Peripheral arterial disease (PAD) affects an estimated 8 to 10 million Americans, a number that is expected to increase as the population ages and as diabetes and obesity become more prevalent. Clinical research has shown that PAD is associated with a high risk of major cardiovascular events. While PAD shares risk factors of those associated with heart attack and stroke, it doesn’t always have a dramatic onset. Even in cases where PAD disease onset is severe, it’s often not treated as seriously as it should be.
New Study Data
In the November 2010 issue of Circulation: Cardiovascular Quality & Outcomes, my colleagues and I used data from the REduction of Atherothrombosis for Continued Health (REACH) Registry to assess hospitalization rates and costs in patients with PAD. The registry included individuals who were at risk of atherothrombosis caused by established arterial disease or the presence of three or more atherothrombotic risk factors.
The societal cost associated with the consequences of PAD is enormous. Prior research from our group estimated the costs associated with vascular-related hospitalizations alone in patients with PAD to be $21 billion in the United States. Roughly half of those costs are associated with PAD-specific treatment, while the other half relates to other cardiovascular-related hospitalizations, such as for heart attack and stroke. Invasive treatment for PAD is costly, and a first invasive procedure becomes a risk factor for further procedures. We are dealing with both clinically and economically severe consequences of a truly preventable disease in PAD.
In this latest study, we looked at the 2-year rates of vascular-related hospitalizations and associated costs in U.S. patients with established PAD across patient subgroups. Of the 25,763 REACH patients who were enrolled from U.S. sites, 2,396 (9.3%) had symptomatic PAD and 213 (0.8%) had asymptomatic PAD at baseline. Symptomatic patients with PAD had claudication (an ankle-brachial index [ABI] of less than 0.90), a history of lower-limb revascularization (eg, angioplasty or stenting), or amputation. Patients were considered asymptomatic if they had an ABI of less than 0.90 without symptoms.
Our investigation revealed that 23% of asymptomatic PAD patients had at least one vascular-related hospitalization during the 2-year study. About 31% of patients with symptomatic PAD had at least one vascular-related hospitalization during the study period. The average cumulative 2-year hospitalization costs per patient were:
$7,000 for patients with a history of claudication.
$7,445 for patients with asymptomatic PAD.
$10,430 for patients with lower limb amputation.
$11,693 for patients with a history of revascularization procedures.
Implications & Interpretations
Several themes from our study emerged, which underscore the significance of the burden of PAD. Patients with PAD have high rates of hospitalization, and the first admission for a procedure does not appear to be a permanent resolution of the underlying condition. When lower-extremity procedures are performed, recurrent hospitalizations are common, as are repeated revascularization procedures and associated costs. This study points out that beyond the provision of procedures for opening leg arteries, there is a need for preventive efforts and early detection.
Increased awareness of the burden of PAD is important for the public in general. In addition to more widespread use of the ABI as an early diagnostic test, preventive strategies—including the adoption of a healthy lifestyle and the control of cardiovascular risk factors—may help to arrest or stall the progression of the disease and minimize the risk of adverse outcomes and associated economic burden. A toolbox of scientifically accurate information from the PAD Coalition, a non-profit organization, may help physicians and can be found at www.padcoalition.org.
Readings & Resources (click to view)
Mahoney EM, Wang K, Keo HH, et al; on behalf of the Reduction of Atherothrombosis for Continued Health (REACH) Registry Investigators. Vascular hospitalization rates and costs in patients with peripheral artery disease in the United States. Circ Cardiovasc Qual Outcomes. 2010;3:642-651. Available at: http://circoutcomes.ahajournals.org/content/3/6/642.abstract.
Jaff MR, Cahill KE, Yu AP, Birnbaum HG, Engelhart LM. Clinical outcomes and medical care costs among medicare beneficiaries receiving therapy for peripheral arterial disease. Ann Vasc Surg. 2010;24:577-587.
Norgren L, Hiatt WR, Dormandy JA, et al. The next 10 years in the management of peripheral artery disease: perspectives from the ‘PAD 2009’ Conference. Eur J Vasc Endovasc Surg. 2010;40:375-380.
Aronow H, Hiatt WR. The burden of peripheral artery disease and the role of antiplatelet therapy.Postgrad Med. 2009;121:123-135.
McCann AB, Jaff MR. Treatment strategies for peripheral artery disease. Expert Opin Pharmacother. 2009;10:1571-1586