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Morning Consult: Policy Reforms Needed to Address Most Traumatic Impacts of Diabetes

Dec 1, 2017

According to the American Diabetes Association, more than 30 million Americans today are living with diabetes. With a new diagnosis every 21 seconds, it’s a disease that’s forcing growing numbers of Americans to contend with a variety of significant health challenges. Uncontrolled, it can rob patients of their vision, kidneys and even their lives. In 2014, diabetes was the nation’s seventh leading cause of death.

Yet, even as millions of Americans learn to address – and hopefully avoid – some of diabetes’ most common complications, one of the most traumatic remains a dangerously silent threat, particularly for minority populations.

Diabetes is a major risk factor for Peripheral Artery Disease – a narrowing of the arteries feeding the body’s lower extremities, which causes pain, poor mobility, tissue death and life-threatening infections. Each year, tens of thousands of disproportionately African American patients undergo lower-limb amputations as a result of diabetes and PAD. According to recent research, regions across the country with larger populations of African Americans living with diabetes see amputation risks as much as three to four times higher than the national average.

Our initiative, Standing TALL, specifically aims to increase understanding about the startling racial disparities that exist among American amputees because far too many minority Americans experience limb removal when amputation could have been prevented.

It’s a trend that’s devastating both for vulnerable patients and our health care system. Nationally, the amputation rate among African American Medicare patients was nearly three times higher than the rate among other beneficiaries (5.6 per 1,000 vs. 2.0 per 1,000). The costs of these amputations to the U.S. health care system reach an estimated at $10.6 billion annually – with Medicare being the largest payer, covering an estimated 66 percent.

While health care providers, advocates and researchers have made enormous strides when it comes to diabetes education, treatment and even prevention, there is still a tremendous dearth of progress related to stopping the associated causes of PAD and amputations. It’s a shortfall largely attributable to lack of knowledge – both on the part of patients and their providers.

It’s estimated that as many as 18 million Americans unknowingly live with peripheral artery disease, unaware of the potentially significant implication of leg pain and the need for early screening and intervention. And even when patients do seek expert consultation and receive a PAD diagnosis, there is significant variation in whether a clinician chooses amputation versus limb-saving revascularization therapy.

Whenever options exist to help patients avoid amputation, it’s incumbent upon health care providers to use their knowledge and expertise to try to save the limb. Increased screening is, indeed, one of the best places to start. Today, although the U.S. Preventive Services Task Force cites insufficient evidence for PAD screening for the general population, guidelines issued by the American College of Cardiology and American Heart Association disagree: both groups recommend screening of at-risk patients (those over age 65, have a history of diabetes, smoking, and/or PAD; or have been diagnosed with other vascular disease).

Increased screening, along with the establishment of best practices for PAD patients facing amputation are long overdue. For example, there is still no intragovernmental federal health policy to ensure patients are assessed for non-amputation treatment options before they suffer limb loss. Instituting such a policy, which would require arterial testing – could push adoption of quality measures, guidelines and appropriate payment incentives to ensure patients receive appropriate arterial evaluation prior to costly amputations.

Working together, policymakers and the health care system have the power to reduce amputations, which are tragic, particularly when you consider that many are completely avoidable.  Increased awareness, screenings and multidisciplinary care – like centers of excellence across the country that have been effective in driving amputation rates down to near zero – will get us there.

We must, however, put muscle behind this effort, starting now.  As we round out National Diabetes Month, it’s important to advance initiatives that ensure PAD and limb loss don’t remain silent, avoidable and largely unknown consequences for patients with diabetes.

Jeffrey Carr is an interventional cardiologist and endovascular specialist, as well as the founding and immediate past president of the Outpatient Endovascular and Interventional Society, a multispecialty medical society, and 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.

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