Large Primary Care Study Outlines PAD Burden and Incidence in United States

KEY FINDINGS

• In United States primary care settings, PAD was more commonly diagnosed in older adults, men, current smokers, and individuals with substantial cardiovascular and metabolic comorbidity.
• Non-Hispanic Black and Hispanic patients had higher odds of PAD diagnosis than non-Hispanic White patients, even after adjusting for age and comorbid conditions.
• Patients with PAD were more likely to reside in socioeconomically disadvantaged neighborhoods, highlighting the role of social determinants of health in PAD burden.
• There was a notable increase in PAD in 2021, suggesting potential delayed diagnosis or post–COVID-19 vascular effects.

ENDOVASCULAR TODAY ASKS...

Study investigator Elsie G. Ross, MD, MSc, with University of California San Diego School of Medicine in San Diego, California, commented on how specialists can partner with primary care providers to help diagnose PAD earlier, effects of delayed diagnosis on vascular care, and what actions can be taken to improve disparities in care.

Your study highlights that PAD is frequently diagnosed in primary care and disproportionately affects Black, Hispanic, and socioeconomically disadvantaged populations. How should specialists partner with primary care clinicians to improve earlier referral and vascular evaluation for these high-risk groups?

As specialists, it can be easy to play a passive role in the process of PAD detection and diagnosis. A provider suspects PAD in a particular patient and then sends a referral to one of us. One way to improve detection rates is for specialists to become more active participants in the referral process. Specialists are great educators. Simply meeting with primary care providers in your local area regularly to educate them on screening and management of PAD would be of great benefit. Regular engagement can help answer provider questions, bust myths about who is or isn't likely to have PAD, and clarify what current evidence supports for medical management and follow-up.

Another way to be an active participant is to champion informatics and process improvement initiatives within your health system that prioritize and make it easier for providers to screen and refer for PAD. Helping make ankle-brachial index testing an easier task for providers can also help.

Lastly, and most importantly, it's about being more intentional about doing this work with community partners who are more likely to see patients at highest risk. For instance, are there certain health systems in your area that have a higher proportion of Black or Hispanic patients? Consider reaching out to them first. For socioeconomically disadvantaged populations, working with federally qualified health centers can be a great way to increase screening and earlier referral and evaluation. We should also think about what happens after referral. For uninsured or underinsured patients, knowing which practices in your area offer charity care or which county health systems have affordable coverage options can make the difference between a referral that leads to care and one that dead-ends. Building those referral pathways proactively, rather than expecting patients to navigate them alone, is part of being an active participant in this process.

Given the increase in PAD diagnoses observed in 2021, what implications do your findings have for downstream vascular care, including demand for imaging, endovascular intervention, and limb salvage services?

The jump we observed was truly surprising. Compounding this is the rising rates of diabetes and amputation in the American population. Often, our most difficult patients to manage are those who have diabetes and PAD. We should also anticipate that patients diagnosed after pandemic-related delays may present with more advanced disease—meaning greater demand not just for imaging but for complex limb salvage rather than elective intervention. Vascular practices and health systems should plan accordingly, ensuring adequate vascular lab capacity, interventional suite availability, wound care infrastructure, and staffing. If we're anticipating a wave of more advanced disease, we can't assume current resources will be sufficient. This is a conversation practice leaders should be having now with hospital administrators and payers.

I think the need for coordinated, comprehensive vascular care is greater than ever, and we should consider how we can organize services so multiple providers can understand the full picture of the patient and intervene appropriately. Many of us know the American health system is extremely fragmented, and given that PAD patients tend to have multiple comorbidities, limb salvage care is costly and intensive, and imaging is of great importance, the question becomes: how can we organize these services in a less disjointed way? How do we make sure we're not "treating and streeting" but following up with patients to ensure optimal care? Large health systems tend to have many things under one umbrella, but communication across providers can be tough. Private and community practices may not have all the services under one roof and thus may need to lean on hospital resources to help coordinate care. Finally, I think many practices could benefit from a nurse manager/coordinator to help keep track of PAD patients. It might seem like an extra cost burden, but if patients are getting the right care in a timely fashion, such a role may pay for itself.

Many PAD patients in the study cohort had significant cardiovascular comorbidities at the time of diagnosis. How might specialists use this information to optimize multidisciplinary risk reduction and longitudinal care once patients reach specialty practices?

Specialists have often been reluctant to get involved in the nonprocedural aspects of patient care. For example, GLP-1 agonists, SGLT-2 inhibitors, novel lipid-lowering therapies, and low-dose anticoagulants have all been shown to reduce adverse events in patients with PAD. More widespread screening of Lp(a) can also help with risk stratification and treatment. However, asking a proceduralist to manage the side effects, refills, and monitoring can be a hard bridge to cross.

I think two approaches could be helpful. First, consider partnering with a vascular medicine specialist who is dedicated to the management of vascular patients and their comorbid conditions. This can be a game-changer. Many vascular medicine specialists also do procedures and preoperative risk stratification, so there are many benefits to including such a specialist in practice. Even without a formal multidisciplinary team, building informal collaborative relationships that include regular communication with a trusted cardiologist, endocrinologist, or primary care provider who understands your PAD population can accomplish much of the same goal. The structure matters less than the commitment to not letting patients fall through the cracks between specialties.

Short of this, staying up to date on the medical evidence and providing this information to primary care providers through direct education (or even at the end of your clinic note) can serve as a way to disseminate important information that can improve your patients' care.

What specific social determinants do you think are most actionable for reducing PAD disparities, and how can vascular specialists help address them through care pathways or community partnerships?

This is a tough one. Preventive care can be an especially hard sell for people who are struggling with other pressing issues. I think this is where showing up where people are is hugely important. I know of specialists who are very active in their community—holding health fairs where they screen for vascular disease and educate community members. These fairs may be standalone or part of other community festivities. The point is that it doesn't require someone to take a day off work to check their health.

Health literacy is another actionable area. Many patients don't recognize PAD symptoms, don't understand their diagnosis, or struggle to adhere to medical therapy because no one explained it in terms that made sense to them. Providing culturally appropriate educational materials, using teach-back methods in clinic, or partnering with community health workers can bridge these gaps. It's low-cost and high-impact.

For the other determinants, it takes multiple levers—political, social, and technologic. Specialists might consider running for office or reaching out to their senators and representatives to help improve policies that increase access to insurance coverage. Social media sometimes gets a bad reputation, but that is where many people are consuming content. One might consider running a social media channel where patients across the socioeconomic spectrum get access to free information. Finally, technologic advancements that allow patients to screen and monitor at home can help patients facing social barriers keep track of their health. We tend to think of many of these things (advocacy, technology development, social media) as outside the scope of clinical practice, but for conditions like PAD where disparities are so stark, engaging beyond the clinic may be part of the job.