A panel discusses how they navigate the technologies available for treating superficial venous disease and the factors that influence widespread adoption.
With Steve Elias, MD, FACS, FACPh
Long question, short answer: “Sooner or later it all comes down to money” as sung by Bruce Springsteen in “The Big Muddy.” This answer may seem cynical or simplistic, but most physicians don’t adopt a new platform or technology unless there is something in it for them—intellectual stimulation, notoriety, novelty, or remuneration. Most people don’t work at their job without compensation. We have seen this movie before many times. In fact, in superficial vein care, we are now realizing the algorithm of care that answers the question, “What forces most drive platform adoption in superficial vein care?” is often, “Because I can get paid.” Money talks and now some vein specialists are doing too many procedures because they can get paid. This is an issue that has been discussed in this publication and others, as well as at societal meetings. We are working on solutions. Another topic for another day.
Currently, we have reimbursed platforms that are safe, efficacious, durable, and relatively patient friendly for treating superficial venous disease. One need not feel as if they are providing inferior or substandard care to most patients most of the time with currently covered and available platforms. Yet, there are new nonreimbursed technology platforms that have some inherent advantages to patients and physicians. Some people are using them. The why and how may help answer the posed question.
We can divide physicians, and specifically surgeons and proceduralists, into three categories: (1) early adopters, (2) secondary adopters, and (3) reluctant adopters. Most proceduralists are not driven to change as long as what they are using seems to be working for them and for their patients. Most are not comfortable with feeling uncomfortable, except the early adopters. Most will adopt new platforms only if they need to or if they get paid. Yet, there are early adopters who simply embrace the new. These are the ones involved in clinical trials and platform development so that they can gain experience for their patients and themselves. They are the first wave. Reimbursement may not be an issue because their experience and their patients’ experience are gained by clinical trial support. However, these cases are the minority.
The great majority of physicians are secondary adopters. They wait for data, demand, and reimbursement. This is what drives their adoption. They wait and they wait, but their patience usually pays off for their patients and themselves. Their patients get treated with procedures, technologies, or platforms that are proven and reimbursed. Although this approach may not be as interesting or stimulating as the early adopters’ approach, it is the standard safe approach that is time-proven.
Luckily, reluctant adopters are the minority. By the time the reluctant adopters consider using new platforms, most of them have been vetted by research, time, and results. The losers of the reluctant adopter approach are both patients and physicians. The patients more than physicians because good care and new platform technology has been withheld longer by these physicians for their patients than most other patients.
It is the nature of medicine and surgery to progress and change. We all want to improve patient care. It is also the nature of new platforms to take time for data, results, and reimbursement to accumulate. There is at least a 3-year lag time from market entry to successful reimbursement for most platforms. Forces driving platform adoption are linear. Who adopts and at what point along the line of the “adoptive path” depends on the “adoptive attitude” of each individual practitioner. Some are early adopters, most are secondary adopters, and a few are reluctant adopters. But in reality, for most, the forces that drive platform adoption is the Jerry Maguire mantra, “Show me the money.” Not cynical or simplistic, merely realistic.
March is national Blood Clot Awareness Month known as Deep-Vein Thrombosis (DVT), a public health initiative aimed at raising awareness of this commonly occurring medical condition and its potentially fatal complication, pulmonary embolism. According to the American Heart Association, up to 2 million Americans are affected annually by DVT, more commonly known as blood clots. Yet, most Americans (74 percent) have little or no awareness of DVT, according to a national survey sponsored by the American Public Health Association.
Dr. Steve Elias Director of The Vein Center at Englewood Medical Center has written a few examples below of what people should look for if they think they may have a blood clot or DVT.
Even though he was wearing a helmet when riding his motorcycle, in the Emergency Room the CT scan of Dick’s head showed some bleeding around his brain. He was a safe driver and was coming home from work when he was hit from behind while stopped at a light. After brain surgery to remove the blood, Dick was in the hospital bed recovering and not moving around that much. Ten years later he is doing fine but his left leg swells as the day progresses.
He wears compression stockings that help a little bit. John has chronic DVT commonly known as blood clots.
Jane was always an athlete. Running was her main activity but in her 50’s Jane’s left knee was painful during and after running. After much physical therapy and medication, Jane had a knee replacement. Three years later she is back competing in triathlons. Her left leg is always more swollen than the right. It feels heavy and throbs by the end of the day. Jane has chronic blood clots.
What happened to Dick and Jane? What is their problem? Can they be helped? March is National DVT Awareness Month. Dick and Jane both had a blood clot in the past that was unrecognized and untreated. They now have symptoms due to the clot and the damage that occurred to their veins. People get blood clots for many reasons: immobility from accidents or surgery, inherited clotting disorders, hormone therapy, long air or car travel, etc. Usually a blood clot is diagnosed early and it is treated with blood thinners. Usually the blood clots don’t damage the veins but sometimes the veins develop scarring and narrowing and don’t work correctly. This is what happened to Dick and Jane.
The veins bring the blood back to the heart. When we walk the muscles in our legs pump the blood up the veins back in the direction of the heart. If the veins are scarred and narrowed (blocked), the blood can’t flow back as quickly as it should. Blood backs up and patients experience symptoms of: swelling, pain, pressure, throbbing in their legs. This is usually worse by the end of the day. Sometimes they even develop ulcers or skin discoloration around their ankles. Until recently patients were told that there really wasn’t much that could be done. All they could do was to wear compression stockings and elevate their legs. Now things are different. Now many times we can help by using procedures that stretch and widen the veins so that the blood can flow back to the heart more normally.
Angioplasty and stenting are what these procedures are called. Many of you may be familiar with the terms from treating blockages in the blood vessels of the heart. Veins are different, they are bigger. They may get blocked by previous blood clots or phlebitis (inflammation). Treating them is much less risky than treating the heart arteries. Once the diagnosis is made by either: ultrasound, MRI, CT scan or venography patients can have the narrowed parts of their veins made wider by stretching these areas with balloons (angioplasty) and then keeping them open by placing stents in the stretched veins. All of these procedures require no incisions or stitches, only a needle stick. Most patients return to normal activity in a day or so.
If you’ve had a blood clot, if you have a leg ulcer, if you have symptoms that affect your quality of life then you should seek out a vein specialist that can help you. The diagnosis is non-invasive and the treatments are minimally invasive. Not every patient is a candidate for these procedures but many are. It depends on each individual’s anatomy and level of vein damage. Most patients can be helped. If you’ve had a blood clot or know someone who does, take the responsibility during National DVT Awareness Month and share the information to get the help that is needed. Select a an experienced vein specialist and learn about the numerous non-invasive quick procedures to prevent blood clots. Dr. Steve Elias Director of Center for Vein Disease at Englewood Hospital and internationally recognized world leader in venous disease teaching doctors from all over the world, for an appointment or consult call 201.894.3252 or visit veindisease.com