I attended a podiatry lecture last week. It was a sponsored dinner put out by one of the makers of a rotorooter device for clogged arteries. The first speaker was a podiatrist who was informing his audience how not enough PAD testing was being performed.

He went on and on how the American Diabetes Association recommends that every diabetic over 50 have one of these exams and the speaker went on to inform the audience how "its good practice management as well".

He continued to let us know it should be done every 6 months and it is paid for both times.

Tonight, I stumbled across an article/blog how the U.S. Preventative Services Task Force released findings back in Sept that "it's unclear whether using the ankle brachial index to screen for PAD and assess the risk for heart disease is beneficial in people with no symptoms".

The American heart Association states PAD becomes more common with age, often goes undiagnosed and people who have it have a 4-5 times more risk of heart attack or storke.

A Dr. McDermott was quoted as saying "there is not high qualilty evidence to demonstrate that screening for PAD with ABI's reduces cardiovascular event rates".

The article which was from a site or blog called "Healthday" states PAD is usually treated with blood pressure medications and cholesterol lowering drugs.

I have many questions after reading this:

1) I don't know anyone that treats PAD of the lower extremity at least with blood pressure medications or cholesterol lowering medications. To me, blood pressure reducing medications are given to people who have high blood pressure not to anyone with a low ankle arm index. Similiarly, cholesterol lowering agents are given to people who have high cholesterol analyzed in blood work not from an ankle arm index.

2) What exactly is the correlation with PAD and heart disease? Whenever, I. personally send a patient for a vascular consult SHOULD I also be sending him for a cardiology consult? Should the vascular doctor be checking heart function as well as lower extremity function?

3) Ever look at Medicare guidelines for when performing ABI's are reimburseable? At the point where they are the patient is likely at a higher risk and at that time needs an MRA not a non invasive test.

4) Perhaps the reason why many cases are undiagnosed is because patients may be neuropathic or the early stages are not painful? In which case screening is a good idea.

5) The speaker of my dinner likely should have his ABI equipment revoked. I think every diabetic over 50 twice a year testing is a bit much. This overindulgent type of practice is what got us into this Obamacare mess to begin with. Some sense of honesty and ethical behavior is mandated. (Okay, lets not revoke his equipment, let his equipment not enable him to furnish a bill twice ayear only once....unless medical hx changes.)

YOUR THOUGHTS?

 

 

 

 

 

 

  • Comments (9)
  • William you peaked my interest. - when I take pedal pulses, I use my right hand on the patients left foot foot, and left hand on the patients right foot, but then if not readily palpable, I do "crossover" as you say and place my right hand on the right foot. I am a dominant righty (as are most white jewish basketball players from my era.) and feel my tactile sensation is more delicate on my right hand. I have also been experiencing signs of carpal tunnel in my left hand (which were really bothering me yesterday, if anyone has pointers please let me know. I no longer wear a watch,)

    Why would it matter what hand you palpate pulses with????
  • Ditto on above remarks, and to augment Dr. Hadi's comments in a more visual format, I am borrowing from the Vasc Sgn Dr. Hakbari's lecture at Desert Foot 2011. 

    Interestingly enough, in this lecture which is available to stream (for free) on this website (under Lecture Hall--> Conferences), Dr. Hakbari breaks it down very simply and makes it clear:  Making the diagnosis of lower extremity PAD and CLI is done via a proper history and physical exam along with basic objective test findings. 

    In addition, in his vascular lecture (found at the same sub-tab on this website), he demonstrates with photos how to properly take the pulses all the way down the chain of the lower extremity; and I have seen plenty of people NOT doing them correctly, including Podiatrists. 

    Pop quiz:  do you use your right or left hand on the left or right foot (not crossing over, that is)??  How many fingers do you use to take a Dorsalis Pedis pulse??  What is the correct technique for taking a Popliteal arterial pulse??

    In any event, as most of you know, it requires a constellation of factors (information, data), both subjective and objective, leading to an index of suspicion for making the diagnosis of PAD and CLI.  Moreover, changes in the moderate to high risk patient can occur swiftly.  -->> Echoing Dr. Hadi's input, in the case of higher risk patient populations, more frequent vascular screenings [P.E. and perhaps test(s) of choice] may then be required -- {documented!}, or you/we as providers could be "caught watching the paint dry"...  see free lecture on this website by Dr. Hakbari; on this topic, it is very telling, informative, simple, and straight-forward slides in order to understand that one expression of mine (the progression and downward spiral of the patient with decreasing vascularity and narrowing options for blood flow interventions, wound healing, and limb salvage). 

