AHA Seeks to Drive Down Amputations 20% by 2030

A substantial proportion of the approximately 150,000 nontraumatic lower-extremity amputations that occur each year in the United States are preventable, even among patients with advanced PAD. Now, in a new policy statement, the American Heart Association (AHA) proposes recommendations that they hope can improve limb outcomes and drive amputation rates down 20% by the year 2030.

Meeting the goal, said writing committee chair Mark A. Creager, MD (Dartmouth-Hitchcock Medical Center, Lebanon, NH), requires cooperation among multiple sectors ranging from clinicians, to researchers, patients, family members, regulatory agencies, and the healthcare system.

“All these different stakeholders have a role in making the appropriate changes in what they're doing to take steps that will reduce the likelihood that someone with peripheral artery disease will progress to the point that they develop critical limb ischemia [CLI] and need an amputation,” he told TCTMD.

Amputations and their disproportionate impact on people of color in the United States have long flown under the radar of many physicians As TCTMD has previously reported, a small but vocal group of physicians—“hope dealers,” as one advocate call himself—are urging a multipronged approach to ending unnecessary amputations. The AHA policy statement represents a concrete step towards that goal.

Most of the public has no idea what PAD is, or even that a primary care physician should be looking at their feet at every visit. Mark A. Creager

Published online ahead of print in Circulation, the policy statement notes that despite the more than 40% decline in lower-extremity amputations from the mid-1990s to around 2010, major and minor amputations have been on the rise among diabetic patients, increasing by 50% from 2009 to 2015, according to National Inpatient Sample data.

“There’s a precedent to indicate that we were on a trajectory to decrease the rate of amputations, so we believe we can easily get back to that with the appropriate attention and with awareness. Most of the public has no idea what PAD is, or even that a primary care physician should be looking at their feet at every visit,” Creager said. “Clinicians need to take off the socks and shoes and feel the pulses.”

Disparities, Costs, and Management

In the statement, the committee notes that Medicaid expansion may be one way to increase access to care and minimize PAD-related disparities. They also urge more research into the quality-of-life ramifications for those who do undergo necessary nontraumatic amputations to better understand how to help patients recover physically and psychologically.

Beyond the toll on patients, the committee notes that amputations add considerably to healthcare costs because patients are likely to require readmissions for a number of issues, including wound-related complications. “One study estimated that the aggregate costs of readmissions for patients with CLI who undergo revascularization exceed US $300 million annually, and a study from the Partners Research Patient Data Registry showed that patients after amputation had an average of 71 hospital days per year up to 3 years,” they write.

Creager noted that while guidelines differ on the use of the ankle-brachial index (ABI) to screen for PAD, the committee is in agreement that it should be used in high-risk patients such as smokers, diabetics, and those with other manifestations of atherosclerosis.

“We also recognize that we need to help our clinicians. Hospitals need to have electronic medical records that signal to them, like we do with many other things particularly in high-risk groups, to look for PAD,” Creager said. Appropriate wound care and timely referral to vascular specialists also need to be given more priority in order to improve PAD care once it is diagnosed, as well as to allow patients and families to be actively involved in the care process, the statement notes.

Creager said another major issue that needs to be addressed is the use of performance measures at institutional levels. Since 2008, performance on quality measures for acute MI, heart failure, and pneumonia have been publicly reported. Additionally, improvements in those measures have been linked to a decline in disparities in the use of evidence-based therapies between white, Black, and Hispanic adults.

The policy statement further notes that regulatory/legislative and organizational/institutional policies are needed to ensure adoption of better care measures for PAD, including US Food and Drug Administration regulation of tobacco products, smoking cessation therapy that does not require a co-pay, consistent reimbursement for the ABI test across all states, and dedicated funding to support research related to PAD.

“These are just some things we can do, and it’s not a huge list. In the aggregate, I think they'll make important differences in our ability to identify PAD, treat it appropriately, prevent progression, or if progression occurs despite best efforts, make sure patients get timely and appropriate treatment for CLI so that they don't end up losing their limb,” Creager added.

Later this year, the AHA plans to unveil its first public health campaign for PAD. The National PAD Action Plan, which Creager noted is still in the planning stages, will emphasize focused public health interventions and public outcome reporting.