{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,23]],"date-time":"2026-08-23T18:09:01Z","timestamp":1787508541740,"version":"build-2736575974"},"reference-count":36,"publisher":"MDPI AG","issue":"19","license":[{"start":{"date-parts":[[2025,9,26]],"date-time":"2025-09-26T00:00:00Z","timestamp":1758844800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Society for Vascular Surgery Foundation Community Awareness and Prevention","award":["20201549"],"award-info":[{"award-number":["20201549"]}]}],"content-domain":{"domain":["www.mdpi.com"],"crossmark-restriction":true},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Although most amputations caused by diabetes and peripheral artery disease (PAD) are preventable, current limb preservation efforts in the United States remain poorly understood. This study aims to identify key barriers and facilitators to limb preservation from the primary care provider (PCP) perspective. We plan to use the insights from this work to promote targeted intervention strategies. Methods: Using a mixed-methods design, an online 5\u201310 min survey was distributed to Oklahoma primary care providers who could elect to participate further in a semi-structured, audio-recorded interview. Descriptive analysis was used to summarize survey results. Interviews were transcribed and qualitatively analyzed using grounded theory. Donabedian\u2019s structure, process, and outcome framework was used to categorize how each identified barrier and facilitator increases or reduces the risk of limb loss for at-risk patients at the practice level. Finally, we compared and contrasted survey and interview findings. Results: Thirty surveys were completed (approximately 14% response rate), and seven interviews were conducted with PCPs geographically dispersed across Oklahoma. Most clinicians reported in the survey that they see at-risk limbs at least once every 1\u20132 months (n = 29, 96.7%). Half of clinicians were satisfied or very satisfied with access to vascular surgery (n = 15, 50.0%), interventional specialists (n = 13, 43.3%), and endocrinologists (n = 12, 40.0%). Finally, survey respondents reported that social needs most often affecting their patients with a limb at risk of amputation include income, health education, transportation, and health insurance. Interviews confirmed PCPs frequently see at-risk limbs. We identified thematic barriers to limb preservation that included limited access to specialty care, limited PCP and patient amputation prevention education, and patient social struggles surrounding transportation, finances, and insurance. Patient advocates (community, clinical, or personal), affordable medications, and more time with patients were reported as facilitators in amputation prevention. Conclusions: Oklahoma PCPs frequently see at-risk feet, realize poor access to care, and desire structural change to support excellent preventive care in diabetes and PAD. Limb preservation in Oklahoma is contingent upon shifting from disempowerment to engagement that requires systemic reform, clinical innovation, and community engagement. We identified several intervention strategies, including increasing education for PCPs to empower them to initiate early prevention, improving early identification and preventive therapy for patients at risk for limb loss, and cultivating specialty care access via networking and policy change.<\/jats:p>","DOI":"10.3390\/jcm14196817","type":"journal-article","created":{"date-parts":[[2025,9,26]],"date-time":"2025-09-26T11:28:32Z","timestamp":1758886112000},"page":"6817","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Primary Care Providers Describe Barriers and Facilitators to Amputation Prevention in Oklahoma"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0009-0004-2177-0714","authenticated-orcid":false,"given":"Austin","family":"Milton","sequence":"first","affiliation":[{"name":"School of Community Medicine, University of Oklahoma, 4502 E. 41st St., Tulsa, OK 74135, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dana","family":"Thomas","sequence":"additional","affiliation":[{"name":"School of Community Medicine, University of Oklahoma, 4502 E. 41st St., Tulsa, OK 74135, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Freddie","family":"Wilson","sequence":"additional","affiliation":[{"name":"School of Community Medicine, University of Oklahoma, 4502 E. 41st St., Tulsa, OK 74135, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6170-7964","authenticated-orcid":false,"given":"Blake","family":"Lesselroth","sequence":"additional","affiliation":[{"name":"Department of Medical Informatics, School of Community Medicine, University of Oklahoma, 4502 E. 41st St., Tulsa, OK 74135, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Juell","family":"Homco","sequence":"additional","affiliation":[{"name":"Department of Medical Informatics, School of Community Medicine, University of Oklahoma, 4502 E. 41st St., Tulsa, OK 74135, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wato","family":"Nsa","sequence":"additional","affiliation":[{"name":"Department of Medical Informatics, School of Community Medicine, University of Oklahoma, 4502 E. 41st St., Tulsa, OK 74135, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter","family":"Nelson","sequence":"additional","affiliation":[{"name":"Division