Opportunity Knocks: Starting a Peripheral Artery Disease Program

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 - Decision

One decision some cardiology groups may wrangle with is whether or not to launch a peripheral artery disease (PAD) program. Local geography, community needs and physician interest all play a role in the decision, but the overall demographic and clinical trends point to a sound case for launching a PAD program—provided certain conditions are met.

The increasing prevalence of obesity and diabetes in the U.S., coupled with the general aging of the population, means the denominator of potential patients with PAD is increasing. Plus, the use of antilipidemic drugs and more extensive use of antiplatelet agents and antihypertensive medications means patients with these PAD-predisposing conditions are living longer and also are manifesting PAD problems that impact quality of life and daily activities.

And the trend is projected to continue. “PAD and cardiovascular disease will continue to be a problem for at the next 30 years,” predicts Sanjay Misra, MD, of the Mayo Clinic Gonda Vascular Center in Rochester, Minn.

People living with peripheral artery disease (thousands) worldwide

  2000 2010 Rate of change (2000-2010)
25-29 years 13,068 14,419 10-34%
30-34 years 14,272 15,103 5-82%
35-39 years 14,733 17,119 16-19%
40-44 years 15,209 18,645 22-59%
45-49 years 15,936 19,205 20-51%
50-54 years 14,808 19,603 32-37%
55-59 years 13,641 20,118 47-49%
60-64 years 14,416 18,029 25-06%
65-69 years 13,704 15,670 14-35%
70-74 years 12,547 15,063 20-05%
75-79 years 9,768 12,382 26-75%
80-84 years 6,123 9,118 48-92%
85-89 years 3,658 5,115 39-84%
90 years 1,717 2,474 44-09%
Total 163,600 202,062 23-51%

Estimated number of people living with peripheral artery disease and worldwide in the years 2000 and 2010, and the rate of change from 2000 to 2010

Source: 2013 Lancet;382:1329-1340.

Studies have connected the dots between the growing patient population and procedure volume. The utilization of endovascular lower extremity revascularization, a common PAD intervention, nearly tripled among Medicare beneficiaries between 1996 and 2006 (J Vasc Interv Radiol 2012; 23:3-9).

As practices assess whether or not to move ahead with a PAD program, they need to consider multiple factors. These include physician interest and commitment, infrastructure, practice configuration, education, training and marketing. They also need to evaluate the evolving issues in reimbursement and comparative effectiveness.

Ready or not?

No one single specialty owns PAD. Board-certified physicians in a number of specialties—interventional cardiology, interventional radiology, vascular surgery, vascular medicine—manage patients with PAD.

Regardless of the specialty or location of the practice, experienced clinicians who care for these patients agree on one prerequisite for starting a program. Providers must be interested and committed to taking care of patients with PAD. “You can’t just dabble in PAD,” says James Benenati, MD, medical director of the Peripheral Vascular Laboratory at Baptist Cardiac and Vascular Institute in Miami. “It has to be a full-time commitment.”

Physicians who care for patients with PAD need to understand the anatomy and pathophysiology of the disease as well as noninvasive therapies like exercise or drug therapies and image-guided and surgical interventions. Foundational expertise should be acquired during internship, residency and fellowship training rather than a weekend course.

Physicians who understand the patient population and  are willing to evaluate and care for them both in an acute setting and longitudinally may be the best-equipped to meet patient needs and achieve the economic goals of the practice. “There has to be some level of subspecialization,” continues Benenati. Technology, devices and medications are rapidly evolving, which requires a commitment to ongoing training.

In addition, volume comes into play. A practice may find that its volume cannot support six physicians performing stenting, but the same volume could support three physicians and also help them grow skills and expertise and build efficiencies, which can translate into improved patient care.

In addition to clinical interest, infrastructure is a must. “You need a certain amount of infrastructure—a clinic space to see and evaluate patients, an on-site vascular laboratory or lab access at a local hospital and the ability to perform interventional procedures, if indicated,” says Bret Wiechmann, MD, a vascular and interventional radiologist with Vascular & Interventional Physicians in Gainesville, Fla.

The vascular lab