Translating vascular health equity into action

We all do better when we all do better.

—US Senator Paul Wellstone, excerpt from a 1999 speech to the Sheet Metal Workers’ Union

In the United States, the treatment of ischemic vascular disease has reached a point of reckoning. Despite years of investment and development of safe, available, and effective evidence-based practice to reduce cardiovascular (CV) risk, those with atherosclerotic cardiovascular disease (ASCVD), and especially those with peripheral artery disease (PAD), have not been justly rewarded with improvements in clinical outcomes. All the while, rates of diabetes and food-related chronic diseases are on the rise, and increasing costs have reduced access to care and further destabilize efforts to improve community health. Misaligned incentives that glorify profits have spurred healthcare market consolidation, which has not reduced the costs of care nor the quality. At the 2022 Scientific Sessions of the American Heart Association, Robert Califf, MD, commissioner of the Food and Drug Administration, petitioned for the ‘need to do something more than we’re currently doing, and something different, because what we’re doing now has stalled and is not working the way it should’. ¹

So, what should be done? To begin, it should be acknowledged that low utilization of evidence-based practice and the consequent burden of poor outcomes are disproportionally carried by marginalized populations enduring social, political, and economic isolation. ² This fact is perhaps no more relevant than among the population with PAD. Vascular specialists will recognize the perennial challenges with low disease awareness that is, in part, cultivated by a lack of support for PAD screening ³ along with layered health-related social needs that present barriers to optimal vascular health. With declining access to care, rural patients with CV disease are significantly less likely to receive evidence-based practice and are more likely to experience worse outcomes. ⁴ The non-Hispanic Black population experiences a higher prevalence of PAD, presents with more advanced symptoms, and suffers rates of nontraumatic major amputation that are four times higher than the non-Hispanic White population. These striking differences in care and outcomes have rallied a national call to action to improve vascular care and reduce amputations by 20% by 2030. ⁵ However, prevailing economic forces exacerbate these disparities, presenting significant headwinds for the clinician motivated to seek change. On their own, healthcare providers do not possess the resources, incentives, or bandwidth to remedy these prodigious challenges. The inability to effectively address barriers to high-quality, equitable care also creates an environment of moral injury for professionals and engenders mistrust among patients. Apathy and burnout ensue. In a ‘sorry pal, you’re on your own’ society, the magnitude of the underserved is likely to grow, continuing to frustrate healthcare delivery as margins to deliver care tighten and further strain the healthcare team. Perhaps more aptly, what can be done?

To create the sustainable change Commissioner Califf has called for is likely to require broad realignment of incentives, a shared vision, with multistakeholder engagement to implement meaningful change. In October 2021, the Centers for Medicare and Medicaid Services (CMS) Innovation Center released their white paper announcing plans to align 100% of Medicare beneficiaries with risk-based, value-oriented payment arrangements by 2030. ⁶ Leading health policy experts have recommended that the CMS Innovation Center accelerates the movement to value-based care to drive broad transformation. With strategic objectives from CMS to (a) drive accountable care, (b) advance health equity, (c) support innovation, (d) address affordability, and (e) partner to achieve system transformation, there exists a unique opportunity for specialists to lead in implementing change among those with vascular disease. To be sure, these priorities and the rapidly increasing prevalence of diabetes and an aging population ensure the relevance of PAD in these new models for years to come.

Transformative solutions perhaps begin by acknowledging the opportunity to measure and optimize care that broadly manages risk among diverse populations, including those with vascular disease. Aligning incentives with flexibility in payment and regulatory requirements will lead to actionable value-based arrangements key to sustainable transformation. Success from there starts and ends with a plan supported by partnerships and the ability to act. To that end, significant progress is underway.

