For the study, researchers looked at Medicare data on 188,995 patients who underwent a total of 222,956 PAD-related major lower extremity amputations between 2010 and 2018. The analysis focused on patients living in 31,391 zip codes across the country where at least 100 of these amputations were done. More than 3 in 4 patients who got amputations lived in metropolitan areas, and more than half of the ZIP codes with the highest amputation rates were also in cities, the study found. Within cities, each 5 percent increase in the proportion of Black residents was associated with a 6.8 percent increase in amputation rates, the study found. And, each $10,000 decrease in median household income was associated with a 4.4 percent increase in amputation rates. “We found that closer proximity to specialized PAD care within metropolitan areas does not ensure access to high quality care,” says lead study author Alexander Fanaroff, MD, an interventional cardiologist and an assistant professor at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. Peripheral artery disease develops when the arteries carrying blood from the heart to other parts of the body narrow, typically in the lower extremities, reducing blood flow to the legs and feet. Symptoms can include fatigue, cramps, or pain in the legs or hips when walking or climbing stairs. Left untreated, patients can start to feel similar pain at rest, develop open wounds on their feet, and eventually require amputations.
Unequal Access to Care
“Limb amputation can be delayed and or prevented by timely and aggressive treatment,” Dr. Fanaroff says. “However, lack of access to specialized care may delay PAD diagnosis and limit efforts to save the limbs if it has progressed to the advanced disease stage.” One limitation of the study is that it used insurance claims data, which lacked detailed clinical information on individual patients that might help clarify inequities in amputation rates, the study team notes. However, Black Americans are more likely to be diagnosed with PAD when it’s more advanced and harder to treat, increasing their amputation risk, says Michael Hall, MD, associate division director of cardiovascular diseases at the University of Mississippi Medical Center in Jackson. Black patients are also less likely to receive adequate treatment for risk factors that can worsen PAD outcomes, including high blood pressure, diabetes, and smoking, notes Dr. Hall, who wasn’t involved in the study. When PAD progresses, Black people are also less likely to get what’s known as revascularization surgery to restore blood flow to the legs that may help save limbs. “Even beyond access, on a broader scale, Black people with cardiovascular diseases are not as optimally treated compared with other racial or ethnic groups,” Hall says.
Earlier Studies Highlight Disparities
When Black patients with PAD develop so-called critical limb ischemia (CLI), dangerously restricted blood flow that can lead to amputations, they’re 78 percent more likely to get amputations than white patients with the same condition, according to a scientific statement from the American Heart Association (AHA) published in September 2019 in Circulation. An earlier study in the Journal of Vascular Surgery looked at data on roughly 90,000 amputees and found that prior to amputations, Black patients were significantly less likely than white patients to undergo revascularization, have any hospital admissions to treat their limbs, toe amputations that can sometimes ward off more aggressive amputations, or wound debridement to treat open sores caused by PAD.
Preventing PAD and Complications
The best ways to prevent PAD are to get plenty of exercise, avoid smoking, and manage conditions that can lead to PAD such as high blood pressure, high cholesterol, and diabetes, according to the AHA. These measures can also help prevent complications when patients do develop PAD. Some Black and low-income patients have the odds stacked against them because they miss out on opportunities for prevention that may be more readily available to white and more affluent individuals, says Joseph Ladapo, MD, PhD, a cardiovascular disease researcher at the David Geffen School of Medicine at the University of California Los Angeles. “Patients that can’t get to providers for ideal treatment of these risk factors often don’t show up until things are really bad,” says Dr. Ladapo, who wasn’t involved in the new study. At this point, “surgeons appear more likely to offer amputation to Black patients than to offer salvage procedures that would prevent or delay amputation,” Ladapo says. “From my clinical experience, I am led to believe that sometimes, physicians treat patients differently based on their appearance.”
