‘My Patient Did Not Have to Die the Way She Did’
In the fall of 2021, a soft-spoken woman in her 60s came to the emergency room where I worked, complaining of pain in her foot. When I examined her, I could see that I would need to amputate the infected leg immediately, or she risked sepsis and death. I amputated her leg that night. She died 14 months later.
The entire episode could probably have been prevented. My patient was one of the estimated eight million to 12 million Americans with a condition called peripheral artery disease, in which clogged arteries limit the flow of blood to the legs, damaging and eventually killing the tissue. While the disease can’t be cured, it can often be managed with routine monitoring and lifestyle changes like exercising, quitting smoking and taking blood-thinning and cholesterol-reducing medication. If the disease worsens, more aggressive treatments can help unblock or bypass blood vessels to increase blood flow to the foot. Amputation should always be a last resort.
But this wasn’t my patient’s experience. Peripheral artery disease is more common among Black Americans, like my patient, in part because they are less likely to be effectively treated for its predisposing conditions like diabetes and hypertension. Many, like my patient, don’t seek treatment until they have a wound that won’t heal, the last stage before an amputation. This is largely because of a lack of access to health care and also because there is no gold-standard treatment for people with the disease.
Low-income adults, regardless of race, are at greater risk of advanced-stage peripheral artery disease. Still, Black people are losing limbs at a rate triple that of others. Worse, 40 percent to 70 percent of the patients who undergo amputation will die within five years of the surgery. Black Americans with the disease are less likely to be offered treatment that can restore blood flow, known as limb salvage, compared with white patients. Black Americans also pay more for hospitalization costs and have a lower rates of successful limb salvage compared with white patients.
The reasons for this, I believe, are treatment disparities rooted in the lack of standardized approach for treating the disease. Broader issues in health care like unconscious bias or barriers to health care access for certain populations are also likely to blame.
While general guidelines exist for treating peripheral artery disease, there are few incentives or penalties for not adhering to them. As a result, care is at the discretion of the doctor, who may not be well versed in limb salvage care or have the resources to perform limb-saving procedures. A lack of oversight and standardization in treatment has led to too many unnecessary and inappropriate procedures.
Medicine needs a standard for treating advanced peripheral artery disease and an incentive structure to enforce it so that hospitals and doctors amputate only as a last resort. To do that, we need large, government-funded population studies of peripheral artery disease patients. This will help vascular experts determine what the average amputation rate should be for patients with certain disease patterns and characteristics.
This isn’t a new idea. In 1971, President Richard Nixon initiated a campaign against cancer that led to the creation of accredited treatment centers and research that helped establish national care standards. Nowadays, a patient with a cancerous tumor is treated according to clinical practice guidelines.
Cancer centers that provide care are regulated by the government or accreditation bodies to ensure they are providing an acceptable standard of care. The idea is that wherever a patient may go, the care pathway should be the same for every patient regardless of race. It is not a perfect system, and racial disparities remain, but it has helped narrow major gaps in care. Policymakers and hospitals could take some of those same lessons in collecting data on peripheral artery disease and apply them to creating a standardized approach to care and centers to treat patients.
In the current “fee for service” model, a surgeon’s pay is based on surgeries she performs. But hospitals and doctors should be paid not just for doing the physical labor of an amputation but also for overall doing the right thing, which may or may not be limb salvage. The outcome matters. Rewarding doctors for providing data- driven care that are factors in better health outcomes can help lower amputation rates.
Having a more standardized and enforced approach to treating peripheral artery disease could not only save millions of lives, but also millions of dollars, for Medicare, which covers most of these patients. There are already task forces that are trying to establish standardized practices, including the Society for Vascular Surgery or the Congressional Peripheral Artery Disease Caucus, but we need to accelerate the work and test the models with urgency.
When I told my patient that we’d have to amputate her leg, she asked me what she could have done differently. I told her that perhaps if she had come to me sooner, I could have adjusted her medications and fixed her leg blood supply so her wounds would not have become infected. But the underlying problem is that the health care system is not providing equitable treatment to this population.
My patient did not have to die the way she did. We should work together to create a gold standard of care to treat patients with peripheral artery disease, no matter the color of their skin.
Anahita Dua is a vascular surgeon at Massachusetts General Hospital and associate professor of surgery at Harvard Medical School. She is co-director of the Peripheral Artery Disease Center and Limb Evaluation and Preservation Program at Massachusetts General Hospital.
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