Eliminating Racial Disparities in Peripheral Artery Disease Care: Where Do I Begin?

Introduction

Peripheral artery disease (PAD) affects over 12 million individuals nationwide and significantly contributes to the estimated 185,000 major lower extremity amputations that occur annually.^1,2 Many patients with PAD are asymptomatic and unaware of their underlying problem. Those who do present with symptoms often describe varying degrees of pain and/or nonhealing lower extremity wounds or gangrene, all of which can significantly impair one's quality of life, decrease independence, and present significant risk to limb and life. In fact, PAD is associated with three times the average risk of cardiovascular events and mortality.³

Racial Disparities in PAD Care

Health disparities, including those based on sex, race, geography, socioeconomic status, etc. have been well documented for decades. Communities of color have a disproportionate prevalence of high-risk comorbidities and modifiable behaviors that are associated with PAD development, progression, amputation, and death.^4,5 Specifically, Black patients have a higher prevalence of PAD⁶; are treated differently when they present with symptomatic PAD⁷; and experience worse outcomes related to PAD⁸. Several theories as to why this occurs have been presented, however, very little ground has been gained in determining which factors are the primary drivers of racial disparities in PAD. Therein lies the danger: When a patient comes to the office and asks about the benefits of statin therapy or a loved one wants to know the risks after lower extremity revascularization; we can all readily answer these questions. When a Black male patient asks, "why is my risk of losing my leg 2–5 times that of a White male?," this is much more challenging to explain. This challenge exists because we do not fully understand the complexities that surround racial disparities in PAD care, however, the unknown represents a call to action.

PAD is a public health crisis that requires thoughtful, systematic, multi-level solutions to create necessary change and move the needle towards health equity. In the American Heart Association (AHA) Scientific Statement, "Health Disparities in Peripheral Artery Disease", race-based disparities are the primary focus. The authors discuss several mechanisms that mediate racial disparities in PAD, ranging from vascular health measures such as oxidative stress to the social determinants of health, and present thoughtful action items to which we should all pay attention. As a junior surgeon-scientist often presented with overwhelming problems such as how to eliminate racial disparities in PAD care, I often ask myself, "where do I begin?"

We need to apply the appropriate rigor, sophistication, and innovation to this problem. This begins with understanding what race is, and what it is not. Race does not represent biology and cannot serve as a substitute for genetic ancestry. Race is a social construct and is not a determinant of health, although it is a proxy for a myriad of factors that are. This is an extremely important concept to understand when designing, interpreting, and presenting a study on race-based differences in PAD care. So often we see publications that inadvertently simplify associations and attribute racial disparities in PAD outcomes to a higher burden of comorbidities, advanced disease severity, worse socioeconomic status, and lack of patient investment. To not delve deeper would be a critical failure as this misses the complex interplay that exists between individual-level discrimination (e.g., PAD treatment discretion by providers caring for vulnerable populations), cultural racism (negative normative beliefs and attitudes that inform both treatment delivery and acceptance), and structural racism (e.g., residential segregation, varying patterns of education spending, policies that disincentivize PAD screening and prevent early diagnosis).^9,10 To be more thoughtful and inclusive in one's approach to the study of racial disparities in PAD care, consider engaging intersectional approaches to add dimensions of inequity to groups, examining neighborhood level determinants that may help to disaggregate the intricacies of race and place, and including experts on your research team from other disciplines as well as individuals who identify as a member of the populations you are studying.

Developing a working understanding of the political determinants of health is vital. Political determinants "involve the systematic process of structuring relationships, distributing resources, and administering power.¹¹" Some scholars suggest that these are the primary drivers of health disparities. For example, understanding the enduring effects of the legacy of enslavement, redlining, residential segregation, environmental injustice, food insecurity, and neighborhood disinvestment on PAD prevalence, treatment, and outcomes will undoubtedly prove illuminating. Thus, we need to develop and utilize multilevel and multidimensional measures of structural racism to better understand the complex relationship between structural racism and PAD care.

We should encourage and normalize stakeholder engaged PAD research. Engaging and listening to individuals from disadvantaged communities as true partners on the research team helps to bridge gaps that have long prevented truly sustainable solutions to disparities in PAD care. This includes assessing health status among patients with PAD and engaging them in the research process.¹² The genesis of community based participatory research (CBPR) stems back to the 1940s, however, this partnership approach to research is widely underutilized, particularly in PAD research. CBPR benefits include leveraging community knowledge, expanding perspectives held by more traditional investigators, developing well-informed and tailored multi-level interventions that employ a ‘for us, by us' approach to interpretation and dissemination of results, and more. This collaborative approach allows for synergy in a space that gives voice to the community, cultivates stakeholder informed multi-level interventions, and promotes sustainability in equitable PAD care.

Community awareness and education helps to foster relationships with the community, improve disease-specific knowledge, and recruit willing participants for stakeholder engaged research. This work can be amplified if those of us from different specialties can forget our differences and work together. As vascular specialists, we serve a community of patients with PAD who are largely unaware of the name of their diagnosis and associated consequences. Similarly, while several experts have called for referring physicians to ‘take off their (patients') shoes' to improve detection of PAD, this is an approach that places more weight on an already overburdened primary care workforce. Leveraging the electronic health record system with artificial intelligence and machine learning to identify those at highest risk for PAD and predict PAD outcomes among key subgroups is long overdue.¹³ The quest for health equity in PAD care needs a paradigm shift to where the population with PAD is at the center.

Conclusion

The AHA scientific statement highlights one of the most important population health concerns of our lifetime. Several experts have debated how to measure quality, quantify cost, and understand value in PAD care.¹⁴ Improvement efforts have largely focused on opportunities for all comers with PAD. However, focusing on the collective group will leave those who suffer most even further behind. This is because racial disparities represent the greatest threat to quality. There is a critical need for a wide scale public health campaign that places PAD on the same level of community understanding as heart attack and stroke. There is a dearth of good science in this space and a need for rigorous, community engaged implementation research focused on disaggregating race from place and measuring structural racism in PAD care. There is a moral imperative to advance health equity and eliminate racial disparities in PAD care. This will not happen unless all PAD stakeholders work together. That is where we should begin.