Preventing Amputations Starts with PCPs

J.A. Mustapha, MD, works to save limbs. A big part of his challenge is persuading primary care physicians to refer patients with peripheral arterial disease to specialty services like his, where amputations may be prevented.

One of J.A. Mustapha's most prized possessions is a photo of one of his patient's walking his daughter down the aisle at her wedding.

J.A. Mustapha, MD, FACC, FSCAI, saved the man's leg from amputation.

More than 100,000 adults lose limbs each year due to vascular disorders, as I report this month in HealthLeaders Media Magazine, and with an increasingly aging and heavier population at risk for diabetes, more are likely to do so.

As director of Metro Health Hospital's endovascular intervention program, Mustapha works to save limbs, and he often does. He specializes in treating patients at risk for losing limbs due to vascular disorders.

Mustapha is enthusiastic about what he does. He is grateful that he has saved many more limbs than he thought possible, at the 208-bed Metro Health Hospital in Wyoming, MI.

But some primary care doctors counseling patients whose limbs are in jeopardy don't seek out the specialty services of Mustapha or others like him, Mustapha tells me. Instead, many physicians simply examine the limbs and recommend amputation.

I found this bit of information troubling. Why would physicians not refer to him, or other specialists, if there were a chance that an amputation could be prevented? Most patients at risk of losing limbs are afflicted with peripheral arterial disease, a circulatory problem in which narrowed arteries reduce blood flow to the arms or legs.

2 Barriers to Referrals
"Typically, there are two reasons a physician would not refer to an amputation prevention specialist," Mustapha says. "Lack of knowledge on the part of the referring physician about the currently available limb salvage techniques is the primary reason. The second reason is when physicians know these techniques do exist, but choose not to refer the patients for the limb salvage procedures as some would view this as a defeat on their part."

"Hence," he adds, "our push to patients and their families to be the primary advocates for saving their limbs, and their lives."

Mustapha's specialty is performing artery and vein catheterizations designed to open vessels and improve circulation. The treatment he developed at Metro uses an ultrasound-guided interventional device through the foot and an ultrasound transducer that helps identify blood flow that traditional angiography misses.

When the endovascular intervention program began five years ago, the Metro Health System saved at least 88% to 92% of limbs that had been recommended for amputation, often by the patients' primary care physicians. It now saves even more—96% to 98%, says Mustapha.

Motivated to "Never Give Up'
Mustapha is touched deeply by his patients' experiences. He recalls a man in his late 50s who had visited other physicians and believed he had no other options, but an amputation. The patient desperately hoped otherwise. The man had read about Mustapha in a newspaper article, and came to see him for advice.

Indeed, the patient had been told that, "he had no options and needed an amputation," Mustapha recalls. The patient had had diabetes since childhood, but had led an active life as a teacher and sports referee. He simply wanted to keep his leg long enough to "walk his only daughter down the aisle in 6 months," says Mustapha.

Thanks to Mustapha and his team, the man was able to realize his wish. The surgeons were able to revascularize his limb, and amputation was avoided. "One of my most prized possessions is a photo of him walking his daughter down the aisle," he says. "Four years later, he is still very active and thankful for each step he has taken without pain in the past 4 years."

"It is patients like him that motivate me to never give up." [For more on what drives him, watch the video at the end of this column.]

Undertreatment Observed
Non-specialist physician awareness of vascular ailments, particularly peripheral artery disease, isn't where it should be. An extensive Harvard study in 2012 showed that peripheral artery disease (PAD) remains "under diagnosed and undertreated."

More than a decade earlier, a separate University of Minnesota Medical School study also showed that primary care physicians had limited awareness of the potential for peripheral artery disease, "PAD may be under diagnosed in primary care practice."

While there have been many studies addressing the need for more awareness and scrutiny of vascular disease, there has been less so about preventable amputations, Mustapha says. "My sense is that the majority of physicians do not refer appropriately to an amputation prevention specialist."

One of the concerns is that podiatrists and wound care specialists treat the symptoms (wounds and foot pain) without referring for an evaluation for "potential ischemic causality, " Mustapha says, referring to the restriction of blood supply to patients' tissues.

In addition, some physicians still make the decision to recommend amputation based on "patient symptoms without obtaining a selective angiogram," a specific X-ray to determine blood flow.

But Mustapha says he holds a glimmer of hope that research and attitudes are changing, especially among primary care physicians.

"The tides are changing due to an increase in awareness, advocacy, and available data," Mustapha says. Physicians who are referring cases to specialists like him are spreading the word that amputations can be prevented.

Amputation Prevention Efforts Spreading
Amputation prevention programs such as the one at Metro Health are "a small, but growing field as this is a very important area of medicine," Mustapha says. He and his partners take every opportunity they can to improve awareness among physicians, patients and the community, he says. And Mustapha directs an annual national conference, the Amputation Prevention Symposium, devoted to critical limb ischemia.

Of those physicians whose patients later go to him on their own, and have an amputation prevented, some, but not all, are "very happy, seeking more information and increasing their referrals," Mustapha says.

Others remain obstinate, "avoiding the discussion and not changing their practice," he says.

The physicians willing to change "tend to ramp up their screening efforts and refer more patients and refer them earlier in their disease process," Mustapha says. "We always make an effort to let the patient knew their foot was saved because their current physician recognized the problem and sent them to ."