The recent reintroduction of the bipartisan Amputation Reduction and Compassion (ARC) Act—aimed at improving peripheral arterial disease (PAD) education, increasing access to PAD screening and preventing avoidable lower limb amputations—has drawn a mixed response from vascular surgeons.
The move gained the support of the CardioVascular Coalition, a collection of physicians, care providers, advocates and manufacturers that says it is dedicated to “community-based solutions designed to improve awareness and prevention of PAD, reduce geographic disparities in access to care, and secure patient access to high-quality, cost-effective interventional treatment across America.”
But some in the vascular community found fault in the bill.
“I (nor USPTF [United States Preventive Services Task Force]) am not aware of any evidence that screening for PAD reduces costs, anxiety, or amputations in any population,” wrote Westley Ohman, MD, assistant professor of vascular surgery at Washington University School of Medicine in St. Louis, in a Twitter exchange that followed a call for surgeons to encourage their lawmakers to co-sponsor the ARC Act. “There is ample evidence that overtreating ‘low grade’ PAD leads to CLTI and, thus, amputation.”
“Amputation reduction is a noble goal, and PAD education is a must. However, this bill (as written) does not accomplish that,” he added.
Joshua Balderman, MD, a vascular surgeon in Tucson, Arizona, voiced strong disagreement to the call’s sentiment. “Keep clinical judgement in the hands of clinicians,” he wrote. “There’s a reason device companies are behind this bill, and it’s not out of the goodness of their own hearts.”
Guillermo Escobar, MD, associate professor of surgery in the division of vascular surgery and endovascular therapy at Emory University School of Medicine in Atlanta, described how near the bill comes to tackling the problem. “It’s unfortunate—it almost gets to where we would agree (fund screening), then veers away (don’t pay unless imaging is not done prior to amputation),” he wrote.
Bryan T. Fisher, MD, chief of vascular surgery and limb salvage expert at Tristar Centennial Medical Center in Nashville, related how he had contributed to the bill, and though it had been some time since he had read through it, he was concerned some were reacting without having looked over its current contents.
“My biggest issue is it tries to mandate clinical decision-making, reducing physician autonomy. Never a good thing,” responded Reid Ravin, MD, assistant professor of vascular surgery at Mount Sinai in New York. “It also advocates reimbursing screening that may or may not be beneficial. Non-targeted screening can be harmful, leading to overtreatment.”
The Society for Vascular Surgery (SVS) is engaged, Margaret (Megan) Tracci, MD, associate professor of vascular and endovascular surgery at UVA Health in Charlottesville, Virginia, noted. She described how a working group led by Lee Kirksey, MD, vice chairman in the department of vascular surgery at Cleveland Clinic, and Sean Lyden, MD, chairman of same department. They have been “working through both positives (raising awareness of PAD and amputation prevention) and concerns (specific provisions such as amputation coverage),” she explained.