Feb 13, 2018
Did you know that more than 185,000 Americans – enough to fill 2 1/2 football stadiums – lose a limb each year due to amputation? Did you also know that half of those amputations are the result of completely preventable vascular diseases like peripheral artery disease? Even though we’re well into the 21st century, tens of thousands of Americans experience completely unnecessary painful, devastating and life-altering amputations. This is a significant public health concern that demands the attention of the federal government.
PAD is typically caused when the arteries in a person’s legs become blocked by a build-up of plaque. Patients who smoke, are over the age of 60, or have a history of chronic conditions like diabetes or high blood pressure are most at risk. Though PAD can affect anyone, many of these risk factors are common in minority communities with studies showing that African-Americans and Hispanics with PAD are between two and four times more likely to undergo an amputation than white patients.
The toll of PAD-related limb loss is far reaching. Not only does it leave individuals permanently disabled, research shows that patients who have an amputation are at a significantly higher risk of needing a second one several years late. Furthermore, the lifetime cost of care for a person with limb loss can be as high as $500,000, taking an additional toll on family finances and taxpayer-funded public health programs alike.
We have the technology – and the capability – to identify and treat patients early on in their diseases progression. We also have the means to screen at-risk individuals and prescribe interventional treatment before PAD even develops. What’s missing is a commitment from the federal government to make non-traumatic amputations a thing of the past.
Thankfully, Congress is beginning to listen. A group of lawmakers, led by Congressmen Erik Paulsen (R-Minn.) and Donald Payne Jr. (D-N.J.) – recently sent letters to the Departments of Health and Human Services and Veteran’s Affairs urging the administration to adopt a national strategy for reducing PAD-related amputations through increased awareness, increased screening for at-risk populations, improved access to multidisciplinary care, and policies that ensure no one receives an amputation without first undergoing arterial testing.
To start, we must do more to raise awareness about PAD. Though as many as 18 million Americans are estimated to be living with PAD, there is no dedicated awareness program from the Centers for Medicare & Medicaid Services to engage and educate at-risk individuals about their condition and its accompanying risks. Such a program, which could be modeled after CMS’ Fistula First Breakthrough Initiative that successfully encouraged providers to switch to low-infection fistulas for diabetes patients, would go a long way toward increasing screening and vascular interventions.
Second, the administration must make screening for at-risk patients a priority. Despite recommendations from the American Heart Association and the American College of Cardiology that all patients who smoke, are over 65, or have been diagnosed with another type of vascular disease get screened, the U.S. Preventative Services Task Force does not recommend screening for the at-risk population. CMS should update these guidelines so potentially at-risk patients aren’t left unscreened.
Additionally, CMS must recognize that awareness is not always enough. There must be policies in place to ensure that patients are assessed for all other treatment options before they receive an amputation. According to a 2014 study, a third of late-stage PAD patients had no arterial testing in the year before their amputation to determine if they were a candidate for limb-saving procedures. Without testing, there is no way to know for sure whether an amputation is truly necessary.
And finally, more must be done to expand multidisciplinary care for at-risk patients. Though many Centers of Excellence across the country have been successful in driving their amputation rates to near zero, there are still too many patients who don’t live close enough to benefit. The Administration should make it a priority to expand access to such care, especially in minority communities.
I applaud the bipartisan lawmakers in Congress who are calling for a robust, comprehensive, nationwide strategy to “sprint to zero” for non-traumatic amputations and encourage others to lend their voice to this effort. Only then can we save limbs – and lives. No patient should have to endure the pain and trauma that comes with losing a limb, especially if their amputation occurs unnecessarily.Jeffrey Carr, MD, is a member of the CardioVascular Coalition’s Board of Directors and founding president of the Outpatient Endovascular and Interventional Society.