Opinion

Stopping Limb Loss Starts with Understanding Diabetes and PAD

Often referred to as the “silent killer,” diabetes is a disease that is notorious for surprising its victims. With very few noticeable symptoms at first, it can unknowingly build and build into a devastating crescendo of life-threatening problems that become anything but silent.

According to the American Diabetes Association, an estimated 30 million Americans are living with diabetes. These individuals, whose bodies have quietly endured elevated blood sugar levels due to age, obesity or other factors, ultimately find themselves contending with serious health issues like blindness, heart attack, stroke, kidney failure and vascular disease.

Perhaps one of the most life-changing sequela of diabetes, and one that we are starting to see far too often, is lower-limb amputation. According to the Amputee Coalition, nearly two million Americans are living with limb loss, and another 185,000 will undergo an amputation this year.

The physical and emotional costs of losing a limb are unquantifiable, but the economic impacts are well-documented and alarming: Amputation costs the U.S. health care system an estimated at $10.6 billion annually. Medicare, the largest payer of major amputations in America, covered 66 percent of all amputations in 2010.

As a cardiologist who specializes in peripheral artery disease, I have unfortunately had a front row seat in witnessing how so many patients with diabetes become amputees.

Diabetics face a higher risk of developing vascular disease, or PAD, which causes narrowing or blockage of the vessels that carry blood from the heart to the legs. Poor circulation not only causes excruciating pain, it can also lead to complex, untreatable wounds or ulcers and tissue death. Today, 1 out of every 3 diabetics over the age of 50 is likely to have PAD.

The tragedy of losing a limb is compounded exponentially by the fact that amputations are, in many cases, avoidable. The Amputee Coalition estimates that nearly 60 percent of all amputations related to diabetes could be prevented by early and appropriate clinical intervention. Data also show diabetic patients are far more likely to undergo an amputation than the average American — at an astounding cost to their lives as well as the health care system.

Last, the impact these diseases have on the African American community is particularly troubling. PAD is more common in African Americans than any other racial or ethnic group because the greatest risk factors, including diabetes, are more common among African Americans. According to a Dartmouth Atlas Project examining 2007-11 data, African American Medicare patients with PAD are more than twice as likely as other patients to have a leg amputated. Data also suggest that as the population ages and comorbidities rise, PAD disparities may accelerate.

Thus, it’s critical that providers and policymakers work toward enhanced public awareness about the connection between diabetes and limb loss. Addressing amputation and racial disparities in limb loss begins with addressing diabetes and related health conditions including PAD.

November, which is American Diabetes Month, is an excellent time to start.

Our nation must better educate those with diabetes about the symptoms and risks of ulcers, vascular disease, and amputation, as well as proper disease management. We must also encourage the discovery and delivery of live saving and cost-saving interventional treatments, such as advanced revascularization for PAD. Doing so will help protect patients, end lower limb amputations and save billions of taxpayer dollars.

To that end, policymakers should establish policies that support clinically appropriate interventions to reduce health care spending, particularly Medicare expenditures. Increased accessibility of vascular care can help to dramatically reduce the number of amputations in patients with PAD. We know that there is room for improvement. In fact, one recent study found that 30 percent of patients who undergo non-traumatic amputation never receive arterial testing to evaluate whether they are candidates for revascularization or other interventions, which could potentially save their limb.

Although the onset of diabetes and related vascular diseases can be terrifyingly silent, we need to speak loudly related health risks and treatment options. It’s a matter of life — and limb — for patients when we don’t.

 

Jeffrey Carr is an interventional cardiologist and endovascular specialist. He is the founding and immediate past president of the Outpatient Endovascular and Interventional Society, a multispecialty medical society. He is also the physician lead for the CardioVascular Coalition, a group dedicated to raising awareness for PAD and advocating for national health care policy and amputation prevention.

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