Racial Disparities in PAD Care Highlight Urgent Need for Reform

Joseph M. Kim, MD, of Beth Israel Deaconess Medical Center, discussed a study examining racial disparities in the treatment and outcomes of peripheral arterial disease (PAD), particularly among Medicare beneficiaries with chronic limb-threatening ischemia (CLTI). Dr. Kim highlighted that Black patients often present with more advanced disease, are younger, and face a higher burden of comorbidities and socioeconomic disadvantage compared to white patients. Despite similar mortality rates, Black patients receive fewer revascularization procedures and are more likely to rely on emergency care due to inadequate access to consistent outpatient vascular management. The study emphasizes the importance of integrated, multidisciplinary care and early intervention in reducing disparities, noting national initiatives such as the PAD Pulse Alliance as critical steps forward.

Transcript:

Cardio Care Today: How do you interpret the finding that Black patients are 46% more likely to undergo major amputation after chronic limb-threatening ischemia (CLTI) compared to white patients, despite having a lower risk of mortality?

Dr. Kim: A great question. Our study highlights a complex interplay between the severity of peripheral arterial disease, the timing of medical interventions, and healthcare utilization patterns. What we see is that in a contemporary population of US Medicare beneficiaries with critical limb ischemia or chronic limb-threatening ischemia, black patients have more advanced ischemic disease. They’re younger and have a significantly higher burden of cardio metabolic morbidity, such as heart failure, hypertension, cholesterol, diabetes, and kidney disease, which are all also independent risk factors of peripheral arterial disease. And they are also more likely to be socioeconomically disadvantaged compared to white patients. And when we look purely just at the numbers, descriptive numbers, we see that black patients have a far lower percentage of revascularization procedures in the US compared to white patients, and numbers-wise, they have a similar rate of mortality.

And it’s once we account for their disease severity, comorbidities, younger age, and socioeconomic backgrounds, that the risk of mortality falls significantly below that of white patients. And what this tells us is that the patient profile of the black patients undergoing CLTI revascularization is significantly sicker than that of the white patients with CLTI going into their first revascularization procedure. Another part of our study involves conditioning our analysis on patients undergoing revascularization. This decision lies at the intersection of race, disease severity, access to specialist care, and physician referral patterns. And so, one aspect that we do have to acknowledge is that collider bias could artificially distort that mortality comparison between black and white patients.

Can you discuss the implications of higher emergency department utilization and hospital admissions for Black patients with CLTI in terms of healthcare access and disease management?

So, higher emergency department utilization and readmission among black patients highlight a lot of what we wanted to cover in our study in terms of inadequate access to preventative and longitudinal outpatient vascular care. Reliance on emergency care suggests that any complications from CLTI are often going unmanaged until they reach a critical stage, requiring urgent intervention. This pattern results from potentially limited outpatient follow-ups, as we found gaps in routine vascular surveillance and difficulties navigating the healthcare system. This ultimately leads to substantial strain on both healthcare resources and patients themselves. And therefore, it should come as no surprise that it leads to worse clinical outcomes, higher costs, and increased risk of severe complications, in particular, as we found in much higher rates of major amputation among black patients. Effective management of CLTI is not just the revascularization itself, but it requires proactive, continuous outpatient care rather than episodic emergency interventions, emphasizing the need for better healthcare integration and coordination to address these disparities.

Given the disproportionate burden of major amputation among Black patients, what are some actionable steps healthcare systems can take to improve early detection and intervention for PAD and CLTI?

There are some national multidisciplinary efforts ongoing, particularly the PAD Pulse Alliance, which is made up of the Society of Cardiac Angiography and Interventions, Society of Interventional Radiology, the Society for Vascular Surgery, and, in particular, the Association of Black Cardiologists. And this is just one multidisciplinary alliance. The AHA also has a similar initiative ongoing to encourage the implementation of a multi-modality, multidisciplinary action plan targeting early detection and intervention for PAD and CLTI, as you mentioned. One of them is for enhanced screening programs, including routine PAD and CLTI screening in high-risk communities, as well as in community clinics or via mobile units. We need multidisciplinary limb salvage programs that establish integrated care models combining primary care, podiatry, vascular surgery, wound care, endocrinology, in addition to cardiology and vascular specialist services, to manage risk factors more holistically. Additionally, we need an improved referral system that establishes clear, standardized guidelines for primary care providers to identify and rapidly refer at-risk patients to vascular specialists. And finally, we need better patient navigation and outreach programs to overcome logistical barriers such as transportation, appointment scheduling, and follow-up care.

What key takeaways would you like to leave our audience with regarding your research?

I think our key takeaways from our study are that we have a long way to go in providing equitable care for those most vulnerable patients with peripheral arterial disease and chronic lymph-threatening ischemia. And we found in previous studies that almost 70% of black and Hispanic patients with PAD are unaware of what the symptoms of PAD are. And many of them ascribe these symptoms to natural aches and pains of aging, when in effect, there are signs of very specific disease progression. And to be able to catch these early and treat them effectively for these vulnerable populations is going to be critical from both a public health and individual care standpoint, and importantly, for policy reform going forward.