Speaker: ‘Refocus the lens’ on preventing amputation in Black patients with CLI
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Amputation is too often the result for Black patients with critical limb ischemia, and much work must be done to overcome systemic inequities, a speaker said during the International Symposium on Endovascular Therapy.
“The crisis that we’re talking about is basically a clinical, economic and human impact that has been a generational impact, one in which [can be attributed to] systemic practices and policies at institutions and medical practices, and how those have worked in fragmented norms, in addition to how social determinants of health play a role in perpetuating disparities in outcomes when it comes to amputations,” Foluso Fakorede, MD, founder of Cardiovascular Solutions of Central Mississippi in Cleveland, Mississippi, said during a presentation. “Most of us have practices where we see CLI in its end stage, but what we have to do is refocus our lens on how do patients end up with [CLI and amputation] in the current dynamics of our health care system.”
In men aged at least 50 years and in women aged at least 60 years, Black individuals have the greatest prevalence of peripheral artery disease among races and ethnicities in the U.S., Fakorede said, noting that Black race confers a twofold relative risk for PAD. Other major risk factors include smoking, diabetes and chronic kidney disease.
In addition, he said, among Medicare beneficiaries, Black individuals have a 2.3-fold increased risk for CLI; Black individuals present with more severe symptoms such as gangrene compared with others; diabetes and chronic kidney disease are more prevalent in Black patients with CLI than in white patients with CLI; Black patients with CLI are more likely to be women than white patients with CLI; and Black race compared with white race is associated with onefold to fourfold increased risk for amputation in patients with CLI.
Eighty percent of health income disparities can be attributed to social determinants of health and only 20% to issues with health care systems, and most current efforts to resolve the problem are not addressing social determinants of health enough, Fakorede said.
“We know that where you live and your socioeconomic status and your hospital vascular program and your insurance status play a role in terms of if you get amputated or not,” he said. “It is sad to see that many of these amputations are occurring in Southern areas in ‘distressed ZIP codes,’ particularly those that house Black and brown patients. Unfortunately, the revascularization rates in these areas are also the lowest.”
Too often, Black patients receive amputation as their first and only therapy for CLI; do not receive an angiogram despite angiogram use being associated with reduced rates of amputation; and do not receive revascularization, Fakorede said, noting that his team initiated an angiographic screening program that led to an 87.5% reduction in amputations.
“Awareness is at the forefront [of finding solutions],” he said. “Education to the patient from the patient, provider and community standpoints is also imperative.”
A strategy “should not only determine the prevalence of the disease but create policies to increase representation [in clinical trials], create awareness across the board, award grants and scholarships for such programs in rural and metropolitan areas,” Fakorede said. “We need to match what our oncology colleagues have done. We need to do a better job with our curricula across the board. Medical schools need to do a better job of talking about PAD. We need to identify hospital, institutional and community gaps, and to utilize our ‘primetime’ slots to talk about this in conferences. We need to develop regional expertise in CLI to build multidisciplinary teams. And at the core, we need to address social determinants of health.”
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Fakorede F. Session 1: ISET Town Hall: Disparity in the Delivery of Vascular Care. Presented at: International Symposium on Endovascular Therapy; Jan. 16-19, 2022; Hollywood, Florida (hybrid meeting).
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