    We think we know what we know, and all there is to know about LE PAD & CLI; but, I guarantee, everyone out there will pick up some pearls from his lectures archived here on Podiatry.com (from the Desert Foot 2011 conference).  And it'll take no more than 20 minutes to just flip thru; or you can listen at increased voice over speed.  Plus, it's a CME.

    One last remark:  if we do over-utilize diagnostic modalities such as PADnet's in our offices, then yes, I do believe "they" will take it away from us, reduce payments, not cover it, or make it difficult as a test to run.  It would not be right, but that could happen.  Some sort of guidelines as to when to run that test would be appropriate however, and timely pre-authorization perhaps would be in order.  I mean if the patient just had a vascular workup this year or within the last 6 months, then no need to run a PADnet in one's office; if the patient just had a lower extremity interventional procedure, and it was patent and viable; then, unless you had a high index of suspicion that it had closed or narrowed to the endangerment of the limb or foot- again, no need to run a PADnet.  Guidelines would be order; but, no need to make them too wieldy or untimely in terms of the patient getting the test.

    One more thing, really, then I'm out:  It's not the govt changing healthcare, it is corporate hegemony... (DEmocrats, Shmemocrats - today's democrats resemble the republicans of the 1970's; that is a well-known truth/fact).  Healthcare and the ACA is all about more dollars and revenue for the few and the over-privileged (again!) and not us doctors; it is more corporatization; it is the furthing of the corporate take-over of the healthcare system of America and of the world as we know it.  It is locking people into programs, and making us pay what "they" want us to pay, and marketing it to us under another label ALL in the name of big profits.  First, they sold it to us as "oh, these 10's of millions don't have any healthcare or are under-insured; then, it went on from there... and look where we are now!  And we are getting sucked (suckered) in; and now locked in.  *  Bait and switch.  *  And make no mistake about it:  The govt no longer has the power to tell corporations anything, including the media conglomerates.  Sure, the govt can regulate, enact laws, write guidelines, etc. - but whom do you think guides the hands of the regulators, drafters of bills, and edits guidelines??  Ever read or view any Noam Chomsky documentaries for starters??  Look up corporatization on Amazon.com, and be enlightened (many of you already are, I know).  Or be another drone.  Learn to learn (as many of you do, I realize), not just what to believe...

    WG

  • Quote:

    I have many questions after reading this:

    1) I don't know anyone that treats PAD of the lower extremity at least with blood pressure medications or cholesterol lowering medications. To me, blood pressure reducing medications are given to people who have high blood pressure not to anyone with a low ankle arm index. Similiarly, cholesterol lowering agents are given to people who have high cholesterol analyzed in blood work not from an ankle arm index.

    2) What exactly is the correlation with PAD and heart disease? Whenever, I. personally send a patient for a vascular consult SHOULD I also be sending him for a cardiology consult? Should the vascular doctor be checking heart function as well as lower extremity function?

    3) Ever look at Medicare guidelines for when performing ABI's are reimburseable? At the point where they are the patient is likely at a higher risk and at that time needs an MRA not a non invasive test.

    4) Perhaps the reason why many cases are undiagnosed is because patients may be neuropathic or the early stages are not painful? In which case screening is a good idea.

    5) The speaker of my dinner likely should have his ABI equipment revoked. I think every diabetic over 50 twice a year testing is a bit much. This overindulgent type of practice is what got us into this Obamacare mess to begin with. Some sense of honesty and ethical behavior is mandated. (Okay, lets not revoke his equipment, let his equipment not enable him to furnish a bill twice ayear only once....unless medical hx changes.)

    YOUR THOUGHTS?

     


    Just my 2 cents:

    1.  I don't believe the thought is if they have a low ABI that they automatically are placed on cholesterol lowering agents or blood pressure medication.  However, the correlation with vascular disease, cholesterol levels and BP often result in the management of these comorbid factors as they often come hand in hand.  I do not believe the ABI is meant to be the diagnostic factor in initiating these medications.

    2.  As for the correlation of PAD with heart disease:  It is well established that patients with PAD not only display symptoms of claudication either stable (73%) or symptomatic (16%), but may also progress to LE Bypass surgery (7%) or major amputation (4%).  What is also an established fact is that morbidity and mortality also increases in patients with PAD and is evidenced by the risk of "non-fatal" events such as MI, Stroke (20%) and Mortality (30%).  So the correlation is definitely there.  (one article I have referenced is Weitz JL. Circulation. 1996;94:3026-49 and a wonderful talk given at Desert Foot a couple of years ago by Dr. Cameron Akbari, Vascular Surgeon at Georgetown University.

