As a physician on the frontlines of an overlooked epidemic, I’ve seen countless patients who have had no choice but to have their limbs surgically amputated because they didn’t have access to the clinical interventions that could have saved their legs.
No, I don’t work in a developing country. I’m a doctor in the Mississippi Delta.
{mosads}Despite living in the world’s richest country—a nation that spends twice as much on health care as any other – many minority communities in the U.S. suffer disproportionately from chronic diseases that wreak havoc on lives and limbs.
Since April is National Minority Health Month, now is the perfect time to reflect on the inequities facing millions of Americans, as well as how we can collectively pave the path for building stronger, healthier communities.
Each year, roughly 200,000 Americans – about 548 each day – will have their limbs amputated because of non-traumatic causes like peripheral artery disease (PAD). Never heard of PAD before? Neither have many of my patients until it is too late.
PAD occurs when fatty deposits in the arteries restrict the blood flow to the limbs, resulting in pain in the legs, poor healing of diabetic ulcers, gangrene, and eventual amputation. An all-too-common complication of diabetes, PAD is a risk for the over 30 million Americans living with diabetes and 84.1 million living with prediabetes. Unfortunately, minority communities are most at risk: according to the American Diabetes Association, African Americans are 1.7 times more likely than non-Hispanic whites to have diabetes.
It is no wonder then that PAD disproportionately impacts minority populations most severely. Data show that African-American patients with diabetes are nearly four times more likely to have their limbs surgically removed than whites. Similar trends exist for Native Americans in the West and Hispanics, who are twice as likely and 75 percent more likely, respectively, to suffer from PAD than their Caucasian counterparts. Tragically, even higher rates are seen for minorities living in my home state of Mississippi, which is the epicenter of the PAD epidemic.
This increased prevalence is further compounded by lack of access to quality care. Even though early screening and treatment can reduce the probability of an amputation by an estimated 90 percent, it is still extremely underutilized and far too many patients do not even realize they have PAD until the disease has progressed too far for intervention. According to research from the Mayo Clinic, even though PAD is more prevalent than all cancers combined, PAD is diagnosed and treated in less than 25 percent of ALL affected patients.
Sadly, in the Mississippi Delta where I practice, more than 90 percent of the amputees I’ve met, most of whom are African American, have never had a diagnostic test for PAD or an appropriate vascular evaluation to salvage their limbs. When it comes to something as serious as amputation, where you live, your skin color, insurance status, or socioeconomic status should not determine whether or not your limb is saved – a phenomenon known as the “amputation lottery.”
As a limb salvage specialist and an African American, I am dedicated to serving not just my patients, but also the whole community. I have made it my mission to both help patients save their legs and influence policymakers to adopt smarter policies to help eliminate the painful PAD disparities that afflict communities of color.
I urge Congress to direct the administration to convene an Intragovernmental Workgroup on Amputation Reduction. Such a working group should focus on implementing three pillars for protecting patients most at risk of PAD. First, stronger policies must be enacted in order to increase at-risk patients’ access to screening. To this end, the Department of Health and Human Services should work with the U.S. Preventive Services Task Force (USPSTF) to develop screening protocols for our nation’s most at-risk patients.
Second, multidisciplinary care must be a priority. Interprofessional Internet Consultation Codes in the Medicare Physician Fee Schedule could encourage multi-disciplinary teams to provide vascular evaluations to provide risk assessments and referral recommendations to underserved communities.
Finally, there must be no amputation without vascular evaluation. Policies should be implemented that require providers to document vascular evaluations in the 12 months prior to having patients undergo non-traumatic, non-emergent amputations. Failure to perform arterial testing should result in non-payment for the amputation from Medicare (and other payors).
By promoting policies that expand access to early detection, screening, and clinical interventions, we can successfully reduce amputations for our most at-risk communities. No one should lose a limb when it can be saved.
Foluso Fakorde, MD is a practicing interventional cardiologist and co-chair of the PAD Initiative for the Association of Black Cardiologists.