New ‘biopsychosocial’ roadmap set out to address PAD treatment and mental health impacts

mental health
Kim G Smolderen and Carlos Mena-Hurtado

A recent proposal has called for “whole-person, multidisciplinary interventions” after an interrogation of the interplay between lower extremity peripheral arterial disease (PAD) and mental health impacts. Published in the Journal of The American College of Cardiology, researchers have put forward a “biopsychosocial” PAD management roadmap, offering solutions to current care “obstacles” to better attend to both behavioral and social health needs throughout vascular treatment.

Posing significant public health concerns, Kim G. Smolderen, clinical psychologist, and Carlos Mena-Hurtado, interventional cardiologist, from Yale University in New Haven, Connecticut, et al note that PAD affects roughly 8.5 million individuals in the USA and 220 million globally. Individuals of workforce age have become a growing area of concern, however, due to an increase in PAD-related hospital admissions presenting with critical limb ischemia, the “most severe” form of the disease.

With PAD, multimorbidity is “common,” which includes both mental and physical health conditions that the authors assert disproportionately affect underrepresented groups and younger people. “Younger patients are most likely to present with mental health conditions and modifiable cardiovascular risk factors with a behavioral component” Smolderen and Mena, founders of the Vascular medicine outcomes (VAMOS) lab at Yale, et al state. They note that these can include obesity, smoking and poor dietary habits.

Rooted in “maladaptive” health behaviors, the authors believe these conditions are directly undermining cardiovascular health and disease management. This link can be seen between depression and anxiety in the context of endovascular and surgical revascularization, which are associated with increased mortality, major amputation and higher costs.

The “PAD experience,” including the clinical and financial burden of the comorbid conditions linked with PAD, have received “little consideration,” Smolderen, Mena and colleagues opine. This lack, they believe, is driving the need to “expand the PAD care paradigm” to a biopsychosocial one, which acknowledges the contribution of both behavior and psychosocial factors on disease management and outcomes. “The substantial societal cost of healthcare for patients with PAD, including the need to close the gaps for observed disparities and health inequities in PAD, requires a broader perspective of PAD care,” the researchers convey.

Their roadmap identifies four domains that, once addressed, can redesign vascular specialty care services to attend to the behavioral and social health needs of all patients.

Identifying first a “fundamental problem” in the way physical and mental health are divided when providing care, the authors pinpoint the “major advocacy efforts” that are needed across professional organizations serving populations of PAD. Their recommendations begin at trainee level across disciplines and specialties, defining “core competencies” which reduce stigma and “unawareness” around mental illness and its effects on PAD.

Second, they outline the evolution of highly technological and procedural care which has been “valued disproportionately” over preventative and psychosocial care in the context of reimbursement and code availability—which the authors note are both presently absent from cardiovascular speciality care. To rectify this, they believe payment reform is needed, allowing for “codes and compensation for integrated care models” which should be piloted to integrate quality metrics of care delivery, including mental health screening and treatment tracking in such a manner to affect payment of services.

Thirdly, Smolderen, Mena and colleagues emphasize that despite several evidence-based interventions stemming from high-level randomized controlled trial evidence across cardiovascular populations, there is a prevalent “lack of awareness” among health administrators regarding the “scope of practice” of allied mental and behavioral health physicians in the context of chronic disease. They believe adopting a formal approach to assessing behavioral health could be a solution for this, assigning “routine components of care” and “expanding system capacity to address health disparities and behavioral health conditions.”

As an extension of their solution, they assert that “interprofessional team-based training” that promotes “a climate of mutual respect and shared values, moving away from a hierarchical system of care delivery and delineating roles” be established. Furthermore, Smolderen, Mena, et al state that investments in program building and coordination for vascular patients must be made, as well as the promotion of integrated care for diverse and uninsured populations, to “broaden access” and remove barriers to PAD care.

Their fourth and final area of proposed reform concerns integrated behavioral care practice guidelines for PAD management, and the formation of better evidence-based workflows derived from comparative effectiveness and implementation research—which they currently believe to be “lacking.”

“Funding budgets for research,” the authors state, “is needed to generate evidence for implementation models of integrated care delivery, tailored to the PAD context”.  Smolderen, Mena et al conclude that research is needed to address “clinical, operational and financial” outcomes—which includes decreased cost of care for comorbid patients—relevant to multiple stakeholders. To this end, they believe quality efforts at a national level will help to “benchmark data” for PAD care, “integrating social determinants of health, and tracking the use of integrated care services for vascular populations.”


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