of Vascular Surgery, Department of General Surgery, School of Community Medicine, University of Oklahoma, 4502 E. 41st St., Tulsa, OK 74135, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kelly","family":"Kempe","sequence":"additional","affiliation":[{"name":"Division of Vascular Surgery, Department of General Surgery, School of Community Medicine, University of Oklahoma, 4502 E. 41st St., Tulsa, OK 74135, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,9,26]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1808","DOI":"10.1161\/ATVBAHA.120.314595","article-title":"Epidemiology and Risk of Amputation in Patients with Diabetes Mellitus and Peripheral Artery Disease","volume":"40","author":"Barnes","year":"2020","journal-title":"Arterioscler. Thromb. Vasc. Biol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"515","DOI":"10.1016\/j.jvs.2024.03.446","article-title":"Analysis of Oklahoma Amputation Trends and Identification of Risk Factors to Target Areas for Limb Preservation Interventions","volume":"80","author":"Kempe","year":"2024","journal-title":"J. Vasc. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e171","DOI":"10.1161\/CIR.0000000000001005","article-title":"Lower Extremity Peripheral Artery Disease: Contemporary Epidemiology, Management Gaps, and Future Directions: A Scientific Statement from the American Heart Association","volume":"144","author":"Criqui","year":"2021","journal-title":"Circulation"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"2002","DOI":"10.1016\/j.jacc.2016.04.071","article-title":"Critical Limb Ischemia: An Expert Statement","volume":"68","author":"Shishehbor","year":"2016","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1119","DOI":"10.1016\/j.jvs.2022.12.015","article-title":"The global burden of peripheral artery disease","volume":"77","author":"Eid","year":"2023","journal-title":"J. Vasc. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1317","DOI":"10.1001\/jama.286.11.1317","article-title":"Peripheral arterial disease detection, awareness, and treatment in primary care","volume":"286","author":"Hirsch","year":"2001","journal-title":"JAMA"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1046\/j.1464-5491.2002.00612.x","article-title":"Amputations and diabetes: A case-control study","volume":"19","author":"Trautner","year":"2002","journal-title":"Diabet. Med."},{"key":"ref_8","unstructured":"Molina, C.S., and Faulk, J.B. (2025, August 01). Lower Extremity Amputation, Available online: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK546594\/."},{"key":"ref_9","first-page":"16","article-title":"When a diabetic foot ulcer results in amputation: A qualitative study of the lived experience of 15 patients","volume":"60","author":"Foster","year":"2014","journal-title":"Ostomy Wound Manag."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1747","DOI":"10.1016\/j.jvs.2016.06.096","article-title":"Amputation trends for patients with lower extremity ulcers due to diabetes and peripheral artery disease using statewide data","volume":"64","author":"Humphries","year":"2016","journal-title":"J. Vasc. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e1313","DOI":"10.1161\/CIR.0000000000001251","article-title":"2024 ACC\/AHA\/AACVPR\/APMA\/ABC\/SCAI\/SVM\/SVN\/SVS\/SIR\/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines","volume":"149","author":"Gornik","year":"2024","journal-title":"Circulation"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1053\/j.semvascsurg.2025.01.003","article-title":"A scoping review of limb preservation interventions with primary care providers caring foUSUUSIndigenous patients with diabetes and peripheral artery disease","volume":"38","author":"Homco","year":"2025","journal-title":"Semin. Vasc. Surg."},{"key":"ref_13","unstructured":"(2025, August 01). Clinical Practice Guidelines. Available online: https:\/\/vascular.org\/vascular-specialists\/practice-and-quality\/clinical-guidelines\/clinical-guidelines-and-reporting."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"e875","DOI":"10.1161\/CIR.0000000000000967","article-title":"Reducing Nontraumatic Lower-Extremity Amputations by 20% by 2030: Time to Get to Our Feet: A Policy Statement From the American Heart Association","volume":"143","author":"Creager","year":"2021","journal-title":"Circulation"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"2453","DOI":"10.2337\/dc20-0586","article-title":"National and State-Level Trends in Nontraumatic Lower-Extremity Amputation Among U.S. Medicare Beneficiaries with Diabetes, 2000\u20132017","volume":"43","author":"Harding","year":"2020","journal-title":"Diabetes Care"},{"key":"ref_16","unstructured":"Creswell, J.W. (2009). Research Design: Qualitative, Quantitative, and Mixed Methods Approaches, Sage. [3rd ed.]."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Guest, G., Namey, E., and Chen, M. (2020). A simple method to assess and report thematic saturation in qualitative research. PLoS ONE, 15.","DOI":"10.1371\/journal.pone.0232076"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"387","DOI":"10.1089\/pop.2023.0095","article-title":"Perspectives on Lower Extremity Peripheral Artery Disease: A Qualitative Study of Early Diagnosis and Treatment and the Impact of Health Disparities","volume":"26","author":"Grant","year":"2023","journal-title":"Popul. Health Manag."