Mr. Robley,

I believe that we met at the last SVT meeting... I am selling a Vascular
reporting and accreditation software package. We touched on the idea of
using your sales force to help promote our software with renumeration to
those sales people. If you are interested, please contact me. I am in Sam
Phyllis' teritory and we have talked briefly. I have referred 3 sales of
Nicolet to him within the past few months.

Phil White 804-550-5385

-----Original Message-----
From: UVM Flownet [mailto:[log in to unmask]] On Behalf Of Richard T.
Robley
Sent: Friday, December 04, 1998 11:16 AM
To: [log in to unmask]
Subject: Re: Duplex vs Physiologic

Bravo!

[log in to unmask] wrote:

> To Flownetters:
> >From Rob Daigle.
> To play the devils advocate on the issue of physiologic segmental studies
> versus duplex, I'd like to voice an opinion. This opinion has been
sculpted
> by my mentors in vascular surgery and radiology, experience in the
trenches,
> and by comments,criticisms, and attacks when I've lectured in support of
> Duplex imaging of native arteries.
>
> #1) Although a bilateral duplex scan from aorta to the ankles takes 5-10
> minutes for those who have been scanning arteries since before sliced
bread
> was invented, for most of us it takes a lot longer. For a patient with
> bilateral disease in the iliacs and fem -popliteal segments, a two hour
exam
> duration is more likely. (time flies when you're having fun). Sure, the
exam
> could take 30 minutes, but sometimes the quality of the test is severely
> compromised. There is always a tendency to forget how much time it takes
to do
> the tough ones. The memory of pain is short!
>
> #2 . For many of us, the iliacs are a bitch, in terms of scheduling time,
> technical difficulty, bowel gas and frustration, one does not approach
this
> potentially very difficult segment without a good indication that you need
to
> scan there. Often the patient must return another day with bowel prep, NPO
to
> accomplish this exam.
>
> The question posed by Jean Primozich, of why not take just take ankle
> pressures and then scan, is important, for technical and reimbursement
issues.
> Ankle pressures, as long as the patient does not have calcific medial
> sclerosis, and many do, will indicate normal versus abnormal, but if you
want
> to find where the disease is, with this protocol, you've got to scan the
> entire limb(s). (Waveform analysis at the CFA is only good at detecting
> severe aorto-iliac disease.) And the tibial arteries, all three of them,
are
> no picnic either!
>
> #3) Reimburse is an issue for many that rely on medicare and insurance
> carriers to keep their labs going. An ankle- brachial pressure index is
not
> reimbursable without other physiologic testing, waveforms etc. Many
states
> will not reimburse for a duplex exam unless surgery or intervention is
> planned, nor will they reimburse for a normal duplex exam.
>
> Guidelines have been written to suggest appropriate methods for arterial
> testing. The Medical Policy manual from the mid western states (KA, MO
NE),
> reads "Duplex scanning and physiologic studies are reimbursed during the
same
> encounter if the physiologic studies are abnormal or to evaluate trauma,
> thromboembolic events and aneurysms."
>
> The guidelines further state " In most patients, segmental blood pressure
> measurements (not just ABI, rd) before and after exercise should be the
> preferred procedure in evaluating arterial insufficiency." Many states
are
> adopting similar guidelines. So what we feel is the best way to do things,
> might not be the way we get paid for doing them. This is fine if you're
funded
> by grants or Powerball.
>
> 4) Physiologic segmental testing, when performed for appropriate
indications,
> is reimbursable in all states, whether the result is negative or positive.
> It takes 15 minutes (ABI with waveform) - 60 minutes max (for a full test
with
> exercise) , regardless of tech experience.
>
> Indirect testing accurately ( numerous articles) predicts whether the
disease
> is above or below the inguinal ligament, an important consideration for
> patient management.
> It provides objective, physiologic information about the effect of
stenosis
> and occlusion on the patients' distal perfusion. Duplex data does not
provide
> this.
>
> It tremendously helps to differentiate vascular claudication from pseudo-
> claudication, especially in referrals from non-vascular specialists.
>
> And finally, unless the vascular surgeon is prepared to operate without a
> preoperative angiogram (some do, but most do not) ( and I feel that Duplex
> imaging in the hands of the true experts with many years experience, Bill
> Schroeder comes to mind, is more accurate that angiography) duplex
imaging of
> the arteries is redundant to the angiogram, a waste of time ( a precious
> commodity in a busy lab) and someones money. Ditto for angioplasty.
> Duplex imaging is fun though.
>
> Just an opinion from an average tech who is now an average product manager
for
> Nicoletvascular, manufacturer of physiologic testing equipment.
> Thanks
> Rob Daigle