    3. I will have to look at the medicare guidelines...

    4. I think many cases are undiagnosed in part due to neuropathy....but not because patients do not feel the ischemic pain, but because often times it is written off as "neuropathic pain".  This I believe, is why it is important to do routine screening in regards to ABI and non-invasive testing...along with a thorough vascular exam in clinic further facilitated by doppler evaluation of pulses.

    5. We have come to blame a lot of things on "Obamacare"...that's the extent of my political reference...but I do again believe at minimum an annual evaluation should be done for screening purposes and this is the philosophy we follow at our facility.  I personally believe every diabetic should have an initial lower extremity arterial evaluation (non-invasive studies).  However, there are those patients with claudication, that is symptomatic that do get more frequent screening every 6 mos.  So, I believe just like anything else, you have to be judicial in regards to how often you prescribe to a treatment...I agree, not everyone requires studies every 6 months.

    I suppose we have to consider a particular physician's patient population.  By the time patients are sent to the vascular doctor, often times they have progressed disease and it may be feasible that they would require testing every 6 months.  The cormobid correlations with PAD of the LE are well defined and identifying this level of disease in this particular population is critical.  And yes, I also believe every diabetic should have some level of a cardiac work up especially if they have associated comorbidites (pedal ones such as neuropathy, h/o charcot, reduced pulses, etc.) and if they have high cholesterol, hypertension, etc...and I believe the primary care doctors often do screen patients in this regard as well.

     

    again, just my 2 cents.

     


     

  • Marc - I would love to hear your "alternative revenue streams" ....are they in podiatry? Lol......
  • CAD and PVD are highly correlated-90% of subjects when angiography was used http://circ.ahajournals.org/content/114/7/688.full.  However, I believe you would do well to send the patient back to the PCP for cardiac workup and let him/her place the cardio consult if necessary. I just believe it is better etiquette, and takes into consideration that the PCP may be able to manage their cardiac issues or is already monitoring the patient for such issues. I would definitely refer to a vasc surgeon when a LE vasc test turns up with segmental variability or the ABI and DBI are under .80.

    "Screening" should not be done based on neuropathy.  The test can only be paid for if there is an absent or weak pulse with other symptoms such as ulcer, cyanosis, gangrene, pain etc (I do not have the real list in front of me, so pardon the lack of accuracy or completeness).

    I do suggest sending patients for an NIVA if you plan to bill for "DM covered nails" with PVD indications. CYA

    I quit using PADnet.  In part, because the cuffs failed and with staff turnover I was looking at spending another $1200 on parts and re-certifications.  In VA there has been a bit of oscillation in the legitimacy of the PADnet certification vs a real vascular technician.  I forget the acronym. At one time there was discussion as to recoupment if techs were not full vascular techs.  The whole thing has deterred me from using it.

    There is alot of marketing of "alternative revenue streams"  which is looking more attractive as insurance changes make me want to wear my brown pants more often.  But we really need to get critical on some of these things.

     

  • Quote:

    I attended a podiatry lecture last week. It was a sponsored dinner put out by one of the makers of a rotorooter device for clogged arteries. The first speaker was a podiatrist who was informing his audience how not enough PAD testing was being performed.

    He went on and on how the American Diabetes Association recommends that every diabetic over 50 have one of these exams and the speaker went on to inform the audience how "its good practice management as well".

    He continued to let us know it should be done every 6 months and it is paid for both times.

    Tonight, I stumbled across an article/blog how the U.S. Preventative Services Task Force released findings back in Sept that "it's unclear whether using the ankle brachial index to screen for PAD and assess the risk for heart disease is beneficial in people with no symptoms".

    The American heart Association states PAD becomes more common with age, often goes undiagnosed and people who have it have a 4-5 times more risk of heart attack or storke.

    A Dr. McDermott was quoted as saying "there is not high qualilty evidence to demonstrate that screening for PAD with ABI's reduces cardiovascular event rates".

    The article which was from a site or blog called "Healthday" states PAD is usually treated with blood pressure medications and cholesterol lowering drugs.

    I have many questions after reading this:

    1) I don't know anyone that treats PAD of the lower extremity at least with blood pressure medications or cholesterol lowering medications. To me, blood pressure reducing medications are given to people who have high blood pressure not to anyone with a low ankle arm index. Similiarly, cholesterol lowering agents are given to people who have high cholesterol analyzed in blood work not from an ankle arm index.

    2) What exactly is the correlation with PAD and heart disease? Whenever, I. personally send a patient for a vascular consult SHOULD I also be sending him for a cardiology consult? Should the vascular doctor be checking heart function as well as lower extremity function?

