Screening for PAD: Why You’re Not Doing It…..But Should Be
Screening for PAD: Most physicians now realize that peripheral artery disease (PAD) is common among those over 65, or over 50 with a history of diabetes or smoking, and that those with PAD have significantly increased risks of myocardial infarction, stroke, and death. (One in four of your patients with PAD will suffer one of those outcomes in the next five years.) PAD also leads to disabilities such as leg pain at rest or while walking, and if it progresses, to ulceration, gangrene, or amputation.
The early institution of treatment for PAD such as statins or aspirin can reduce the morbidity and mortality from PAD. Reductions of up to 65% in mortality have been reported.
THE BIG REASONS FOR SCREENING
Targeting higher risk patients for PAD screening along with appropriate care has been shown to result in:
- Fewer deaths and extended, better, healthier lives
- Increased practice revenues and patient satisfaction
- Lower national healthcare costs
In a typical practice by finding and treating PAD patients you will be able to help at least ONE PATIENT A MONTH be alive five years from now when they wouldn’t be if not treated. We know that helping patients live longer and healthier lives is why you have chosen this profession. PAD screening will help you do this.
WHY YOU PROBABLY AREN’T SCREENING
Despite the evidence showing the benefits of PAD screening; it is still not practiced in most primary care offices. There have been several studies looking at this, and the reasons most often include:
- It takes too long
- There is no reimbursement for screening
- The ABI takes training and practice
- We don’t have many patients complaining about PAD
- PAD screening only gets an “I” – Indeterminate – rating from USPSTF
Let’s look at these excuses one by one:
- It takes too long.
Certainly, the time available for primary care is a legitimate issue. Trying to fit more into a 15-minute visit is difficult. In the past many reports said that ABIs would typically take about 20 minutes. However, modern computer based ABIs can be done in as little as 5 minutes. If you are curious about how easily and quickly ABI tests can be performed, please watch this short video of an ABI test being performed.
Some new PAD tests are even faster and easier than an ABI . See #3 below.
- There is no reimbursement for screening.
It’s true that CMS does not pay for PAD screening. (At least not yet. A bill has been recently introduced to Congress that would require reimbursement of PAD screening since it would save lives and reduce national healthcare costs, including the costs paid for amputations.) However, there is more than one way to approach this if you would like to increase your income from PAD screening:
- You could consider charging your patients for the test. Millions of patients have paid Lifeline screening for non-invasive screening tests including an ABI. Many health fairs charge some minimal amount – usually $50 to $100 – for ABI testing. Patients are often willing to pay for the test since it is informative and non-invasive. We’ve taken part in some of these health fairs and the main issue we have seen is that too many young healthy people want to have the test done.
- Many organizations realize that screening for PAD can bring patients into their organization for long-term care including (lucrative) interventions if necessary.
- When the screening exam indicates the presence of PAD question the patient about possible symptoms. If it turns out that they are in fact symptomatic the test could be billed to CMS. (CPT 93923, national CMS average $149.) Consider that if the practice has 1000 high-risk patients, (see “WHO TO SCREEN” below) 290 of them will have PAD. Not all will be symptomatic, but if 80% are that means that 232 patients could be billed, and at $149 each that would be an annual practice income of $34,568.
- Medicare Advantage insurers should be willing to pay for screening since each patient that is found to have vascular disease increases their compensation from CMS substantially. Since the odds of a high-risk patient having PAD upon testing is high (29%) it makes sense to test all high-risk patients to find those that do have PAD. Rightly or not, finding vascular disease increases the payment to the insurance company by more than $3000 a year using the risk adjustment codes.
- The ABI takes training and practice and the equipment is expensive.
It’s not as hard as you might think with modern systems. Doing an ABI is just adding an ankle blood pressure to the one done all the time at the brachial. A Doppler probe is used instead of the stethoscope. Modern ABI systems can do the calculations for you. Some new systems don’t even require the Doppler.
One of these new PAD tests comes from Newman Medical recognizing that a faster, easier test for PAD would be of help to the primary care practice. Newman Medical has developed a new exam, the ABI-Q (Q for quantitative). This exam is based on a quantitative analysis of the blood pressure waveform (PVR) at the ankle and requires no Doppler and less operator training. It is faster than the typical Doppler ABI and can be done while taking vital signs. If you still want to do the Doppler ABI, the ABI-Q exam can be part of a system that also can perform the Doppler ABI.
As far as the cost of the equipment, it’s true that hospital physiologic testing systems are typically $30,000 and up. However, Newman Medical point-of-care SimpleABI Cuff-Link automated systems are typically less than $5000 including in-service training.
- We don’t have many patients complaining about PAD
Both physicians and patients have been reported to consider signs of PAD as lower priority than other conditions. Typically, physicians take a reactive view and only consider PAD if the patient brings up some of the symptoms. However, many patients feel that their PAD symptoms are only signs of getting older, or of arthritis, and so they often don’t bring up the problems. They may have learned to limit their walking distance to avoid leg pain. Patients that come to the clinic for other problems tend to not bring up their PAD symptoms.
PAD takes patience and education. You and the patient must understand that by treating this now you may be preventing a heart attack or stroke sometime during the next five years. Patients may need educated to understand that although there may be no magic bullet to relieve their leg pains today, (unless they are so bad as to require intervention) treating their PAD today will help them live longer, better lives, with less disability in the future.
- PAD screening only gets an “I” – Indeterminate – rating from USPSTF.
Recent studies underline the facts that early diagnosis and treatment of PAD can reduce mortality and disabilities. With mortality reductions of 65% or more in recent studies, it is hoped that the next time USPSTF revisits this is may change its rating.
Dr. Joshua Beckman, one of the USPSTF reviewers, in an article entitled “Shouldn’t USPSTF Follow Its Own Rules?” disagreed with the “I” rating and said: “Vascular screening, including an ABI, would save more lives than all other screening services currently recommended.”²
WHO TO SCREEN
Blanket screening of all adults is not recommended, but only those that have one or more of these factors known to increase the risk of PAD:
- Age over 65 years
- Over 50 with a history of diabetes mellitus
- Over 50 with a history of smoking
- Obesity
- Hypertension
- Hyperlipidemia
- Family history of PAD, heart disease or stroke
The PARTNERS study found that 29% of these high-risk patients will have PAD. Black Americans are twice as likely to be impacted by PAD and are four times as likely to have a PAD related amputation.
HOW TO SCREEN
By far the most recommended point-of-care test for PAD is the ankle-brachial index, or ABI. This test uses a vascular Doppler along with a blood pressure cuff and sphygmomanometer to measure the systolic blood pressure at the brachial and ankle arteries. The ratio of the ankle pressure divided by the brachial pressure is the ankle-brachial index. An ABI less than 0.9 is considered indicative of PAD.
Some feel that palpation of the foot arteries can find PAD, but this has been shown to be unreliable. According to the most recent AHA guidelines, “The gradual but progressive nature of functional decline in PAD is difficult for clinicians to detect without objective testing”.
As mentioned earlier, the ABI-Q exam can help make the PAD test faster and easier and can be used by itself or to help select patients for further Doppler ABI testing.
NATIONAL SOCIETIES RECOMMEND SCREENING
The AHA, ACC, ADA, and APMA and others all recommend screening for PAD using the ABI.
CONCLUSION
PAD awareness has increased significantly over the last few decades. Now, that awareness can be put into action by point-of-care screening for PAD in the primary care practice. Doing so will ultimately be good for your patients and good for your practice. Your patients trust you to help find and treat their PAD, allowing them to live longer and better lives.