The big business of clogged arteries

Millions of Americans have peripheral artery disease, a disorder primarily caused by fatty deposits that can narrow arteries and block blood flow to the legs. Often, the first symptom they feel is leg pain. Experts say that most treatments are safe, but some have expressed a growing sense of alarm that doctors may be doing procedures that patients don't need, exposing them to unnecessary risks. ProPublica looked into artery procedures and found that some doctors are making millions of dollars doing a questionable number of treatments. Government insurers pay well for vascular procedures that are done outside of hospitals, and doctors can bill tens of thousands of dollars for treatments done in a single office visit. One doctor in Maryland made millions of dollars from the federal government for performing thousands of vascular procedures. A state medical board investigation found that his inappropriate treatments put patients at risk of serious harm. One man had to have his leg amputated after invasive treatments for mild pain, according to filings in a settled lawsuit. A grandmother bled out and died shortly after the same doctor cut into her, according to another ongoing lawsuit. The doctor denied the allegations in legal filings, but declined to be interviewed and did not respond to emailed questions. Some doctors worry about the overuse of procedures and think there should be more oversight. They compare outpatient vascular care to the Wild West and say there are not enough protections to stop patients from getting unnecessary treatments. We made this guide to help patients ask the right questions and get good health care. This article is not intended as medical advice, so it's important to speak with your own doctor and use other resources before you make any decisions. What Is Peripheral Artery Disease? Peripheral artery disease occurs when plaque or other deposits build up on the walls of blood vessels, often in the legs, and restrict blood flow. Smoking, high cholesterol and diabetes can increase your risk of developing the condition. Around 6.5 million Americans over 40 have peripheral artery disease, which usually affects older people. What are the symptoms of peripheral artery disease? People with this chronic disease can live a long time, especially if they exercise, stop smoking and eat healthy food. Up to half of patients don't have any symptoms, but others feel pain when they walk or exercise, a condition known as claudication. This happens because their leg muscles may not be receiving enough oxygen. At first, the pain might not be severe, but it can worsen over time and begin to occur even at rest. Some people might also feel coldness or numbness in their legs or feet, see changes in the color of their skin or have a weakened leg pulse. A fraction of patients may eventually develop critical limb ischemia, which can result in an amputation, but this is less likely if the disease is diagnosed early and treated appropriately. Experts told ProPublica that only about 5% of patients who are diagnosed early on in the disease will require an amputation within five years. "If you go to the doctor and you're having only walking problems and they tell you that you're going to lose your leg, they are wrong," said Dr. Michael Dalsing, a vascular surgeon at Indiana University Health Physicians and a former president of the Society for Vascular Surgery. How Is Peripheral Artery Disease Diagnosed and Treated? Doctors can administer noninvasive tests like ultrasounds or blood pressure measurements to see how blocked your blood vessels are. They may also suggest a treadmill exercise test to determine how severe symptoms are. Peripheral artery disease can't be cured, but it can be managed with routine monitoring and lifestyle changes. For mild cases, like patients with just claudication, best practices recommend that doctors start with noninvasive treatments, which can slow or even reverse symptoms. Plans may include regular exercise, changes to your diet and quitting smoking. They might also involve medications to lower your cholesterol, control your blood pressure, prevent the buildup of plaque in your vessels, or reduce leg pain. If the disease worsens or symptoms are disabling or limb-threatening, doctors may suggest more aggressive treatments that unblock blood vessels. Endovascular procedures are minimally invasive treatments, where a doctor makes a small incision near the hip to access the vessels and threads in flexible catheter tubes to treat blockages. Typical treatments may include balloon angioplasty, the placement of stents or the removal of plaque with a bladed catheter, also known as an atherectomy. These treatments have a relatively short recovery time and can be done in outpatient centers. Alternatively, a doctor may recommend bypass surgery, where blood flow is rerouted around blockages in the vessels. All of these more aggressive treatments have risks of complications, like clots, bleeding or even amputation, so your doctor should talk to you about what could happen. When Should You Ask Questions About a Vascular Treatment? While most doctors do their best to help their patients, ProPublica's reporting has found that some doctors suggest invasive treatments that may be too aggressive for mild symptoms. This can increase the risks of complications and may worsen peripheral artery disease. "You want to start with the lowest-risk thing because claudication rarely leads to an amputation," said Dr. Peter Lawrence, the former chief of vascular and endovascular surgery at the University of California, Los Angeles. Patients should feel comfortable asking questions and learning about their treatment plan, especially before signing off on invasive interventions. ProPublica spoke with more than a dozen vascular physicians to understand when patients should seek more information. When treatment decisions are not explained well. "The physician should be able to explain the importance and the significance of what they found to justify what they're planning to order," said Dr. Gary Lemmon, a vascular surgeon who serves on the appropriateness committee for the Society for Vascular Surgery. Navigating the health care system to figure out the best treatments can be confusing. Doctors should take time to explain what tests reveal, what disease progression might look like and how it should be treated. Doctors should be aware of what professional practice guidelines and criteria recommend and be able to clearly explain the options to patients. Setting