Uncovering why many veterans with PAD in the South experience amputations

September 2021

Olamide Alabi

Among the nearly 12 million Americans that have peripheral artery disease (PAD), a condition where narrowed arteries reduce blood flow to the lower extremities, there are overlapping populations that commonly experience worse outcomes, such as veterans, African Americans, and people who live in underserved and/or disadvantaged communities.

"Veterans and socially underprivileged individuals tend to have a higher prevalence of risk factors that are associated with PAD, such as smoking, diabetes, and high blood pressure," says Olamide Alabi, MD, an assistant professor of surgery in Emory's Division of Vascular Surgery and Endovascular Therapy with a growing portfolio of extramural funding focused on PAD, quality, and health equity. "Add to that the fact that Black patients with PAD are three-to-five times more likely to experience major amputation than white patients, and major amputation rates are higher in the Southern United States, it is not surprising to find that Black veterans in the south with PAD are more likely than other groups to have major lower extremity amputation."

With assistance provided by a Veterans Administration DEI Research Supplement award, Dr. Alabi aims to examine access to care among veterans with PAD, investigate care variations that lead to potentially preventable lower extremity amputation, and begin devising innovative solutions to improve the quality of care provided to veterans with PAD. 

Luke Brewster, MD, PhD, chief of vascular surgery at the Atlanta VA Healthcare System and one of Emory's top vascular surgeon-scientists, will be the lead mentor on Dr. Alabi's project. His investigations of promising new therapies for veterans with PAD will lend a valuable perspective to the study, particularly his effort to develop cellular regenerative applications that could provide more sustained and complete healing of ischemic tissues to avoid amputation, funded by a VA Merit Award. 

The advisory team will be completed by Emory medical sociologist Molly Perkins, PhD, an expert in mixed methods research and theory development and the Atlanta VA site lead for the Birmingham/Atlanta VA's Geriatric Research, Education, and Clinical Center, and Kelly Hunt, PhD, a cardiovascular disease epidemiologist and health equity researcher from the Medical University of South Carolina and the Charleston VA Health Equity and Rural Outreach Innovation Center.

DEI Supplement awards are administered by the VA's Office of Research and Development and used to fund mentored research experiences for early career investigators from backgrounds that are underrepresented in medicine. Dr. Alabi's award is among the first wave of the program's funding cycle, which is specifically pairing junior researchers with established VA scientists who can help guide their careers.

Early medical and procedural interventions are vital for PAD management to prevent lower-limb amputations. Numerous studies have delineated ethnoracial disparities in various stages of care for the PAD patient. Dr. Alabi believes that race is likely a surrogate for place and/or access, and that evaluation of social and geographic determinants can yield important information and targets for designing novel strategies to alleviate disparities in the timely diagnosis and treatment of PAD. 

"Societal and environmental determinants of health have much to do with who gets quality treatment and who does not," she says. "Prior studies, including my own, have found that the absence of care plans with appropriate risk factor and lifestyle modification, lack of accessibility to specialty care, and delays in referral and diagnosis are probably contributing to poorer outcomes for veterans with PAD in the South. There are potential social/sociocultural conditions as well, such as access to nutritious food or adequate transportation and patient-provider discordance, particularly in the form of trust issues."

Being a woman of color born to immigrant parents who came to the U.S. from Nigeria, Dr. Alabi is well acquainted with the socioeconomic inequities that can hinder prospective patients in minority communities from receiving quality medical care.

"I distinctly remember attending a career day in elementary school. There were a number of professional experiences like 'spend a day with a pharmacist or doctor,'" she says. "They sent me to McDonald's. Essentially, they were telling me that other people had a professional trajectory that was distinctly different from mine. However, I've never allowed someone else's misguided perceptions or personal biases to define or deter me. Once I began my medical training, the challenges were similar, but I persevered. When I walk into a room, it is rare to see someone who looks like me. While I encounter that all the time, I do not want to become complacent. No matter where I've gone or what I've done, I've always been the first. However, I will not be the last."

Another takeaway from Dr. Alabi's life experiences thus far is that communication, from how things are said to how knowledge is transmitted and acquired, is central to how people perceive and interact with the world around them. She views communication with patients as essential, and hopes to understand what concerns are most important to patients, not just their physicians. "My long-term goals are to better interpret patient reported outcomes and the measurements thereof so that we can improve factors that matter to veterans, not just what matters to physicians who care for veterans," she says.