Pandemic underscores racial disparities in amputation; paradigm shift needed

Issue: January 2021

ByBryan T Fisher Sr., MD

The first thing she asked was, “Is my husband going to get to come?”

The patient had been married for 60 of her 90 years on Earth. I could see in her eyes that she knew the answer. COVID-19 would not allow that. But she could not put off her operation any longer, even if that meant spending nearly a week alone recovering in a hospital bed. She suffered from peripheral artery disease, a serious health condition where narrowed arteries reduce blood flow to the legs. She needed an operation — an open vascular bypass and graph procedure to restore blood flow to her leg below the knee — to save her limb.

Graphical depiction of source quote presented in the article — **Bryan T. Fisher Sr., MD,** is chief of vascular surgery and co-director of limb preservation at Centennial Medical Center in Nashville and medical director of the Outpatient Procedure Center at The Surgical Clinic in Nashville.

The operation went well, and after 5 days confined to a hospital bed, she was reunited with her love. Yet, I was still troubled.

Delayed presentation of PAD

Not all my patients with urgent needs will have the same resolve during the COVID-19 pandemic. Similar to what physicians around the country are seeing with MIs, strokes and cancer, my clinic has seen delayed presentation of PAD. Delayed treatment for these patients can be life-threatening and can further exacerbate racial disparities in care. People from traditionally underrepresented backgrounds are already more likely to be amputated than white people. For people with advanced PAD who develop critical limb ischemia, the severe blockage in the arteries of the lower extremities that often requires an amputation, the outlook is grim. One-quarter of patients who develop CLI will be dead after 1 year; more than 60% will be dead after 5 years.

Most people living with PAD don’t know these stats, of course. What they do know is that COVID-19 is caused by a highly contagious virus, and people at hospitals either have it or are catching it, so they are steering clear of medical facilities. People are staying home rather than seeking treatment for their PAD, which means many are living with chronic leg pain, limited mobility and, if interventions are delayed too long, risk for amputation. Nearly half of all of my patients who were able to be contacted over the summer told us that they did not want anything done right away. Even as nonurgent cases started to be performed again, patients would rather wait until things settle down before they’ll venture out and consider having operations.

Pandemic effect on amputation rates

This bothers me because amputations are already too common for people living with PAD, so I’m deeply worried that amputation rates will soar during the COVID-19 pandemic unless all of us in the PAD community step up to ensure amputations are a last resort for people living with PAD.

An estimated 50% of patients who receive an amputation die within 5 years, yet the best way to prevent amputation is through early intervention. But with established patients putting off procedures and skipping their appointments, and others staying home until it’s often too late to save their lower limbs, there has never been a more critical time to strengthen our commitment to ending unnecessary amputations. We have to increase awareness and connect patients to the tools they need to seek high-quality treatment and reassure them that they can do so safely.

COVID-19 may be with us for the foreseeable future, so we must use this as an opportunity to educate patients that their procedures can be done safely. At the height of the pandemic, we were forced to delay all but the most urgent cases, but now some restrictions on activities are loosening. At our clinic, for example, we can start to safely see more cases because we offer a setting where fewer people are involved during procedures, and we’re regimented in our screening process for those that enter our building. We’re actively engaging patients and letting them know that we’re taking steps to ensure that they’re safe. This may seem small, but it’s a critical step.

If patients with PAD present later, the cases may grow in complexity, straining the resources or expertise, particularly in rural communities, where vascular-related amputations are taking their toll. We are also reaching out to physicians in our area to let them know that we’re still a resource for them to consult prior to or even during cases, so that providers in these communities understand when an amputation is a last-resort option.

Here is why this keeps me up at night: 30% of patients do not receive any formal workup before the decision to amputate is made. Black and Hispanic patients are approximately twice as likely to be amputated as are white patients. These are pre-pandemic stats, and we have only seen racial disparities in care increase as COVID-19 has spread across the country. If people continue to view the hospital or clinic as unsafe, and delay treatment for PAD, then the combined effect could be tragic.

Paradigm shift needed

We need a paradigm shift when it comes to PAD, CLI and amputation prevention. We need the same accountability systems in place for amputations that we have for patients with breast cancer or stroke. For these conditions, there are explicit protocols and benchmarks in place. That is not the case for amputations today. Today, you can walk into the room of a patient with PAD and say, “I’m going to cut your leg off,” and few checks and balances are in place to scrutinize whether that is an appropriate mode of care. The PAD community needs to come together, pool its resources and develop a consistent method to address this lack of accountability.

We also need top-down changes if we are going to be able to eliminate disparities in PAD and make sure patients get the appropriate standardized care. A nationwide prospective and retrospective analysis of patients with PAD who had amputations is needed so that we can assess whether amputations were truly necessary and, if not, where along the continuum we could we have prevented a patient from suffering the loss of a limb.

I am very passionate about reducing amputations. I have bold ideas, but I feel like what I’m saying is right. I’ve walked the walk. I’ve spent that time up at 2 a.m. taking care of someone who didn’t have the resources they needed to save their limbs. I’ve heard the pain in their voices lately after they’ve waited until nearly too late to get treatment.

Crises have a way of sharpening our focus on what is important in life. For me, there is nothing more important than making sure no one gets an amputation that could have been avoided.

References:

For more information:

Bryan T. Fisher Sr., MD, is chief of vascular surgery and co-director of limb preservation at Centennial Medical Center in Nashville and medical director of the Outpatient Procedure Center at The Surgical Clinic in Nashville. He can be reached at The Surgical Clinic, 356 24th Ave. N., Suite 400, Nashville, TN 37203; email: bfisher@tsclinic.com; Twitter: @amputationsuck.

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Sources/Disclosures

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Source:

Mustapha JA, et al. J Racial Ethn Health Disparities. 2017;doi:10.1007/s40615-016-0261-9.

Disclosures: Fisher reports he has financial ties with Abbott, Cordis, Philips and Shockwave Medical.

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