Disparities remain in treatment of CLI

W. Schuyler Jones

SAN DIEGO —The number of major limb amputations has decreased, but disparities remain in the treatment of patients with critical limb ischemia, according to a presentation at TCT 2018.

“We have a lot of evidence about the underdiagnosis and undertreatment for PAD,” W. Schuyler Jones, MD, associate professor of medicine at Duke University School of Medicine and director of the Duke Adult Cardiac Catheterization Lab, said during the presentation.

He also presented information on the basic understanding of the trends of treatment variation. Major lower-extremity amputation rates have decreased as revascularization procedures significantly increased, Jones said. Medical therapy has not changed as much, although adherence is very low, he noted.

He said when given a slide with the rates of lower-extremity amputations in 2006 in all counties in North Carolina, he was made aware of the disparities in peripheral artery disease. This was also seen when assessing the geographic variation in lower-extremity amputations in the United States.

In a study published in Circulation: Cardiovascular Quality and Outcomes in 2014, Jones and colleagues found that up to 30% of patients did not get arterial testing before amputation in the United States from 2000 to 2010.

“What we’ve focused on are these things that occur,” Jones said. “Some of it is probably research, some of it’s the effect of behavior.”

In a treatment framework for PAD, some major questions include whether the patients who are at risk for CLI are identified, whether patients at risk are receiving referrals for medical therapy or whether patients are seeing surgeons or undergoing endovascular revascularization in time, Jones said. Anatomy and the use of medication may also come into play into why disparities exist in patients with high risk.

In a study published in Vascular Medicine in 2015, researchers found that disparities regarding amputations were stable despite a reduction in the general rate of amputation. The above-the-knee amputation to below-the-knee amputation ratio was significantly higher in women and black patients compared with other patients in the study.

Disparities remained in a National Inpatient Sample from 1998 to 2005 in patients admitted for CLI, those who underwent an open vs. endovascular procedure and patients who underwent amputation, according to a study published in Vascular and Endovascular Surgery in 2013.

“It’s not all explained by the comorbidities,” Jones said. “There’s something else to this.”

The issue regarding disparities may be related to limited comprehensive studies that assess effectiveness and safety, in addition to inadequate data sources, heterogeneity that complicates our ability to understand PAD treatment and lack of clinical outcomes in electronic health records, Jones said.

“Some of [the ways to eliminate disparities] is increasing awareness, some of this is getting out into the community,” Jones said. “Is that enough? Is that the easy button to get patients to the place where ... we can deliver care, and the answer is that it’s probably not enough. You’ve got to do other things. You’ve got to work together as a team to create centers of excellence.” – by Darlene Dobkowski

References:

Jones WS. Critical Limb Ischemia Deep Dive. Presented at: TCT Scientific Symposium; Sept. 21-25, 2018; San Diego.

Hughes K, et al. Vasc Endovascular Surg. 2013;doi:10.1177/1538574413510618.
Lefebvre KM, et al. Vasc Med. 2015;doi:10.1177/1358863X14565373.

Vemulapalli S, et al. Circ Cardiovasc Qual Outcomes. 2014;doi:10.1161/CIRCOUTCOMES.113.000376.

Disclosure: Jones reports he receives research grants from AstraZeneca and Medtronic and honoraria from Bayer, Bristol-Myers Squibb and Janssen Pharmaceuticals.