Foluso A. Fakorede, MD, a cardiologist in Bolivar County, MS, has used prevention, screening, and treatment strategies to reduce amputations by 88% in the Mississippi Delta area where he practices. Here, Dr. Fakorede discusses risk factors for peripheral arterial disease (PAD) and amputation in patients with diabetes, and how to reduce disparities in diabetic amputations.

Q: How common are lower extremity amputations among people who have diabetes? What are the burdens of diabetic amputations—in terms of medical costs and impact on quality of life?

A: There’s an epidemic of amputations, which disproportionately affects people who have diabetes. Overall, about 200,000 people in the United States have amputations each year, and about 130,000 of those people have diabetes.

There’s also an epidemic of diabetes, which affects about 34 million U.S. adults. The CDC estimates that one in three American adults will have diabetes by the year 2050. A significant percentage of these people may develop advanced PAD, which can lead to critical limb ischemia—blockage of blood vessels in the lower limbs that leads to foot ulcers and nonhealing wounds. These wounds may be treated with an amputation-first strategy, instead of revascularization. When offered before amputation, revascularization may unblock blood vessels, restore blood flow, and save a limb.

Therefore, a mindset to prevent the diabetes epidemic and reduce amputations is needed. Even though technology has advanced over the past couple of decades, amputation rates have increased. For our health care system, amputations lead to billions of dollars in direct and indirect medical costs. For people with diabetes, amputations lead to permanent disability, high rates of chronic pain and depression, and sometimes the loss of the ability to be productive in society.

Q: Does the risk of diabetic amputation vary in different populations or in different regions?

A: Yes. The epidemics of diabetes and amputation are associated with cardiovascular disease (CVD), which includes PAD. Minorities—especially Black Americans—are projected to have the highest rates of CVD over the next couple of decades. Most people who have diabetes and CVD present to health care professionals with more severe or later-stage CVD, have more amputations, are at higher risk for heart attacks and strokes, and die younger. Of those who have an amputation, 80% will die within 5 years.

Certain factors determine whether you will undergo an amputation—this is what I call the amputation lottery. These factors include

• region. People who live in the southern United States have the highest rates of amputation. They also have the lowest rates of revascularization.
• race. Most people receiving amputations are minorities: Black Americans, Hispanics/Latinos, and American Indians.
• age. Many people who receive amputations are older. PAD may be missed in older adults because the symptoms are attributed to arthritis or gout. Also, primary care doctors may not know about PAD and may not screen patients for PAD early. Patients undergo an amputation when they are older because PAD was missed.
• socioeconomic status. Poorer patients and those living in poorer regions of the country have less access to quality health care and have the highest amputation rates. Unfortunately, many of these patients are minorities with low incomes.
• hospital volume of vascular procedures. Hospitals are better at preventing amputation if they can assemble a team of specialists proficient in aggressive limb salvage, wound care, nutritional care, and diabetes management and treatment. Rural areas, such as those in the southern United States, don’t have a significant number of these specialists.

These factors determine a person’s chances in the amputation lottery and lead to higher amputation rates in rural areas and in minority and low socioeconomic status populations.

Q: For people who have diabetes, how does PAD increase the risk of amputation? What other factors increase the risk?

A: PAD and critical limb ischemia are prevalent in people with diabetes because they are not being screened for PAD in time. One problem is a lack of awareness. While most people have heard about heart attacks and strokes, only one in four Americans has heard of PAD. Another problem is that guidelines and policies don’t encourage primary care doctors to screen at-risk patients for PAD, which leads to delayed diagnosis, worse outcomes, and higher amputation risk.

Patients with diabetes and PAD are more likely to present to health care professionals with foot ulcers and gangrene that won’t heal without an intervention. Diabetic neuropathy and loss of pain sensation may also prevent the patient from noticing an ulcer and seeking care right away. These patients have severe blood vessel blockages, mainly below the knee, that require skilled, technical intervention. However, these patients may show up to health care centers that are underequipped to treat them. They may not be offered an angiogram and revascularization procedure to find the blockage and restore blood flow and may be treated with an amputation-first strategy.

Social determinants of health also play a huge role in the worse outcomes we see in the most vulnerable populations, particularly when it comes to amputations. For example, people with a foot ulcer may put off seeking care due to transportation issues, lack of access to health insurance and health care, concerns about medical bills or missed work, or a lack of health literacy.

Q: How can health care professionals identify patients with a higher risk for PAD and diabetic amputation and help lower their risk?

A: Health care professionals should tell every patient who comes into their office to take off their socks during exams. Health care professionals should also help patients identify their risk factors for PAD. At-risk patients include those who

• have diabetes
• smoke or use nicotine
• are younger than age 50 and have diabetes and one other risk factor, are between the ages of 50 and 64 and have at least one risk factor, or are age 65 or older
• have claudication—lower extremity symptoms that occur with exertion—or have abnormal pulses in their lower extremities
• have had a plaque buildup in other major organs, like the heart, or are on dialysis
• have obesity
• are Black, Hispanic/Latino, or American Indian

After you help patients identify their risk factors, focus on preventive strategies. Start patients on optimal medical therapy and lifestyle changes to manage diabetes and other risk factors. Make sure patients understand that their A1C should be less than 7% and that increases in A1C also increase plaque in their blood vessels. Emphasize the importance of being physically active, managing blood pressure and cholesterol, taking medicines, and keeping up with appointments with wound care specialists, podiatrists, optometrists, and other health care professionals.

Q: How should health care professionals screen for PAD in patients who have diabetes?

A: Screening at-risk patients for PAD can increase early diagnosis and treatment, help prevent amputations, and save health care dollars.

Health care professionals can screen for PAD by checking pulses in a patient’s lower extremities and by performing a test called the ankle-brachial index (ABI). The ABI is a ratio of the stiffness of the blood vessels in the lower and upper extremities. The ABI is an affordable and efficient assessment and has been proven to yield benefits in screening for PAD in at-risk patients and populations.

The American College of Cardiology, the American Heart Association, and the Society for Cardiovascular Angiography and Interventions endorse using the ABI to screen at-risk patients for PAD. However, the U.S. Preventive Services Task Force (USPSTF) has not endorsed screening or risk assessment for PAD, and this lack of endorsement discourages testing and perpetuates disparities in outcomes for patients who are mainly seen by primary care providers. We should provide primary care providers with the knowledge and tools to screen patients and reduce these disparities.

Q: What changes in medical practice or policy could help reduce disparities in amputations in the United States?

A: First, health care professionals need to recognize the epidemic of amputations, which has been ignored for decades. We also need to recognize the epidemics of diabetes and obesity, which will be our biggest health challenges over the next couple decades.

Second, we need to raise awareness about PAD, and we need policies in place to identify and screen at-risk patients early. Legislation should authorize funds to establish or coordinate a program through the U.S. Department of Health and Human Services to cover the cost of PAD screening tests, without any cost-sharing for at-risk patients. The legislation should also require quality measures to reduce amputations related to PAD and to disincentivize nonemergency amputations that are performed without arterial testing.

A bipartisan PAD Caucus was established to lead this effort. Congressman Donald Payne, Jr. and his colleagues were instrumental in introducing legislation called the Amputation Reduction and Compassion Act. If passed, this legislation could help decrease the number of unnecessary amputations, which especially occur in communities of color.

How do you help prevent amputations in patients with diabetes? Tell us below in the comments.