realistic expectations is important. Doctors should be able to clearly describe how any procedure will impact your life and to what extent you can expect your symptoms to improve. Decisions about your treatment plan should not be made for you, the experts said. They should be made with you. When treatment decisions are made too quickly. "A quality marker that someone can sniff right away is if the decision is made quickly and not a lot of time is spent with the patient," said Dr. Michael Conte, professor and chief of vascular and endovascular surgery at the University of California, San Francisco. "I would be wary of that sort of interaction." Patients should be cautious if doctors immediately suggest invasive procedures instead of first trying exercise, diet changes and medicine. "If a provider recommends that they be treated without a trial of exercise therapy and use of correct medications, and they recommend treatment before six months of conservative management, that should be a red flag," said Lemmon. Once patients start receiving invasive interventions, they might need more procedures; with each treatment, there's a risk of something going wrong. "One procedure leads to another procedure to another procedure," said Dr. Nicholas Osborne, an associate professor of vascular surgery at the University of Michigan. "Two years later, they've had failed bypasses, they have dead toes, they're looking at a major amputation or maybe a Hail Mary kind of salvage bypass to get them out of the trouble." Peripheral artery disease progresses differently for each person, so doctors need to assess each case carefully before recommending any procedures. "In some patients, that clock ticks really slowly and it takes a long time for them to get from claudication to ever needing anything," said Dr. Joseph Mills, the current president of the Society for Vascular Surgery and chief of vascular surgery and endovascular therapy at Baylor College of Medicine. "And for others, it's a more rapidly ticking clock. But when you start to do interventions, whether it's a bypass or a stent, the clock speeds up." When scare tactics are used to push you into a procedure. Patients with mild vascular disease told ProPublica that they agreed to invasive procedures because doctors told them they would lose their leg without an intervention. "I see a lot of patients in clinic that come for a second opinion," said Dr. Caitlin Hicks, an associate professor of surgery at Johns Hopkins University School of Medicine. "And they'll have been told by some surgeon, 'You have a narrowing in your blood vessel, you're going to lose your leg unless we do something.' And that's the story that's fed to many, many patients." Without a full picture of the disease, patients may make less informed choices. Doctors should communicate clearly and explain the risks and benefits of any procedure. Otherwise, patients can get scared and seek a procedure they may not need. How to Find a Doctor You Trust Finding a doctor you trust can be tricky. Specialists like vascular doctors are often found through primary care physicians, but some also advertise directly to patients in Facebook and Google ads, on billboards and at community events like church or senior center meetings. "The vast majority of physicians treating vascular disease practice ethically, but [patients] can't assume that," said Dr. Kim Hodgson, a former president of the Society for Vascular Surgery. "They can't just assume that the physician with the flashy advertising and the certificates on the wall is qualified or competent." It's important to make sure that your health is the doctor's top priority before agreeing to any procedures. Here are some tips on how to find a trustworthy doctor: Check for board certification. There are three main types of doctors that treat peripheral artery disease: vascular surgeons and specialists, interventional radiologists, and cardiologists. Look for doctors who have passed a specialty test and are certified by a board. You can check whether your doctor has board certification through state medical board databases. Look for membership in medical societies or associations. These organizations are committed to upholding standards of care. Research disciplinary records. Check state medical board databases to see whether doctors have gotten into trouble for poor patient care. Some boards also provide information on malpractice lawsuits, but in most states, the best way to access information about those cases is through court records. Consider a second opinion. If you have concerns, make an appointment with another doctor. Look for involvement in programs committed to transparency and quality patient care. Some medical societies, like the Society for Vascular Surgery, have created initiatives to uphold best practices. The Vascular Quality Initiative collects and analyzes procedure data in a registry. Earlier this year, the society also launched the Vascular Verification Program with the American College of Surgeons to help hospitals improve patient outcomes. "We're trying to make things more transparent and safe," said Dalsing, a former president of the society. "As soon as you get things into the light, I think things start to change, and for the better when needed." What Questions Should You Ask Your Vascular Doctor? "Patients have to ask questions, but then the problem is patients don't even know what questions to ask," said Dr. Karen Woo, a vascular surgeon and professor at the David Geffen School of Medicine at UCLA. "Most clinicians don't really go in depth into that risk-benefit conversation and what the consequences are of having an invasive procedure." When you receive a new diagnosis from your doctor, it can be overwhelming and hard to know what to ask. But you need to understand your options to make sure you get the best care, so we asked doctors what you should be asking them. Some recommended questions: Could anything else be causing my symptoms? What are the different ways to treat my illness? Can I make any lifestyle changes before undergoing invasive treatments? What are the risks and side effects of the treatment? Is there a simpler, safer way to treat my illness? What is a good outcome? What is a poor outcome? What happens if I don't receive any treatment? If the procedure is not being done in a hospital, can the doctor take me to a hospital if complications arise, and do they have privileges at a nearby hospital? Will the procedure require any follow-up procedures? ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox.