In the year before amputation, a deep divide was seen between patients who got specialist care and those who did not.
Among patients with severe peripheral vascular disease who ultimately undergo major amputation, those least likely to receive subspecialty vascular care are disproportionately Black, living in rural areas, and have low income, education, and/or employment status, according to an analysis of Medicare recipients.
The researchers say this backstory to the higher amputation rates observed in these populations reinforces the need for quality measures and metrics around PAD and chronic limb-threatening ischemia (CLTI).
"There are opportunities for prevention starting probably 30 years prior to an amputation, but we focused on the year prior. . . . The message here is that there are too many people that we are not even giving a chance at preventing their amputation, because they're not seeing any of the doctors or are having any of the testing that you would do to diagnose or treat PAD or CLTI," senior author Alexander C. Fanaroff, MD (Perelman School of Medicine, University of Pennsylvania, Philadelphia), told TCTMD.
He noted that it wasn't long ago that clinicians and policymakers were looking for ways to coordinate STEMI care to ensure that all patients received the same rapid identification and treatment regardless of where they lived or how they accessed care. The resulting door-to-balloon (D2B) metric as well as the standardization and streamlining of protocols helped vastly improve quality of care and outcomes, and these shifts are credited with reducing disparities. Fanaroff said he and others believe the same actions should be taken in peripheral vascular disease.
"When somebody has chronic limb-threatening ischemia, the pathway of care begins with somebody recognizing that they have it: usually a primary care doctor, but not always. Then they have to refer them for vascular testing, and to a vascular specialist . . . and get them on the right therapy, and consider revascularization. All of that is fairly complicated and often hard for patients to navigate," Fanaroff added. "We think there's a role for health systems to streamline the referral process so that we take care of people with PAD and CLTI better."
In the case of the patients in his study, all were on Medicare, but the look back at what happened in the year before the amputation made it clear that non-Black patients, those from metropolitan areas, and those with higher socioeconomic status still fared best in terms of obtaining necessary vascular care that could make the difference between losing or not losing a limb.
Primary Care and Specialist Visits Lacking
For the study, published January 3, 2025, as a research letter in Circulation: Cardiovascular Quality and Outcomes, Fanaroff and colleagues led by Omar I. Ramadan, MD (Perelman School of Medicine, University of Pennsylvania), analyzed data on 73,237 patients (mean age 75 years; 40% female) who underwent major lower extremity amputation. The study cohort had very high rates of comorbid conditions, including heart failure, hypertension, diabetes, renal failure, and hyperlipidemia.
In the population as a whole, 55.1% had an outpatient vascular subspecialist visit in the 12 months before their amputation, 82% had lower extremity arterial testing, and 38.7% had a revascularization procedure.
Compared with white patients, Black patients were 24% less likely to see a primary care physician prior to amputation and 13% less likely to have had an outpatient vascular specialist visit. Similarly, patients with versus without low socioeconomic status were 38% less likely to have had an outpatient vascular specialist visit, while those in rural versus urban areas were 18% less likely.
Looking at lower-extremity arterial testing prior to an amputation, those with versus without low socioeconomic status were 22% less likely to receive it, while those in rural versus urban areas were 10% less likely.
Revascularization attempts prior to amputation were 10% lower in Black versus white patients, with about the same level of difference in rural versus urban patients. The greatest difference was seen in low socioeconomic status patients in whom a revascularization was 35% less likely compared with those without low socioeconomic status. These two groups also had a 40% difference in the chance of seeing a primary care physician.
We think there's a role for health systems to streamline the referral process so that we take care of people with PAD and CLTI better. Alexander C. Fanaroff
These findings are similar to a 2021 study of Medicare beneficiaries that also showed minimal vascular care in the year before an amputation, with 69% not undergoing a revascularization attempt. That study also linked the intensity of the preamputation vascular care to the risk of death at 2 years.
To TCTMD, Fanaroff said despite many of these studies showing the same dismal findings, the data are important in pushing forward efforts to improve the probability of early vascular care.
"One of the problems is we haven't given health systems any reason to invest in programs that help with this," he said. Again drawing a corollary to STEMI care, Fanaroff said the lack of quality improvement for PAD in comparison to STEMI couldn't be more apparent from the data.
"When your center's rating depends on reducing your door-to-balloon time, you do it. I think something similar is possible where every patient that has an amputation in your system should have some sort of vascular testing in the year prior. They should see a vascular specialist in the year prior to the amputation," he said. "[The STEMI experience] shows what you can accomplish with quality improvement and . . . with a national focus on ways of measuring quality of care. We don't have that in in PAD or CLTI to the same extent."