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1080\/13561820.2021.1920897","article-title":"Good working relationships: How healthcare system proximity influences trust between healthcare workers","volume":"36","author":"Sutherland","year":"2022","journal-title":"J. Interprof. Care"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1290","DOI":"10.1016\/j.surg.2021.01.025","article-title":"Disparities in amputation in patients with peripheral arterial disease","volume":"169","author":"McGinigle","year":"2021","journal-title":"Surgery"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1011","DOI":"10.1016\/j.jvs.2019.10.090","article-title":"The effect of rurality on the risk of primary amputation is amplified by race","volume":"72","author":"Minc","year":"2020","journal-title":"J. Vasc. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"6S","DOI":"10.1016\/j.jvs.2021.03.055","article-title":"Healthcare disparities in vascular surgery: A critical review","volume":"74","author":"Barshes","year":"2021","journal-title":"J. Vasc. Surg."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"P\u00e9rez-Stable, E.J., Dankwa-Mullan, I., Gardner, K.L., Zhang, X., and Rosario, A.M. (2021). The Science of Health Disparities Research, Wiley.","DOI":"10.1002\/9781119374855"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"171","DOI":"10.1002\/jgf2.659","article-title":"Improving outcomes of type 2 diabetes mellitus patients in primary care with Chronic Care Model: A narrative review","volume":"25","year":"2024","journal-title":"J. Gen. Fam. Med."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1353\/cpr.0.0108","article-title":"Expanding the chronic care framework to improve diabetes management: The REACH case study","volume":"4","author":"Jenkins","year":"2010","journal-title":"Prog. Community Health Partnersh."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Chiu, L.Y.C., Syed, M.H., Zamzam, A., Rotstein, O.D., Abdin, R., Laraya, N., and Qadura, M. (2021). Perceived Challenges to Routine Uptake of the Ankle Brachial Index within Primary Care Practice. J. Clin. Med., 10.","DOI":"10.3390\/jcm10194371"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1177\/1358863X13505673","article-title":"Barriers to screening and diagnosis of peripheral artery disease by general practitioners","volume":"18","author":"Haigh","year":"2013","journal-title":"Vasc. Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1016\/j.avsg.2021.08.015","article-title":"Early ABI Testing May Decrease Risk of Amputation for Patients with Lower Extremity Ulcers","volume":"79","author":"Aguirre","year":"2022","journal-title":"Ann Vasc Surg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1101","DOI":"10.1016\/j.jvs.2023.07.020","article-title":"The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer","volume":"78","author":"Fitridge","year":"2023","journal-title":"J. Vasc. Surg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1S","DOI":"10.1016\/j.jvs.2019.04.469","article-title":"Global Vascular Guidelines for patients with chronic limb-threatening ischemia","volume":"69","author":"Lawrence","year":"2019","journal-title":"J. Vasc. Surg."},{"key":"ref_31","unstructured":"(2025, August 01). National Limb Loss Resource Center\u00ae. Available online: https:\/\/www.amputee-coalition.org\/limb-loss-resource-center\/."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1433","DOI":"10.1016\/j.jvs.2019.08.244","article-title":"A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers","volume":"71","author":"Musuuza","year":"2020","journal-title":"J. Vasc. Surg."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"2303","DOI":"10.1016\/j.socscimed.2004.03.023","article-title":"The relationships of social participation and community ratings to health and health behaviors in areas with high and low population density","volume":"59","author":"Greiner","year":"2004","journal-title":"Soc. Sci. Med."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1080\/08998280.2007.11928263","article-title":"CoDE: Community Diabetes Education for uninsured Mexican Americans","volume":"20","author":"Culica","year":"2007","journal-title":"Bayl. Univ. Med. Cent. Proc."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"2248","DOI":"10.1016\/j.mayocp.2022.09.002","article-title":"Changes in Burnout and Satisfaction with Work-Life Integration in Physicians During the First 2 Years of the COVID-19 Pandemic","volume":"97","author":"Shanafelt","year":"2022","journal-title":"Mayo Clin Proc. Dec."},{"key":"ref_36","unstructured":"Petterson, S., Wilkinson, E., Kessler, A.C., Stone, C., and Bazemore, A. (2018). The State of Primary Care Physician Workforce, The Robert Graham Center."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/19\/6817\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,26]],"date-time":"2025-09-26T11:39:11Z","timestamp":1758886751000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/19\/6817"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,9,26]]},"references-count":36,"journal-issue":{"issue":"19","published-online":{"date-parts":[[2025,10]]}},"alternative-id":["jcm14196817"],"URL":"https:\/\/doi.org\/10.3390\/jcm14196817","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,9,26]]}}}