Nov 3, 2018
– Foluso Fakorede, MD, on tackling the epidemic of PAD among minorities
In 1966, Dr. Martin Luther King, Jr., observed: “Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.” Addressing the Medical Committee for Human Rights, he understood that the failure to adequately prevent and treat diseases in minority communities perpetuates the racism and inequity that he rallied against his whole life.
While rapid medical advancements and greater respect for civil rights have helped us make great strides over the last 5 decades, we still have a long way to go towards achieving justice in healthcare. The disparity in treatment of peripheral artery disease (PAD) is a most devastating example of this injustice. PAD is the most prevalent, debilitating, costly, and deadly pandemic that most Americans have never heard of. Which patients live and which patients die from PAD is often determined by race, income, insurance status and geographical location.PAD can be prevented and treated in many patients. However, instead of identifying and treating this disease early, many patients undergo unnecessary amputations. These unnecessary amputations disproportionately plague minorities across the country. Compared with their white counterparts, data show Hispanics are 75% more likely to face amputations, while Native Americans in the West are more than twice as likely to be amputated, and African-American patients with diabetes are over three times more likely to have their limbs surgically removed — with even higher rates in Mississippi.
How is it that there are approximately 200,000 non-traumatic amputations each year in the United States when the majority of them can be avoided with proper care? Experience suggests that lingering disparities in healthcare stem from larger systemic inefficiencies.
For example, the state of Mississippi – where I practice – is the epicenter of the PAD epidemic. Mississippi has the lowest number of physicians per capita and is the country’s poorest state, with an average annual household income of $41,000. Sadly, the results are predictable: more than 90% of the amputees I have encountered in Mississippi have never had a diagnostic test for PAD or an appropriate vascular evaluation to salvage their limbs. PAD is as serious as cancer, yet its risks are vastly underappreciated. If screening for cancer has become routine, why is screening for PAD – which can reduce the probability of an amputation by 90% – so underutilized amongst vulnerable populations?
For the vast majority of PAD patients who remain undiagnosed and untreated, the outcomes are stark. Most amputees will require life-long caregiving assistance, usually from family members, resulting in lost wages and benefits since caregiving is practically a full-time job. In addition to this burden, there are unreimbursed costs for patients and their families with medical and nonmedical expenditures estimated to be $150,000 annually and nearly $800,000 over a lifetime. The tragic reality is that the cost of unnecessary amputations represents a tremendous burden on patients, families, the workforce, the Medicare system, and our national economy.
As a limb salvage specialist, I was so troubled by these trends that I moved to the Mississippi Delta 3 and 1/2 years ago to do my part. With no institutional support, no financial support, and no multi-disciplinary team in my immediate vicinity, I started my own private practice and founded the Cardiovascular Solutions of Central Mississippi. Our approach was to cultivate professional teams to go out into the community directly to increase educational awareness of the importance of screening, seeking a second opinion and having an angiogram prior to amputation.
Through this program, our team was able to decrease PAD-related amputation rates in the region by 87.5%. In the year prior to my arrival, the hospital I currently service – the only hospital serving Cleveland, Mississippi’s population of 12,500 – performed 56 major amputations and zero diagnostic tests for PAD. Last year, that same institution performed just seven amputations and almost 500 diagnostic tests for PAD.
How did our team at Cardiovascular Solutions of Central Mississippi accomplish this as a solo private practice? We assembled a great team of nurses, technicians, and medical assistants and increased our patient base from 128 in October 2015 to 10,000 individuals served in the Mississippi Delta region by September 2018. Our team comprehensively treated every one of our patients as family members. We utilized aggressive early screening, diagnosis and treatment of modifiable cardiovascular risk factors in patients who are at-risk and advocated for diagnostic testing before amputations. We promoted patient medical literacy and advocacy via a faith-based approach – building community navigators, educating the community about PAD and stressing the importance of prevention over cure. We also recognized the social determinants of health and discussed solutions with stakeholders on local and state levels.
These results can be realized elsewhere. I recently joined a group of PAD care providers in Washington, D.C., to call on the federal government to adopt a national strategy to reduce non-traumatic amputations through increased awareness of PAD, increased screenings for at-risk populations and improved access to multidisciplinary care.
As the number of Americans with PAD, obesity, and diabetes continues to skyrocket, it is essential to expand healthcare access to underserved communities across the country and address the health disparities that impact individuals of all ages. Trends show that risk factors for PAD are presenting in patients earlier in life, underscoring the need for solutions to halt the progression of PAD in our most at-risk populations. Just as the systems in our body work in harmony, so too should our healthcare system, our government, our schools, our churches. and community organizations to effect this change. Together, we can take the next step toward the justice Dr. King dreamed of.
Foluso Fakorede, MD, is a practicing cardiologist and CEO of Cardiovascular Solutions of Central Mississippi as well as co-chair of the PAD Initiative for the Association of Black Cardiologists.