It is estimated that non-healing wounds affect approximately seven to eight million people in the U.S. while an estimated nine million people have peripheral arterial disease (PAD).1 Peripheral arterial disease is often an unrecognized cause of the aforementioned wounds, symptoms of pain, functional disability, foot ulcers, infections and amputations. Nationwide, more than 30 percent of patients do not receive vascular testing prior to amputation.2
Each year, there are 130,000 amputations in people with diabetes in the United States.1 Unfortunately, in my experience, these patients often reside in lower income or underinsured areas. Even though there have been significant advances in the field of diabetes care, amputations increased by 50 percent in the U.S. between 2009 and 2015.3 There is also a disproportionate impact on minority populations. A 2016 study involving 62,002 people with type 2 diabetes in New Zealand found that “ethnic groups had significantly different risk of lower limb amputation … .”4 In the U.S. specifically, African-American patients reportedly experience limb loss three times more often than other groups.1
In their aforementioned 2016 study, Robinson and colleagues recommended that “barriers to care should be addressed and intensive prevention strategies known to reduce the incidence of lower limb amputations could be prioritized to those at greatest risk.”4
Last month, six congressional representatives cosponsored the Amputation Reduction and Compassion Act (ARC) (H.R. 8615).3,4 The goal behind the bill is to reduce amputations by increasing testing of at-risk patients and increasing education on PAD for patients and health-care providers.
If the bill is passed, it would …
• provide coverage of (PAD) screening that includes the ankle-brachial index test for at-risk beneficiaries under the Medicare and Medicaid programs without the imposition of cost-sharing requirements;
• prohibit amputations without the completion of arterial testing to determine if there are applicable alternative interventions;
• stablish, support, develop and implement a PAD education program for health-care professionals and the public about PAD and methods to reduce amputations.1,2,5
“The greatest problem with peripheral artery disease is that it can go undetected for years and lead to limb amputations that could be avoided with early detection,” notes congressman Donald Payne, Jr. (D-N.J.), one of the cosponsors of the bill. “The bill provides resources to screen at-risk patients and educate doctors, which in turn will reduce racial disparities in amputations.”1
Tracey D. Brown, President and CEO of the American Diabetes Association, agrees with the congressman. “Policies that make screening and treatment for conditions that cause amputations are urgently needed,” maintains Brown.1
In a recent 2020 study on the care necessary to prevent amputations from diabetes and PAD in Ontario, Canada, researchers noted that while there is wide variation between amputation rates related to diabetes and PAD, they emphasized that “access to assessment and revascularization must be integrated into regional amputation prevention efforts.”6
Unfortunately, similar bills introduced by former congressional representative Richard Baker (R-La.) in 2003 and 2005 did not make it to a vote.7,8 Given the track record of Congress, it does not seem likely that the current bill will pass. However, the social and political climate today differs significantly from 2003 and 2005 and the efforts of a powerful group of representatives may get this current bill passed.
Podiatrists should stay informed about this bill. If it is passed, the bill may help provide a reimbursable service to help prevent ulcers and amputations in patients with diabetes and PAD.
Dr. Hinkes is President and Chief Medical Officer of ePrevenir, Inc. He is board-certified by the American Board of Foot and Ankle Surgery, and is a Fellow of the American College of Foot and Ankle Surgeons and the American Professional Wound Care Association. He is the author of “Healthy Feet for People With Diabetes” and “Keep the Legs You Stand On,” which are available at www.amazon.com.
1. Presser L. The black American amputation epidemic. ProPublica. Available at: https://features.propublica.org/diabetes-amputations/black-american-amputation-epidemic/ . Published May 19, 2020. Accessed November 9, 2020.
2. Presser L. New bill aims to end racial disparities in amputation. ProPublica. Available at: https://www.propublica.org/article/new-bill-aims-to-end-racial-disparities-in-amputations . Published October 19, 2020. Accessed November 20, 2020.
3. Caffrey M. Diabetic amputations may be rising in the United States. AJMC. Available at: https://www.ajmc.com/view/diabetic-amputations-may-be-rising-in-the-united-states . Published December 13, 2018. Accessed November 20, 2020.
4. Robinson TE, Kenealy T, Garrett M, Bramley D, Drury PL, Elley CR. Ethnicity and risk of lower limb amputation in people with type 2 diabetes: a prospective study. Diabet Med. 2016;33(1):55-61.
5. H.R. 8615. Congress.gov website. Available at: https://www.congress.gov/bill/116th-congress/house-bill/8615/cosponsors?searchResultViewType=expanded . Accessed November 9, 2020.
6. de Mestral C, Hussain MA, Austin PC, et al. Regional health care services and rates of lower extremity amputation related to diabetes and peripheral artery disease. CMAJO. 2020;8(4):E659-E666.
7. H.R. 3203 — 108th Congress: Diabetic Foot Complication and Lower Extremity Amputation Reduction Act of 2003. Available at: https://www.govtrack.us/congress/bills/108/hr3203 . Updated September 30, 2003. Accessed November 9, 2020.
8. H.R. 1719 — 109th Congress: Diabetic Food Complication and Lower Extremity Amputation Reduction Act of 2005. Available at: https://www.govtrack.us/congress/bills/109/hr1719 . Updated April 20, 2005. Accessed November 9, 2020.