"In the Black community, if you look at studies, these patients carry a high risk of high blood pressure, diabetes, nicotine use, chronic kidney disease, or end-stage renal disease. But in spite of all the advancements we've made over the past three, four decades in terms of all the technical advancements and all these procedural techniques that we've created, these patients' mortality has not changed; it got worse. So there hasn't been a mortality benefit in the Black population," Fakorede explained. 

COVID pandemic brought disparities into clear public view

The COVID-19 pandemic brought glaring health disparities to the forefront of healthcare. The pandemic exposed gaps in healthcare delivery systems and underscored the urgency of addressing underlying health inequalities.

The pandemic also caused disruptions in healthcare access and preventative services, and in particular diabetes was not being treated. Fakorede said this led to a surge in CLI related amputations post-COVID, particularly among high-risk populations.

"There were patients who were showing up with 'COVID toes,' like blue toes due to embolism from clots and ultimately undergoing amputations. We've seen a rise post-COVID not only in diabetes, but also diabetes in younger patients. So that ultimately is going to affect peripheral disease and CLI," Fakorede said.

Addressing PAD and CLI in minority populations

In PAD and CLI, the highest rates are seen among low-income Black, Hispanic and Native American populations. These populations also make up the majority of CLI-related amputations. 

"We're trying to get these patients back out and getting them screened and getting them treated. But unfortunately, some of them are showing up in the later stages, and some of them just are not aware as to what their options are. The options in CLI care can be minimally invasive with a technically savvy provider like an interventionalist who can go in there and restore circulation. Or a savvy surgeon who can do a bypass graft or what we call deep vein arterialization, where we can connect the arterial and venous conduit and restore blood flow," he said. 

And PAD and CLI care cannot end after the procedure; it needs to continue with active support for the patient to prevent continuation of the root disease factors. One piece that Fakorede said has not been addressed is the aggressiveness of wound care after circulation is restored to preserve the limbs and allow enough time for wounds to heal. Post-revascularization care also needs to include aggressively monitoring and treating diabetes and blood pressure. 

Disparities he runs into include the ability of patients to find transportation to make their followup appointments and the ability of patients to read food labels so they can eat properly. Another question he asks patients is if they have sidewalks where they live to be able to walk and exercise safely, which Fakorede said is a big social determinant of whether they maintain their health. 

"The disparities even continue once the patient leaves your office or your lab or your operating table. The question is, are we actually following them through the whole entire journey of their care? Those are potential gaps in care that we have to face and have to see how we can address in terms of models to bridge those gaps and disparities in both treatments, outcomes, and post-care follow up," Fakorede explained.

Systemic healthcare policies and doctors not wanting to live in rural areas

Some of the big reasons for health disparities in minority populations are based on systemic policies and systemic racism. But, it is also because highly trained physician specialists usually do not want to live in poor, rural areas of the country. 

"The fact that we have failed to address the social determinants of health I think explains 80% of the problem in addressing disparities in treatments and outcomes. But it is also about making sure that we have more vascular specialists or those who are well-trained to maybe bypass big centers, big hospital systems or urban areas and come to rural areas or rural pockets where there's a great need," Fakorede said. 

Access to quality care, healthcare providers, and proper insurance coverage he sees as critical issues. In most cases his patients have some form of insurance, but are not savvy enough to understand what it covers and often do not seek care until it is too late.

This is compounded by an aging healthcare workforce and inadequate healthcare infrastructure in rural areas. Often the patients in his area have a variety of comordities and needs a care team made up of different specialists, but often these specialists are just not available.

How to get more doctors to practice in rural America

There is a rapidly growing shortage of general cardiologists in all parts of rural America regardless of socio-economics of areas. Some areas of the country are also finding it hard to recruit specialists, and that problem is compounded when recruiting or primarily poor, minority communities.  There are few incentives for physicians and specialist to want to relocated to rural areas to help address health disparities. But, Fakorede offered a few ideas for how this might happen.

"In a state like Mississippi, where five in 10 patients have diabetes, we have less than 10 endocrinologists in the whole state. That's a problem," Fakorede said.

Incentives such as high pay and benefits can attract doctors, but for small clinics and hospitals in rural areas where the need is, government programs should do more to incentivize endocrinologists graduating to come to a rural markets and they could have a real impact and help decrease A1C rates 5%. He said a government structure that would help payoff some of their debt or your loans could have a big impact. 

"Let's look at CLI, for instance. It takes a village. It's the vascular surgeon, it's the interventional cardiologist, it's the wound care specialist, it's the infectious disease specialist, endocrinologist, and then the nutritionist and then whoever is in terms of the quarterback from a chronic care disease management standpoint. Maybe it's the advanced practice provider like a nurse practitioner or physician assistant. You're looking at that whole gamut. But, if you live or serve in a vascular desert or medical desert, you might just have one or two of those people," Fakorede stressed.

Hospitals often incentivize doctors they want to recruit, but that is not offered for individuals who want to establish a practice to help a disadvantaged community. He said this is where partnerships might help with a center of excellence that is a couple of hours away. Fakorede said this might include mentorship guidance on how to better engage the community's research support.

Another avenue to consider to gain funding or partnerships with larger institutions is the ability to gather community level data in areas with significant health disparities. Fakorede said getting these patients involved in clinical trials or having granular data of patients with specific disease states in minority communities is often lacking. 

"How do we get into the community and get data from that level? Black patients have only been included in about 5% of all cardiovascular disease clinical trials to date. So if we're going to start making that dent, we need to start getting into the communities and getting community level data at there and then make that generational where even generations can follow through," he explained.

Fakorede saw the major issues with access to care in Mississippi and decided to set up an office-based lab (OBL) in 2015 to see it he could directly impact the disparity gaps. This included community outreach that went beyond telling the locals about symptoms of PAD. He said it is also about making sure these patients are properly insured and given access to literacy of what their insurance entails, and what their medication entails in terms of their coverage.

Read related interviews with Fakorede here:

Cardiologist details the many health disparities he encounters in rural Mississippi

Cardiologist moves to Mississippi to fight back against PAD and limit amputations