- The complicated combination of diabetes and peripheral artery disease (PAD) often leads to limb amputation because of loss of the micro vessels of the foot
- Patients who are socioeconomically disadvantaged or from minority groups are disproportionately affected by both diabetes and amputation
- A new Massachusetts General Hospital program named the Limb Evaluation and Preservation Program (LEAPP) combines expertise from many specialties to proactively improve blood flow; control diabetes; and prevent pain, wounds, infections and amputations
- The program is reaching out to community hospitals, primary care providers and other health care professionals to help recognize which patients need early intervention to prevent amputation and how to refer patients
Vascular specialists at Massachusetts General Hospital have joined forces in a new program that helps patients with diabetes and peripheral artery disease (PAD) manage this complicated pair of conditions. The ultimate goal is to protect their limbs from amputation, a common and traumatic outcome in this population.
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"Patients with diabetes and PAD have multiple medical challenges, including limb pain, wound care difficulties and reduced blood flow. Every 30 seconds in the United States, a leg is amputated because of diabetes, but this outcome may be avoided with early intervention to optimize patient care," says Anahita Dua, MD, MBA, MSc, assistant professor of Vascular and Endovascular Surgery, associate director of the Wound Care Center, director of the Vascular Lab and co-director of the Peripheral Artery Disease Center at Mass General.
The new Limb Evaluation and Preservation Program (LEAPP) at Mass General brings together a multidisciplinary group of specialists to advocate for patients with PAD and achieve better outcomes by providing early, targeted, multidisciplinary intervention to avoid amputation.
Team Approach to Diabetes and Peripheral Artery Disease for Limb Preservation
Dr. Dua and her vascular surgery and medicine colleagues offer the best possible cutting edge options for limb salvage—including open and endovascular deep venous arterialization (DVA) to improve limb blood flow, resolve pain and heal chronic wounds—all with the goal of saving limbs that may otherwise be amputated.
However, Dr. Dua emphasizes that this complicated patient population needs more than invasive interventions at a time of crisis. The care must be holistic from the start.
"As a vascular surgeon, I can give a patient beautiful blood flow with a bypass or a complex endovascular procedure, but if the wound care is not up to scratch, diabetes is out of control or the foot is not appropriately off-loaded, it's not going to matter in the long run because the leg may still be amputated," she says. "Patients often come to us 10 years too late. The time to deal with these issues is not when the person gets a wound—it is all about preventing a wound from every developing by ensuring excellent medical management, education about the disease progression and prompt, multidisciplinary intervention at the earliest sign of an issue. Essentially, to optimize outcomes and prevent amputation, patients need to be seen earlier by a variety of specialists to proactively prevent the issues that can lead to amputation. This is challenging sometimes because there are so many providers that it is difficult for patients to navigate the maze of patient care. That is where our LEAPP program to salvage limbs comes in and takes care of the navigation for our patients."
When a patient is referred to the Limb Evaluation and Preservation Program, a vascular nurse coordinator acts as a care coordinator, gathering all pertinent information, reviewing the case, then making appointments with any and all specialists the patient may need, including:
- Cardiology and interventional cardiology
- Infectious diseases
- Interventional radiology
- Supervised exercise experts
- Wound care
- Vascular lab
- Vascular medicine
- Vascular surgery
"The onus is usually on the patients, who may not even be able to advocate for themselves," Dr. Dua says. "We take the burden off the patient and off the primary care provider. We apply very deliberate patient management strategies to optimize care and outcomes and protect these threatened limbs."
Using Evidence and Tools to Prevent Amputation
One of the program's tools is the toe pressure, a quick, non-invasive test that determines the blood pressure of the toe. The Ankle-brachial index is another readily used tool that can establish a diagnosis of PAD before the condition becomes limb-threatening in a non-invasive, quick way.
If a patient is confirmed to have PAD, he or she then is routed to the specialists they need to manage the disease and prevent long-term complications that can lead to invasive procedures and amputation. For example, if a patient has a wound, poor blood flow and diabetes, the LEAPP program will coordinate visits with podiatry, vascular surgery, vascular medicine, endocrinology, wound care and infectious disease seamlessly and in a timely fashion.
Another example is the management of patients who have no wound but present with calf pain when they walk short distances. For this group, the pain may make walking so difficult it impacts their ability to enjoy life. This is called intermittent claudication where pain in the calves induced by exercise and relieved by rest.
"These patients often wind up having interventional procedures, but data show that they may simply need noninvasive supervised exercise," Dr. Dua says. "We have developed and proven a protocol that can avoid or delay invasive intervention."
The program specialists have a case conference every month to discuss patient progress and needs, ensuring comprehensive, whole-patient care. They follow patients over time, monitoring blood supply, ensuring that wounds are prevented or treated, encouraging diabetics to control blood sugar and making sure patients are not lost to follow-up.
Dr. Dua wants community providers to reach out to the LEAPP before it's too late for their patients.
"We welcome calls from community hospitals and other providers," she says. "We would love to help in any way we can whether that be by consulting about your patients or bringing them into our LEAPP program through the Mass General PAD center to optimize their care."
Reaching Poor and Minority Patients
Published literature shows that both diabetes and limb amputation are much more common among people who are poor or of minority status. Patients who do not have access to health care also may use the emergency department for primary care because of this lack of access or lack of insurance or both.
Dr. Dua is working to educate emergency department personnel about the LEAPP program to ensure these patients are rapidly routed to the team of specialists so their limbs can be salvaged.
"It's endemic, and we need to take conscious action to help," Dr. Dua says. "We want to educate these care providers to recognize the emergent nature of this condition and ideally route patients to the Mass General program so we can get them holistic, multidisciplinary care fast."
She is currently seeking a grant to launch an outreach program that would educate primary care providers about the availability of Mass General's multidisciplinary expertise so that they immediately refer diabetic patients with PAD.
Setting the Standard for Limb Salvage
Dr. Dua says Mass General is perfectly positioned to lead the multidisciplinary care of these complicated conditions, as well as establish the standard of care in the field.
"There is variance in skill, training and outcomes throughout the country and the region, but we have world experts in every specialty needed to care for these patients to reduce amputation rates. Mass General is known for its excellence in care coordination, and this program applies that to a population who really need it. Our specialists talk to each other, eliminate inefficiencies and follow established protocols that work. We have a huge research arm that allows us to see what works, get an evidence base, set the bar for care of this patient population, then be nimble to implement those changes."
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