Diabetes is one of the most common chronic diseases in the United States, with more than 34 million individuals living with the condition.
It’s hard enough to manage this condition on a daily basis — and it gets even harder with the realization that diabetes doesn’t just exist in isolation. A diabetes diagnosis immediately triggers a domino effect of higher risks for other conditions and complications, including kidney damage, eye damage, neuropathy, and cardiovascular disease.
Peripheral artery disease (PAD) may not be the most well-known complication on the long list of health problems related to diabetes, but it can be among the most serious. Because PAD restricts blood flow to the extremities, it often leads to lower limb amputations. And lower limb amputations are associated with a five-year survival rate as low as 20%.
Black Americans are particularly vulnerable to amputations, losing their limbs at three times the rate of other ethnic and racial groups.
It’s time to shine some light on PAD and start taking coordinated, proactive action to prevent this condition from advancing in people with diabetes. Through a combination of policy, education, and technology, we can start to turn the tide on PAD and improve health outcomes for vulnerable communities.
What is peripheral artery disease?
PAD occurs when plaque builds up in the arteries of the extremities, often restricting the flow of blood to tissues in the legs, feet, and toes. About 40% of people with PAD have no symptoms, while the rest may experience pain and cramping while walking.
Officially, 6.5 million people in the United States have been diagnosed with PAD. But just like with diabetes, there are millions more who may not know they are living with the condition. The two diseases often go hand-in-hand. People with diabetes are 2.7 times more likely than others to develop PAD.
PAD can lead to amputations in several ways. First, if left untreated, PAD can progress into critical limb-threatening ischemia (CLTI), which may result in gangrene and the need to amputate dying tissue.
Second, it can exacerbate the poor healing of diabetic foot ulcers. In a person with restricted blood flow, something as simple as a callus or a blister from poorly fitting shoes can significantly damage tissue.
Once a foot ulcer develops, the body demands more blood flow to heal the site — but can’t get it when PAD is present. Gangrene can quickly set in, especially if diabetic neuropathy reduces sensation in the limb and prevents a person from even knowing something is wrong until it’s far too advanced to treat conservatively.
How can we prevent PAD in high-risk communities and improve outcomes for all?
Preventing PAD is complicated, particularly in the large proportion of patients who don’t exhibit symptoms. Because it is a largely invisible disease, screening rates are relatively low to start with. Clinical protocols involve multiple tests, some of which can be invasive but not all. These screening services are often available solely from specialist providers, many of whom only accept commercial insurance.
For many minority communities, there is already a long history of having their health symptoms discounted or even ignored as well. This can be tied to issues such as poor clinical training, but both implicit bias and conscious bias continue to have negative repercussions for patients. For example, patients of color are still more likely to be blamed for being too passive about their healthcare and they often receive fewer cardiovascular interventions and fewer renal transplants – all of which serve to create an even bigger health equity divide.
Patients in rural areas, those with Medicare and Medicaid, and those struggling with social determinants of health (SDOH) that prevent access to preventive care and screening, often experience difficulties finding a provider knowledgeable about appropriate PAD assessments too. That said, outcomes disparities in minority populations are mostly related to access to quality care, including comprehensive screening for PAD and emerging foot ulcers.
In order to make PAD prevention a reality, we must take a three-pronged approach to improve access to preventive care and reduce the negative impact of PAD on high-risk individuals.
The policy is one of the strongest levers we have for enabling patients to seek care and compensating providers fairly for engaging in proactive, value-based care. For example, the bipartisan Amputation Reduction and Compassion (ARC) Act (H.R. 2631), which was introduced in 2021, could have a major positive impact on chronic disease care.
The ARC Act would reduce amputations by requiring Medicare, Medicaid, and group health plans to cover preventive screenings for high-risk individuals without a copay. It also would establish a PAD education program in the U.S. Department of Health and Human Services (HHS), so that healthcare providers become more aware of PAD symptoms. Additionally, HHS would be required to implement quality payment measures that would reduce avoidable amputations, which would be a major incentive for providers to take a more active role in PAD care. Finally, it would deny payment for amputations performed without screening for PAD and for not considering alternative and less catastrophic interventions to address the underlying issue.
Expanding the definition of healthcare is equally important. We must expand and support the delivery of diabetes and PAD education and services to high-risk patients — and we must complement these programs with initiatives that address the social determinants of health, including reliable transportation, medication access, and food security, to ensure that all individuals can participate in their own care. Equally important is for clinicians to have support in addressing their implicit and conscious biases. According to the Joint Commission, these bias-related issues can be overcome with strong organizational support, skills training, cognitive resources, and more.
Lastly, we need to augment these efforts with technology to help people monitor and manage patient diabetes anywhere and everywhere. A growing toolkit of home-based, remote patient monitoring (RPM) devices in the home is quickly becoming vital for getting ahead of potential complications, including foot ulcers, to ensure patients stay as healthy as possible for as long as possible. It is important to note, however, that technology is only as good as the education, coaching, and extended clinical services used to provide the patient with holistic care.
These three tactics can combine to create an ecosystem of care that wraps around every patient with diabetes and PAD — and particularly supports those who need extra resources to manage their health. With a clearer understanding of PAD and its downstream impacts, we can begin to take action on this stealthy, deadly disease and reduce the rate of poor outcomes for the underserved members of communities across America.
About Elizabeth Hogan Hamacher
Elizabeth Hamacher is a solutions-driven healthcare executive with demonstrated success in leading both clinical and administrative growth across multiple healthcare settings. As Vice President of Clinical Services and Support at Podimetrics, she is responsible for scaling the company’s work to efficiently and effectively serve more patients. Elizabeth has held clinical leadership roles at Consumer Medical, Cape Cod Healthcare, and Emerald Physician Services LLC, leading strategic planning, leadership development, operations, and quality improvement efforts. She holds a Master’s degree in Healthcare Leadership from Brown University, a Bachelor of Science in Nursing from Massachusetts General Hospital Institute of Health Professions, and a Bachelor of Science in Mathematical Sciences from Worcester Polytechnic Institute.