    3) Ever look at Medicare guidelines for when performing ABI's are reimburseable? At the point where they are the patient is likely at a higher risk and at that time needs an MRA not a non invasive test.

    4) Perhaps the reason why many cases are undiagnosed is because patients may be neuropathic or the early stages are not painful? In which case screening is a good idea.

    5) The speaker of my dinner likely should have his ABI equipment revoked. I think every diabetic over 50 twice a year testing is a bit much. This overindulgent type of practice is what got us into this Obamacare mess to begin with. Some sense of honesty and ethical behavior is mandated. (Okay, lets not revoke his equipment, let his equipment not enable him to furnish a bill twice ayear only once....unless medical hx changes.)

    YOUR THOUGHTS?

    I'm in agreement with you that 2x/year is way overutilization.

    A few comments in reaction to your list

    1) BP meds and cholesterol meds are for CAD prevention.  The data is pretty high good in support of this.  For PAD, cilostazol and pentoxyfyline are most often used, however usually only if the patient has intermittent claudication.  For vasospastic disorder, I have found that nitroglycerin ointment is the drug of choice.

    2) The data is very strong that if the patient has PAD they also have CAD.  People with PAD most often succomb to CAD. So a wise idea is once the PAD dx is in place, cardiology consult should also be considered.

    3) Do you really need an ABI test on a patient sitting in front of you with ruborous cold feet to make the dx? This is another example of technology people trying to make good-old physical examination techniques obsolete.  A hand-held doppler can easily detect that the patient has no pulses.  I only order an ABI for the following reasons: 1) patient has signs of PVD that I am considering sending for a vascular surgery consult, 2) patient has intermittent claudication, 3) patient is borderline PAD to the point I can't make up my mind whether I want to consider patient for elective procedure.  If I palpate the pulses, or the hand-held doppler has strong tri or biphasic sounds, I'm not ordering an ABI test.  Several years ago I had  PPG unit in my office which was very helpful for helping me make the surgical decisions.

    4) Neuropathic patients often have increased blood flow rather than decreased.  The neuropathy would have to be way above the ankle for them not to feel intermittent claudication symptoms.

    Good for you to question the overutilization of technology.  You're absolutely right - the continued indiscrimate useage of high tech rather than our traditional thoughtful PE got us into Obamacare.  Part of the clamor for national health insurance has been the overutilization and overcharging by many across the medical spectrum.  The doctor-patient relationship, both medically and financially, used to keep medical costs in check.  Once the insurance company was added to the relationship it became a menage-a-trois, which usually ends by the entire system breaking up.

    Best wishes,

    Daryl

  • This is from 2008, I have not found anything on reolutions yet.  I'll keep digging or one of the anxious affiliates of PADNET will post the follow up shortly after they get word that I posted this.  I expect withing 1-2 hours--just guessing.

  • Quote:

     

     

     

    "    

    Additionally, during our post-inspection review of promotional brochures (ML-032 Rev. 1-08 and ML-024 Rev. 5-08) for your PADnet+ systems, we observed that the brochures contain the statement "FDA approved." However, your device has not received approval from the FDA. The PADnet+ device is marketed under a premarket notification [510(k)]. Under 21 CFR § 807.97 ("Misbranding by reference to premarket notification"), "[a]ny representation that creates an impression of official approval of a device because of complying with the premarket notification regulations is misleading and constitutes misbranding."

    We received a response from Will Rogers, Chief Technology Officer, concerning our investigator's observations noted on the Form FDA 483, List of Inspectional Observations that was issued to you. The response discusses some corrective actions, but fails to provide complete evidence that corrections have been made: and will be effective going forward. In this case, a follow-up inspection will be necessary to determine the adequacy of your corrections.  "

    I have a PADNet for sale.......

    arterial only.

     

    Any offers.

    Dennis

  •  

     

     

    "    

    Additionally, during our post-inspection review of promotional brochures (ML-032 Rev. 1-08 and ML-024 Rev. 5-08) for your PADnet+ systems, we observed that the brochures contain the statement "FDA approved." However, your device has not received approval from the FDA. The PADnet+ device is marketed under a premarket notification [510(k)]. Under 21 CFR § 807.97 ("Misbranding by reference to premarket notification"), "[a]ny representation that creates an impression of official approval of a device because of complying with the premarket notification regulations is misleading and constitutes misbranding."

    We received a response from Will Rogers, Chief Technology Officer, concerning our investigator's observations noted on the Form FDA 483, List of Inspectional Observations that was issued to you. The response discusses some corrective actions, but fails to provide complete evidence that corrections have been made: and will be effective going forward. In this case, a follow-up inspection will be necessary to determine the adequacy of your corrections.  "