PAD Resources for Physicians
PAD Statistics
Lower-extremity peripheral artery disease (PAD) affects >200 million adults worldwide and 8 to 10 million adults in the United States.
Its global prevalence increased by 24% from 2000 to 2010 (26% and 23% increase in individuals >65 years and <65 years of age, respectively).
Among patients with diagnosed PAD, ~11% are likely to develop critical limb ischemia (CLI; also known as chronic limb-threatening ischemia), a clinical condition in which the blood supply to the limb does not accommodate the resting metabolic needs of the tissue, resulting in persistent foot pain, skin ulceration, and gangrene.
A quarter of patients with CLI require limb amputations within a year after the diagnosis to resolve limb pain, non healing wounds, and life-threatening infection.
Nonetheless, several reports have shown that the incidence of nontraumatic lower-extremity amputations declined steadily in the 1990s and 2000s.
Using data from Medicare and Medicaid, Goodney et al reported that the rate of lower-extremity amputations decreased by 45%, from 196 procedures per 100,000 patients in 1996 to 119 procedures per 100,000 patients in 2011.
The proportion of patients with CLI requiring major amputation declined from ~17% in 2003 to ~11% in 2011.
Among patients with diabetes, after a 43% decline between 2000 and 2009, amputation rates increased by 50% from 2009 to 2015.
For patients without diabetes, the rate of non-traumatic lower-extremity amputations appeared to plateau between 2012 and 2015. Accordingly, in 2015, there were ~150,000 nontraumatic lower-extremity amputations in the United States.
Although amputation is an important and potentially sole treatment option for some patients, it often is preventable, even among patients with advanced PAD.
Thus, a concerted effort is needed to address the burden of nontraumatic lower-extremity amputation and to institute policies to mitigate its incidence and improve limb outcomes among patients with PAD.
Some racial and ethnic groups and those who are living in poverty have an elevated risk of PAD but less access to high-quality vascular care, leading to increased rates of amputation.
Improving the diagnosis and management of PAD could have a great impact on health care disparities.
Disparities
Among Medicare beneficiaries with diabetes and PAD, 4-fold differences in amputation risk are recognized between black Americans and other racial/ethnic groups.
Even after patients receive invasive treatment, these disparities continue to manifest. After similar revascularization treatments, black patients are more likely to undergo amputation.
Lower socioeconomic status (eg, income) is independently associated with higher risk of lower-extremity amputation.
Per 100,000 patients with PAD, the Mountain region observed 5500 amputations, whereas the East South Central region had 8400 amputations.
Patient impact
Despite advances in surgical technique and critical care, mortality rates after major amputation for PAD remain high, such that post-amputation mortality is often equated to the mortality risk of advanced cancer.
A recent meta-analysis reported a 3-year mortality risk of 71% after lower-extremity amputation.
Mortality risk increases with older age, proximal amputation level (eg, above the knee), and comorbidities, particularly cardiac and kidney disease.
Average 30-day post-amputation mortality has remained relatively stable at 5% to 15% across different clinical settings.
The ultimate goal is to maximize personal outcome priorities and QOL for the remaining life.
A systematic review has shown that walking ability and use of a prosthesis have the strongest influence on QOL in individuals after amputations.
For many people, a perceived loss of ability to participate in previous vocational, recreational, social, and sexual activity can have a greater toll on postamputation QOL than the absent limb itself.
Depression and anxiety are highly prevalent, with rates of 20% to 30% of patients with major depressive disorders.
Post-discharge rehabilitation and prosthetic use play an important part in both physical and psychological recovery.
Recommended approaches for improved public awareness of PAD
Enhanced clinician education
Early detection
Optimal use of evidence-based PAD management
Smoking cessation
Statins
Regular foot monitoring/care in patients with diabetes
Timely referral to vascular specialists
Improved access to health care
And the elimination of health care disparities surrounding these issues
Proposed policies for better treatment of PAD
Adoption of quality and performance measures for PAD care
Screening for PAD in individuals with high risk
Coverage for annual foot monitoring of patients with diabetes
Robust federal regulation of tobacco products
Availability of affordable tobacco cessation therapy
Integration of clinical decision support to diagnose and manage PAD
Consistent reimbursement for the ankle-brachial index (ABI) diagnostic test across all states
Affordable, accessible, and equitable medical care for all patients with PAD
Professional education on PAD diagnosis and management
Dedicated funding opportunities to support PAD research
Importance of the awareness of PAD
Only 26% of people >50 years of age expressed familiarity with PAD.
Primary care physicians were aware of a PAD diagnosis among their patients with a history of PAD only 49% of the time.
Suboptimal awareness of PAD by both patients and health care professionals is likely to contribute to lower-than-expected use of guideline-directed medical therapy for those with PAD.
Among individuals with PAD, only ~30% were taking statins.
Smoking cessation therapy (counseling or medication) was given to only ~35% of current smokers with PAD.
There was no temporal change in the use of preventive therapy and lifestyle counseling among patients with PAD from 2005 to 2012.
Although the American Diabetes Association recommends regular foot care in individuals with diabetes, only ~30% of eligible patients actually receive it.
National PAD Action Plan
Goal 1 - Public Awareness: Reach people with PAD and those at risk for PAD by improving public awareness of PAD symptoms and diagnosis.
Goal 2 - Professional Education: Enhance professional education for multidisciplinary healthcare professionals who care for people with PAD.
Goal 3 - Detection and Treatment: Activate healthcare systems to provide enhanced programs for the detection and treatment of PAD patients, with a focus on understanding and addressing patient-centered outcomes.
Goal 4 - Public Health: Reduce the rates of nontraumatic lower extremity amputations related to PAD through public outcome reporting and public health interventions.
Goal 5 – Research: Increase and sustain research to better understand the prevention, diagnosis and treatment of PAD.
Goal 6 – Advocacy: Coordinate PAD advocacy efforts to shape national policy and improve health outcomes.
Impact on the Healthcare System and Healthcare Costs
The annual cost of providing inpatient care for patients with a primary diagnosis of diabetic foot ulcers was estimated at >$790 million in 2010, as a consequence of nearly 60000 admissions annually at a cost per hospitalization exceeding $13,000.
Among hospitalizations requiring revascularization or amputation, costs were found to be even higher, with open and endovascular revascularization costing ~$60000 per hospitalization and major amputation costing ~$54000 per patient in 2010.