Good morning, everyone. So this is a topic that I think should make all of us simultaneously depressed and enthusiastic because there's so much need and so much opportunity. So just quickly, we're going to look at race, ethnicity, gender, and the prevalence of PAD. The previous speakers have touched on this. Defining PAD as an ABI of less than 0.9 is something we could discuss for hours. But for the purpose of this talk, that is how it was defined. And we can see this age-adjusted prevalence where African-American women are at the highest risk of having PAD, followed then by white women, followed then by African-American men, and that the lowest risk is white men. And this is true at each age group, that this pattern persists from 45 to 64 in this study. This is an older study. And what we know is that vascular care is unequal. I think what we learned from COVID is care is unequal. And this is also unequal. And this heat map is from the Dartmouth study looking at likelihood of amputation in different parts of the country. And the darkest blue are the most amputations. And you can see sort of the stroke belt lights up, but a lot of other sections light up too. The likelihood of amputation in the presence of wounds by race and ethnicity is really disturbing. We see that about one year from the first diagnosis of a diabetic foot ulceration that Native Americans actually have the highest likelihood of a major amputation, followed by African-Americans, and then Hispanics, whites, and others at the most approved risk of life free from amputation. And who are the patients who are undergoing amputation? So being a man is protective against having an amputation, but being black is absolutely not protective. And this is a really disturbing odds ratio of 3.93. Diabetes, we all fear for its risk of amputation. And just to put it into context, that odds ratio is 1.25 compared to just the risk factor of being African-American. So we know black patients are more likely to undergo amputations, and we know women are more likely to undergo amputations from this. Dr. Wiley talked about the differential use of revascularization prior to amputation. It's worth reiterating. So what are the risk factors associated with amputation without an attempt at revascularization? So one is being old. So octogenarians are less likely to undergo an attempt at revascularization before amputation. Another risk factor is having diabetes. An important risk factor is being of African-American race. And an important protective benefit is being in an area that has high-intensity vascular care. So presence of specialists, presence of people who care about PAD, presence of people who diagnose and treat PAD is protective. And we know that intensity of vascular care correlates to decreased amputation risks. So this is all inpatient revascularizations, endo procedures only, open surgical procedures, and the regional amputation rate. And as there's more vascular care in a community, amputation rates go down. However, Black patients are less likely. So this is one, two, and three revascularizations prior to amputation. And you can see that Black patients are less likely to undergo a first revascularization attempt prior to amputation and all subsequent amputation, all subsequent revascularization attempts. When we look at amputation rates by race, socioeconomic status, diabetes, chronic kidney disease, claudication, and CLTI, a really important pattern persists. So there's a lot of information on this. We're going to go slowly and break it down. So this is patients with claudication, and this is patients with CLTI. And we're looking at Black patients versus White patients at a salary of less than or greater than $40,000 a year. So you can see that for claudicants, who should actually have a really low three-year risk of amputation, Black patients who make less than $40,000 a year have about a 4.5% amputation rate if they have co-incident diabetes and CKD. So that's a terrible statistic. And as socioeconomic status improves and salary goes up, that improves a little, but not a lot. What improves it is being White. And when we look at patients with diabetes, who we might think have a very high amputation risk, it's still higher in all Black patients than all White patients, and just the lowest rates in patients without diabetes or chronic kidney disease. So then moving over to this critical limb ischemia, CLTI version, now we see really high rates of amputation, which we expect. But I'm not sure that we should be comfortable with one in four Black patients undergoing an amputation at three years at a rate that far exceeds that of White patients, and specifically identifying this terrible risk factor picture of the combination of diabetes and CKD in having an increased amputation risk. This is older data from California from 2005 to 2009, and this was specifically looking at race and ethnicity in patients who had undergone lower extremity PBI. And you can see that non-Hispanic Whites have the best amputation-free survival, followed by Blacks with Hispanics in this cohort at the lowest. And Dr. McGinnigle spoke a lot about women in PAD, but just for the purposes of the discussion of amputation prevention, I will highlight some of the things that she told us so eloquently. So women are more likely to present with atypical symptoms or in an asymptomatic fashion. And when they are symptomatic, they are often older and have more mobility issues and greater walking impairment compared to men who present. We know that women with PAD are undertreated medically. So in this study, we looked at patients coming for PBI. So you know they're getting an intervention, and you know you should discharge them on optimal medical therapy. And at discharge, fewer than half are optimized on optimal medical therapy. And that the risk of being female and older really precipitates inappropriate application of GDMT. And we saw this slide before, looking at the differences in treatment for women versus men with AAA, PAD, and carotid disease. Interestingly, there's no difference in treatment rates for carotid disease, but there is a difference in AAA, and there's a bigger difference for PAD. And we know also from this meta-analysis that women do worse after intervention as far as composite mace and male endpoints. And we know that women, when they undergo amputation, undergo amputation at higher levels than men. So more above-knee amputations than below-knee amputations. So how do we fix it? One part of the solution is access to vascular care. So this is surgical data looking at regional clustering of access to specialists. So from 2018, there were over 3,000 vascular surgeons practicing in 533 counties. But 2,600 counties didn't have a vascular surgeon, leaving almost 100 million people without access to service. And what's important about this is we often think about rural places as underserved, but half of these were urban centers, where so many of us practice. So what are the factors involved in dealing with this? Well, there's the supply and the demand. So the demand on the patient end is diabetes, cardiovascular risk factors, presenting late with end-stage PAD because you never knew you had it. And the supply issue is our vascular physician workforce, access to diagnostic and preventative care, and this uneven geographic distribution of specialists. I'll make a plug for telemedicine. Can it reduce disparities? Maybe. I think what we learned from COVID is that it can be both great and bad, depending on how it's applied. My thought of the ingredients necessary for how telemedicine can reduce disparities is that you need to make sure that the access to the things that make telemedicine work are equally distributed. So patients need to be able to access the internet, or they need to go to a center where then they can communicate with the provider via the telemedicine encounter. We need to be accommodating for disabilities. A lot of our patients are older with PAD. They're deaf. They're blind. They can't use a cell phone. They can't necessarily deal with all the technology necessary to accomplish a routine telemedicine visit. Translation services are highly important, especially when we're thinking about accessing certain underserved populations. And this issue of the patient's facility with technology, depending on either socioeconomic status, age cohort, neighborhood deprivation, is something that needs to be part of the equation in implementation of telemedicine. So to conclude, PAD is more prevalent in African Americans, Hispanics, and Native Americans as well as women. Care is not equal. Translations are not equal. Revascularization and prevention are not applied equally. There are components of care that play a role in these disparities, including access, quality of care, and bias. And technology may help or hurt. Thank you very much.

disparities in care

peripheral artery disease

race

gender

amputations