It is simply unacceptable that in 2017, so many Americans undergo a non-traumatic limb amputation each year. Yet, as we recognize Peripheral Artery Disease (PAD) Awareness Month this September, estimates suggest between 160,000 and 180,000 Americans lose one of their limbs every year — about half of which are attributable to preventable vascular diseases. This figure includes 43,000 Medicare beneficiaries, according to Avalere.
This must change. As a public health crisis, PAD not only results in tens of thousands of preventable amputations, it also disproportionately impacts ethnic and racial minorities and costs taxpayers billions in additional spending.
PAD is caused when the arteries that carry blood from the heart to the limbs become blocked by plaque buildup. Typically, patients who smoke, are older than 65, or have a history of high blood pressure, diabetes, or high cholesterol are at an increased risk of developing PAD. Many of these risk factors are more common in African Americans, Native Americans and Hispanics, which makes them two to four times more likely as whites to develop PAD. Disparities also exist among Americans living in rural areas as well as those with lower incomes.
Compounding these issues is the fact that lifetime care for a person with limb loss can average as much as $500,000. Studies also show that patients who receive a first amputation are at an elevated risk of having to undergo another amputation and a significantly increased risk for mortality.
Fortunately, we already have the technology to identify and treat PAD before it progresses to a point where an amputation is required. We just need a comprehensive strategy to get the right treatment to the right people. If we are going to get serious about reducing limb loss from PAD, the US must adopt a new strategy that integrates increased public awareness and robust screening with non-amputation treatment measures and multidisciplinary care.
First, we must raise awareness about PAD. While as many as 18 million Americans are estimated to be living with the disease, many are completely unaware of the risks and thus may not seek care until it’s too late. Policymakers should consider what more we can do to ensure that there is a dedicated awareness effort to encourage doctors to make patient education a priority.
Second, more could be done to increase PAD screening for those already identified to be at risk. The American College of Cardiology and the American Heart Association recommend that all patients who smoke, are over 65, or have a history of diabetes or another vascular disease be screened for PAD. CMS should work to implement these screening guidelines so that no at risk patient is left unscreened. Earlier in the PAD disease progression, less invasive options such as medical therapy or even supervised exercise therapy can be helpful once the disease has been identified.
Third, policies should ensure that patients who are later in their disease progression are assessed for other treatment options before they undergo an amputation. We know techniques such as minimally-invasive revascularization can be used to clean clogged arteries in the legs and avoid amputation all together. However, studies show that as many as one third of late-stage PAD patients never receive arterial testing to evaluate whether they may be a candidate for this procedure.
Finally, there must be a strong effort to expand multidisciplinary care for at-risk patients. Hospitals and treatment centers that have adopted comprehensive amputation prevention programs have been successful in driving amputation rates to near zero. At the same time, however, the evidence shows that certain specialties are much more prone to amputate than revascularize. As a result, policymakers should consider ways to encourage multidisciplinary care to ensure the option to save a patient’s limb is considered.
The price of developing PAD should not be limb loss, especially when the technologies exist to identify these patients and save their limbs. This September, I hope that policymakers, providers and patients will take a moment to better understand PAD. Only then can we work together to save lives and limbs, and make non-traumatic amputations a thing of the past.
Jeffrey Carr, MD is an interventional cardiologist and endovascular specialist. He is the founding and immediate past president of the Outpatient Endovascular and Interventional Society, a multispecialty medical society. He is also the physician lead for the CardioVascular Coalition, a group dedicated to raising awareness for PAD and advocating for national health care policy and amputation prevention.