Perspectives on Lower Extremity Peripheral Artery Disease: A Qualitative Study of Early Diagnosis and Treatment and the Impact of Health Disparities

Abstract

Lower-extremity peripheral artery disease (PAD), the accumulation of atherosclerotic plaque in the arteries of the legs, causes substantial morbidity and mortality. Frequent under- and delayed diagnosis result in poor outcomes, disproportionately affecting individuals from racial and ethnic minority groups. To understand barriers to early detection and treatment and factors contributing to disparities, American Medical Group Association (AMGA) conducted roundtable discussions and semistructured interviews in 2021. Eighteen participants discussed PAD evaluation, diagnosis, early medical management, and disparities in care. A qualitative case study approach and data reduction methods were used to generate themes, draw conclusions, and make actionable recommendations. Identified themes included lack of (1) prioritization of PAD for population health; (2) engagement of primary care providers in early evaluation and referral; (3) "ownership" of lower-extremity PAD within health systems; and (4) focus on disparities in care. Participant solutions included (1) financial impact of early PAD management, in the context of value-based payment; (2) embedding an advanced practice provider into a vascular surgery practice to facilitate evaluation and provide medical therapy; and (3) leveraging care coordination, multidisciplinary clinics, and telehealth technology to provide comprehensive care for patients with PAD and address disparities. A deliberate focused effort is necessary to close gaps and the accompanying disparities in early evaluation, diagnosis, and treatment for people with lower-extremity PAD. The authors describe 3 models that can be emulated to improve care for this high-risk population. With improved reimbursement and better medical therapies, now is the time to focus on early diagnosis and management of PAD.

Keywords: peripheral artery disease; primary care; screening; treatment; vascular medicine.

FIG. 1.

Underlying pathophysiology and manifestations of PAD. Although the atherosclerotic disease process that underlies PAD is generally progressive and is often present in multiple vascular beds, the symptoms and clinical presentation of lower-extremity PAD are notably variable and individual patients may not experience the classical sequence of symptoms. Observational studies using EHR data are limited to using ICD-10-CM diagnosis codes, which are defined based on a strict progression of manifestations. CLTI, generally associated with the appearance of rest pain, indicates more advanced pathophysiology. Multiple episodes of ALI may occur at any time during the phase of CLTI. [The term CLTI was adopted in 2019. Before that, the term critical limb ischemia (CLI) was commonly used.]. ALI, acute limb ischemia; CLI, critical limb ischemia; CLTI, chronic limb-threatening ischemia; EHR, electronic health record; ICD-10-CM, International Classification of Diseases, Tenth Revision, Clinical Modification; PAD, peripheral artery disease.