Fighting
an Epidemic of Amputations in Bexar County
Let’s
Toe-and-Flow, San Antonio!
Lyssa Ochoa,
M.D., Board-certified Vascular and Endovascular Surgeon; The San Antonio
Vascular and Endovascular Clinic
Over 2,000
Bexar County residents will lose a limb to amputation due to diabetes and
peripheral arterial disease this year alone. Our nationally-high rates of
diabetes (13.3% of adults, 7th highest of 34 U.S. cities with pop.
over 500,000) and obesity (38.4%, 4th highest of 34) are major
contributors to this problem1.
Furthermore,
San Antonio’s unenviable position as the most economically segregated large
city in America2 creates uniquely challenging barriers to preventing
these amputations. In fact, data from the Texas Department of State Health Services
shows that the diabetic amputation rates are highest in zip codes that also
rank highest in the Hardship Index, which aggregates six socioeconomic factors
to identify relative difficulty in daily living.
These
circumstances indicate that we need a wide-reaching amputation prevention
program that specifically targets areas with both the highest clinical need and
strongest socioeconomic barriers. Thankfully, much of the groundwork for the
clinical component has already been established. In a 2010 edition of the
Journal of Vascular Surgery, the “toe-and-flow” model of collaborative
amputation prevention was born3. The article stipulated that the
amputation prevention team should include specialists in podiatry and vascular
surgery at a minimum, along with infectious disease, general surgery, plastic
surgery, diabetology, and primary care, to essentially wrap each at-risk
patient in a proactive bubble of resources. Of course, this combination of
resources and requisite collaboration is more practical in a major academic
center than a lower-socioeconomic area encompassing over 200 square miles, but
modifications can tackle both the logistics and the socioeconomics.
Diagnosis
and Availability of Care
Diagnosis of
the at-risk patient may occur in any practitioner’s office, ranging from
ischemic changes of a toe to obviously infected, non-healing foot wounds. Upon
such suspicion, the practitioner can use a free HIPAA-compliant smartphone app
to alert all other specialists on the team to the presentation, pictures and
all. This simple action launches immediate collaboration toward amputation
prevention. With a few descriptive texts, and entire plan of care arises. One
benefit of community-bases practices is autonomy over clinical schedules. It is
not unfathomable that a committed team of practitioners could perform the
necessary consultations and diagnostics on a same-day to next-day basis.
Transportation
Patients
that face the combined dilemma of clinical amputation risk and socioeconomic
barriers frequently cite transportation as a primary barrier to care. However,
many private insurance plans and Medicare Advantage plans offer transportation
as a benefit. Medicaid will soon provide transportation for all beneficiaries
through all managed and traditional carriers. A little energy from office staff
can go a long way to help patients acquire the “free” transportation included
in their plan. Many of the transportation arrangements will include multiple
stops if multiple offices must be visited in a single day. Furthermore,
non-profit organizations, such as Ride Connect Texas, offer transportation to
those in need at no cost. Eliminating the transportation barrier is a major
step toward a community-based amputation prevention program.
Intervention
Designing
the appropriate clinical intervention strategy for amputation prevention is
truly a patient-by-patient endeavor. The breadth of the available toolbox is
determined by the combined skill sets of the team taking care of each patient.
Primary infection control is commonly obtained through surgical intervention by
incision and drainage, debridement, or digital amputation. Diabetic foot
infections may harbor treatment-resistant bacteria, requiring the infectious
disease specialist to initiate appropriate infection control therapy and guide
long term culture-specific antibiotic therapy. In many cases, arterial
insufficiency is an underlying factor which could require revascularization
ranging from distal arterial bypass to pedal artery angioplasty. Optimal wound
healing may also require the wound specialist to administer hyperbaric oxygen
therapy, requiring 5-day-per-week treatment for up to 2 months. A significant
proportion of patients will have comorbidities involving any mix of heart
disease, kidney disease, hyperlipidemia, and hypertension, adding additional
layers of specialists that need to be consulted and informed along with a major
juggling act by primary care physicians.
The
interventional mix described above would be daunting to most people facing such
issues, but even more so to those with limited resources of finances, time, transportation,
and health education. How can a single, stay-at-home grandmother with an 8th
grade education raising 2 grandchildren on a fixed income without a vehicle be
expected to make all of the appointments requisite to amputation prevention,
let alone understand each step of the way? This is where an emphasis on
Social Determinants of Health by all members of the amputation prevention team
can make the most significant impact. Coordinating resources in today’s
smartphone-connected world is not as challenging as it may seem. Vascular and
podiatric specialists, for example, can be scheduled to see patients inside a
hyperbaric oxygen facility in conjunction with the wound specialist. An
alternative could be that the patient’s transportation for the day be
coordinated to visit multiple specialists at their independent facilities on a
single day.
The
Dream: Upstream Prevention
All of us
healthcare professionals understand that diabetic amputation prevention cannot
begin at the presentation of a diabetic foot ulcer. Amputation prevention begins
in childhood, with the establishment of healthy nutritional and exercise
habits. Amputation prevention continues at every step through life, regardless
of whether one is rich or poor, white or Hispanic, educated or not. We cannot
ignore, however, that risk factors for diabetic amputations have a tendency to
creep into our lives with varying degrees of disproportionality. This opens a
complicated Pandora’s box. What are the roles of government, educational
systems, parenting, community resources, housing, transportation infrastructure,
and safe environments? All of these and more undoubtedly have an impact on
health outcomes, as described by countless studies of Social Determinants of
Health. As a community of healthcare providers, we must optimize the care we
provide to our patients, but we must also challenge ourselves to help our
patients in ways that extend beyond the four walls of the exam room. Only then
will we begin to see diabetic amputation rates fall, along with improved health
outcomes at every turn.
Together,
We Can Make a Difference
The
collective challenges we face in San Antonio which lead to diabetic amputations
may be unique to our city, but a wide range of possible solutions can be found
by applying a little creativity to adapt existing models to our community. Collaborative
amputation prevention can by the future of San Antonio by leveraging the
well-established Toe-and-Flow model, and trading a bricks-and-mortar medical
tower for a technology-enabled, passionate pool of community-oriented resources
who are willing to tackle Social Determinants of Health with our patients.
Achieving this vision would undoubtedly create a new model that may benefit
cities throughout the United States, but it has to start somewhere. Let’s
toe-and-flow, San Antonio!
1. Centers for Disease Control, 500
Cities: Local Data for Better Health, 2018; https://chronicdata.cdc.gov/500-Cities
2. Economic Innovation Group, Distressed
Communities Index Report, 2016; https://eig.org/wp-content/uploads/2016/02/2016-Distressed-Communities-Index-Report.pdf
3. Rogers, et al, Toe and flow:
Essential components and structure of the amputation prevention team, Journal
of Vascular Surgery, September 2010; https://www.jvascsurg.org/article/S0741-5214(10)01325-X/pdf
