
In addition to diabetes, Dr. Fakorede says nicotine use is a “major driver globally” for the PAD epidemic but he adds that not all of these at-risk patients smoke cigarettes. He points out that patients who have a history of dipping snuff or chewing tobacco are clearly missed when asked “if they smoke cigarettes.”
“We need to standardize this line of questioning in our clinical or research questionnaires to include all tobacco products (including smokeless products),” maintains Dr. Fakorede.
Drs. Fakorede and Johnson say other pertinent questions of the social history may include topics such as reliable transportation for appointments; access to walking paths or parks for daily exercise; access to healthy foods and/or fresh produce on a weekly basis within a five-to-10-mile radius of their home; possible challenges with health-care insurance; and periodic screening exams for eyes, feet, and kidneys.
Questions like these can “further engage the patient to understand the confounding factors that could influence the patient’s targeted outcomes in the future even with an appropriate treatment plan,” suggests Dr. Johnson.
Dr. Fakorede emphasizes that the interpersonal and technical competence of local physicians are key to engendering hope and care-seeking behavior in high-risk populations with diabetes and PAD. He also notes that robust provider-community engagement can provide an antithetical counterbalance to physician and patient preconceptions of treatment based on opinions of one’s candidacy for that treatment and the past course of treatment for patients sharing similar characteristics such as race.
“This has led to bridging gaps in health communication (often related to low patient health literacy and lack of culturally competent care), which can significantly affect medical treatment, compliance and long-term outcomes,” says Dr. Fakorede. “Patients are able to discern this unspoken value and understand that their candidacy for a treatment plan or procedure will not be biased by preconceived notions and implicit bias has been eliminated from the care algorithm.”
1. Fanaroff AC, Nathan AS, Khatana SAM, et al. Geographic and socioeconomic disparities in major lower extremity amputation rates in metropolitan areas. J Am Heart Assoc. 2021;10(17):e021456. Doi: 10.1161/JAHA.121.021456.
2. Yates I, Byrne J, Donahue S, McCarty L, Mathews A. Representation in clinical trials: a review on reaching underrepresented populations in research. Clinical Researcher. 2020;34(7). Available at: https://acrpnet.org/2020/08/10/representation-in-clinical-trials-a-review-on-reaching-underrepresented-populations-in-research/ . Published August 10, 2020. Accessed December 22, 2021.
3. Berger JS, Ladapo JA. Underuse of prevention and lifestyle counseling in patients with peripheral artery disease. J Am Coll Cardiol. 2017;69(18):2293-2300.
4. Saxon JT, Safley DM, Mena-Hurtado C, et al. Adherence to guideline-recommended therapy-including supervised exercise therapy referral-across peripheral artery disease specialty clinics: insights from the International PORTRAIT Registry. J Am Heart Assoc. 2020;9:e012541.