PAD Awareness Month And The Case For Limb Preservation

Desmond Bell DPM CWS FACCWS

Unlike October, which is abundant with the color pink and matching ribbons symbolizing Breast Cancer Awareness Month wherever we turn, we have no such ribbon for Peripheral Artery Disease (PAD) Awareness Month.

In my travels over the past few years, I have noted several instances that illustrate a lack of PAD awareness and understanding among providers and the general population.
Last September, I had the good fortune of speaking in New Orleans, Dallas and Saginaw, Mich. In each city, I asked the respective audience members — comprised of a range of healthcare providers, including podiatrists, internists, vascular surgeons, cardiologists and nurses — if they knew which month was PAD Awareness Month. Among more than 200 people in the three audiences, only a total of five people answered correctly.

Additionally, I recently finished three lectures in South Carolina and one in Chicago. Not a single person recognized that September is PAD Awareness Month.

This lack of awareness is not limited to healthcare providers. In my lectures to the general public, I typically ask if anyone has heard of PAD. Usually, a few people raise their hands. The follow-up question I ask is “Do you know what PAD is?” Throughout several years, only one person partially answered this question correctly. “Restless leg syndrome” is a common answer and a general lack of awareness of PAD is the norm.

Peripheral arterial disease remains virtually unknown among healthcare providers and the general population alike. A basic misunderstanding of PAD persists among healthcare providers. They often under-diagnose PAD or simply do not recognize the disease.

The five-year mortality rate for PAD is approximately 64 percent while breast cancer mortality at five years is between 14 and 18 percent.1 With far more people at risk of having PAD, which is often the underlying reason for lower extremity amputation, extensive pain and suffering, why do we not hear more about this disease?

Peripheral arterial disease is also a common complication for those afflicted with diabetes yet many of the ever-growing number of patients with diabetes are unaware of PAD.

Consider that surgeons perform more than 50 percent of lower extremity amputations without even doing a non-invasive vascular test, such as an ankle-brachial index, let alone an arteriogram.2,3

The Sage Group is a for-profit research and consulting company specializing in lower limb vascular disease including PAD, intermittent claudication, critical limb ischemia (CLI), acute limb ischemia and diabetic foot ulcer. According to SAGE Group Co-Founder Mary Yost, the Hallett study, published in 1997, examined more than 20,000 Medicare patients with CLI who had a major amputation.4

Researchers found that practitioners made no attempt at either a diagnostic angiogram or revascularization prior to amputation in 71 percent of these patients.

Since the publication of this study, we have made little headway.

A Look At The Grim Numbers Surrounding PAD

Here are some additional facts to consider when examining the impact of PAD from an economic standpoint:5

• The estimated total cost of PAD in 2010 was between $164 and $300 billion. The range is based on per patient costs in two large studies: the REACH Registry and a study of managed care patients multiplied times 17.6 million with PAD.5-6
• Peripheral arterial disease actually costs more than coronary disease and four times more than costs surrounding strokes.5
• Seventy-five percent of those with PAD are asymptomatic. While they do not have leg symptoms, 70 percent most likely have coronary and/or cerebrovascular disease.5
• Between 5 and 10 percent of patients requiring below-knee amputations die in the hospital. Approximately 15 to 20 percent of patients who require above-knee amputations die while hospitalized.5
• One in-hospital death from PAD or CLI can cost $12,000.5
• There is a high rate of revision amputations. This means the initial amputation did not heal adequately and the patient requires another amputation on that same leg at a higher level. The revision amputation rate is 20 percent in patients requiring below-knee amputations and 12 percent in patients who require above-knee amputations.5

Each of these statistics adds to the total national bill for amputation. This is before you consider the adverse patient outcomes such as the 60 to 80 percent of patients who are unable to walk, those suffering from depression, hospital re-admissions for amputation related problems, the necessity for long-term care, etc.5

Final Notes

The only way we are going succeed in reducing lower extremity amputations will be by driving the issue of PAD awareness and accountability to the public.

When the public begins to better understand what is at stake and the issues associated with PAD, they will demand better care and advocate for supporting the case for lower limb preservation.

Help spread the word. September is PAD Awareness Month.

References
1. Armstrong DG, Wrobel J, Robbins JM. Guest editorial: Are diabetes related wounds and amputations worse than cancer? Int Wound J. 2007; 4(4):286-287.
2. Allie DE. How to address vascular complications with lower extremity wounds. Podiatry Today. 2008; 21(7):85-96.
3. Allie DE, Hebert CJ, Lirtzman MD, et al. Critical limb ischemia: a global epidemic. a critical analysis of current treatment unmasks the clinical and economic costs of CLI. Euro Interventions Journal. 2005; 1(1):75-84.
4. Hallett JW Jr, Byrne J, Gayari MM, Ilstrup DM, Jacobsen SJ, Gray DT. Impact of arterial surgery and balloon angioplasty on amputation: a population-based study of 1155 procedures between 1973 and 1992. J Vasc Surg. 1997; 25(1):29-38
5. Mary Yost of the SAGE Group. Interview, WOKV radio. Jacksonville, FL: July 8th, 2012. Podcast available at www.WOKV.com .
6. Bhatt D, Steg PG, Ohman EM, et al. International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA. 2006; 295(2):180-189.

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