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.
Sent:   Friday, December 04, 1998 11:16 AM
To:     [log in to unmask]
Subject:        Re: Duplex vs Physiologic


[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
> by my mentors in vascular surgery and radiology, experience in the
> 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
> 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
> duration is more likely. (time flies when you're having fun). Sure, the
> 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
> potentially very difficult segment without a good indication that you need
> scan there. Often the patient must return another day with bowel prep, NPO
> 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
> Ankle pressures, as long as the patient does not have calcific medial
> sclerosis, and many do, will indicate normal versus abnormal, but if you
> 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,
> 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
> reimbursable without other physiologic testing, waveforms etc.  Many
> 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
> reads "Duplex scanning and physiologic studies are reimbursed during the
> 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
> 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
> by grants or Powerball.
> 4) Physiologic segmental testing, when performed for appropriate
> 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
> exercise) , regardless of tech experience.
> Indirect testing accurately ( numerous articles) predicts  whether the
> is above or below the inguinal ligament, an important consideration for
> patient management.
> It provides objective, physiologic information about the effect of
> and occlusion on the patients' distal perfusion. Duplex data does not
> 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
> Nicoletvascular, manufacturer of physiologic testing equipment.
> Thanks
> Rob Daigle