Launched in May 2022, the American Heart Association’s PAD National Action Plan ⁷ is the culmination of substantial efforts over years, bringing together thought leaders and committed organizations to define clear goals to improve outcomes by promoting the awareness, diagnosis, and clinical care of PAD. This PAD National Action Plan serves as a guide to focus sustaining efforts and proffer collaboration and alignment in pursuit of priorities held by many stakeholders committed to improving care and outcomes for those with PAD, including patient advocacy and health policy efforts that may inform congressional action, which will be key to sustainable care transformation.

Understanding the gaps between science and practice broadly, and particularly among marginalized communities within local healthcare markets, creates an opportunity to identify key partnerships to support change and influence progress. Alignment armed with learnings of public health needs offers the opportunity to develop learning health systems that may respond to local markets, including extension of care networks outside of the traditional acute care setting, using virtual and in-home care. ⁸ Synergies between primary care and vascular specialists can then evolve into clinically integrated networks ready to execute on such local and national priorities that lean into whole-person care. Coordination with like-minded community partners willing to share data, contribute to registries, and align with nontraditional partners, including payers, employers, nonprofit organizations, public health departments, and professional societies can create an ecosystem to measure impact and deliver results. ⁹ Such implementations will also require rigorous methodology and new skills to ensure efficiency and reproducibility to expand the scope of this work.

Implementation science leverages qualitative and quantitative scientific methods to address key questions of effectiveness and practical assessment of barriers to evidence-based practice. ¹⁰ Garnering support from community members and patients promotes the uptake of evidence-based practice by understanding unique needs and considering meaningful solutions within unique healthcare markets. Creating collective contributions of data, methods, and science supporting a disease-specific focus accountable to metrics of quality care, patient engagement, patient-reported outcome measures, and clinical outcomes delivers its most vital output: trust. Ensuring that health equity and deliberate attention to vulnerable populations are baked into every solution facilitates transformation of care that is relevant and sustainable. And just as it is important for the communities affected by PAD to be aware of the condition, those who care for patients with PAD must be aware of the impact health-related social needs have on the communities they serve. Two-way health literacy is central to these objectives to move away from transactional medicine to building relationships enshrined by high-quality, transparent care. Such systems have been developed, particularly in models of primary care, though specialists will clearly serve an important role in such models.

Clinicians should seek to support local and national health policy to reinforce positive change, recognize the powerful influence of a professional lobby that may resist change, and remain vigilant for policies that weaken priorities to close the gap. Investments in health equity aligned with value-based incentives are central to satisfying the quintuple aim of healthcare, restoring and sustaining purpose among provider organizations, reducing costs, improving patient outcomes, and delivering an exceptional patient experience. By galvanizing science for the community we serve, we better understand the tangible opportunities to improve community health and, ultimately, develop health policy change to ensure sustainability by rewarding clinical excellence and removing waste and inefficiency from the healthcare ecosystem. Delivering on health equity, then, is not a foreboding and insurmountable obligation but, rather, is the key to unlocking transformative potential to deliver sustainable solutions for whole-person healthcare. When we challenge ourselves to deliver culturally sensitive, comprehensive care for all, we are sure to care for all patients exceptionally well.

In his 1999 speech to a union gathering of sheet metal workers, the late US Senator Paul Wellstone suggested that our collective success can be enjoyed broadly if we bring one another along. The challenges of healthcare access and prescription drug coverage addressed in Wellstone’s speech remain as relevant then as they are today, perhaps only deepening nearly a quarter of a century later. Delivering health equity is challenging, costly, complex, and countervails the longstanding practice of fee-for-service medicine, but addressing health disparities and inequities is work worth pursuing. In this work lies the key to delivering the quintuple aim, unlocking transformative potential in a more effective and meaningful version of US healthcare. Efforts to close the gaps in evidence-based practice for vascular health will require commitment to patients and to one another to unmoor the incumbent strategies of fee-for-service medicine that resist meaningful change. These efforts must be met posthaste. The future of healthcare, our economy, and perhaps our country, depends on it. PAD is a great place to focus that collective energy. Let us get to work.