As PAD disparities gain notice, Penn Medicine closes care gaps

The physicians seek to not only provide treatment alternatives to the lower extremity amputations that PAD can induce, but also to prevent the disease from reaching that severity in the first place.

Their efforts come amid a national reframing of the PAD conversation—when the American College of Cardiology (ACC) and American Heart Association (AHA) updated their joint PAD care guidelines in 2024, they examined the impact of health disparities for the first time.

While population differences in the pervasiveness of critical risk factors such as smoking, diabetes, chronic kidney disease, hypertension, and dyslipidemia likely account for a sizable share of PAD disparities, they do not completely explain the gaps, the ACC and AHA say. The groups now cite social determinants of health such as residential segregation, access to quality housing, health care, food, and education, and inequities in income, wealth and insurance coverage.

In a scientific statement on PAD disparities, the AHA further points to physicians prescribing disease-managing medications less often to Black patients and recommending artery-opening procedures less frequently, possibly from unconscious bias about patient needs and follow-up care commitment. The group also highlights an association between racial discrimination and vascular harm, potentially through increased inflammation and vasoconstriction.

Evidence grows that Black patients are deeply affected by PAD racial disparities

As an atherosclerotic disease that can cause debilitating leg pain during activity and more severe complications that can lead to amputation, PAD takes a toll across populations. An estimated 21 million Americans already live with the disease, and PAD’s impact is expected to grow with an aging population and the surge in diabetes.

Still, the risks and harms disproportionately fall on certain groups, including rural residents, patients of lower socioeconomic status, and Black and Hispanic populations. Members of these groups are more likely to develop chronic limb-threatening ischemia (CLTI), the most severe stage of PAD, and to subsequently undergo amputations.

PAD disparities particularly affect Black patients. The lifetime risk of PAD reaches 30% for Black men and 28% for Black women, compared to 22% for Hispanic men and women and 19% for white men and women. When Black patients are diagnosed, they are more likely to already have advanced disease, with their CLTI particularly entrenched.

Even after accounting for disease severity and comorbidities, Black patients are more likely to undergo amputation rather than revascularization. Their amputation risk is up to four times higher than white patients, and they are more likely to receive amputations above the knee versus below the knee, a greater blow to quality of life.

When using Medicare data to determine amputation rates by zip codes, a team of Penn Medicine researchers made a surprising discovery about disparities. As expected, rural residents faced high rates, largely a reflection of distances to medical care. However, zip codes with high concentrations of low income and/or Black residents had similarly high rates—even when situated near top academic medical centers in major urban areas.

The findings, cited in the 2024 guidelines update and published in the Journal of the American Heart Association, point to care barriers going beyond geography and stretching over a lifetime.

“You can see that the effects of structural racism can affect this pathway in a number of ways,” lead author Alexander Fanaroff, MD, told the Penn Advanced Limb Preservation Symposium in 2023. He cited a number of missing pieces—disease education, healthy food, safe spaces to exercise, easily accessed pharmacies, affordable prescriptions, and referrals to specialists.

Penn Medicine initiatives seek to address barriers to PAD care

Further research by Dr. Fanaroff’s group shows that in the year before their amputations, Black patients and other marginalized groups are much less likely to have visited a primary care physician or a vascular specialist—a vascular surgeon, cardiologist, or interventional radiologist.

To ease access to PAD-related care, PALP colleagues help patients see multiple needed specialists in a single visit, reducing barriers connected to transportation, childcare, and work. Patients can also get any vascular testing they need, often the same day, just before seeing a vascular surgeon.

When patients require a PAD intervention and may benefit from extra support—including to overcome distrust of medical care—Philadelphia-area physicians can refer them to The Center for Surgical Health, a nonprofit started by former Penn Medicine residents. Personal navigators accompany patients to appointments and help them get insurance coverage, transportation, translators, and social supports, if needed.

Another Penn Medicine initiative seeks to further determine why patients do not receive timely care that could prevent, or at least manage, PAD. Thus, when patients with severe disease come in for an amputation—sometimes a necessity, despite advances in revascularization—they are asked if they are willing to enroll in a study.

Willing participants sit for an open-ended discussion about anything that got in the way of their medical care, from misapprehensions about seeing doctors to finances, available time and other logistics. The questions apply to the full PAD journey, not just vascular surgery, and are intended for publication.

The object of this effort is to ensure that patients are asked not just about medical conditions, but whether there are things in their lives that prevent them from seeking care in order to better target our efforts to improve care.

PAD screenings can help improve case identification and disease awareness

Recognizing that, at times, care needs to meet people in their neighborhoods, Penn Medicine joins an annual summer community health fair at the Church of Christian Compassion—located in a Philadelphia zip code flagged for high amputation rates among Black residents.

In addition to screenings and preventive information for cancer and high blood pressure from their colleagues, Penn vascular specialists promote arterial health. At a recent event, more than 30 residents got screened for PAD. As tested residents are urged to talk to their friends and family, the messages about PAD and its care options travel into the community, and other groups are encouraged to reach out to set up PAD screenings.

Community physicians can also support efforts to identify PAD. AHA recommendations seek more attention to PAD-related screenings, including blood glucose testing, foot exams for wounds, and lower extremity pulse checks. Ultrasound-based ankle brachial index (ABI)—a test available at vascular programs such as Penn Medicine’s—can then confirm the disease.

Partnering with community physicians in the PAD response

With all aspects of PAD care in one place, the Penn Advanced Limb Preservation makes it easy to refer patients but still stay involved in their care.

By confirming an accurate diagnosis and accessing the latest therapeutic approaches, community physicians can secure the best outcomes for their patients.