I have not written for a while because so much of my time out of work is spent on appealing denial of payments by Novitas, the Medicare administrator for Texas.  They have denied care for patients who have had treatments that are considered as class 1 evidence for management by all the major vascular societies, including the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation, and Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II).  In 25 years of doing this work, I have never encountered such nonsense.  I thought I was the only one going through this trouble.  Then I find out that a cardiology colleague of mine in South Dallas has the same issue.  By word of mouth, I talked to a cardiologist in Illinois who just went through the same  problem.  I bet there are more physicians that are being inappropriately denied payment for standard of care by Novitas.  Nothing against the profession, but I found out my cases were reviewed initially by a licensed vocational nurse (LVN).  Hell, even many physicians don’t fully understand what we do and why.  To add fuel to the fire, apparently Novitas keeps 12% of the amount of money that they recoup from physicians such as myself as a bounty.  When I reviewed a case with one of the Novitas nurses early in the course of this appeal, she told me “Well you know sometimes people need to have an amputation of their leg rather than an attempt at limb salvage.”  THERE IS SOMETHING GOING ON HERE, AND I WOULD LOVE TO HEAR FROM OTHER PHYSICIANS, BILLING PEOPLE, AND HEALTHCARE PROVIDERS ABOUT THEIR PROBLEMS WITH NOVITAS OR ANOTHER MEDICARE ADMINISTRATOR.


Carotid Artery Stenosis and Stroke, Part 2

Someone asked me to wrote more about carotid artery disease, so here goes.  We see a large number of patients with carotid artery stenosis.  Next to aneurysms, I don’t think that there is any other medical condition that raises more anxious feelings for patients.  The paired carotid arteries supply  the left and right side of the brain.  There are ale smaller arteries that supply the back of the brain named the vertebral arteries, and there is a communication between the 2 systems within the brain called the Circle of Willis.  But the dominant supply to each side of the brain is via the carotid artery.  Blockages in the carotid artery can lead to strokes.  The typical symptom of a stroke are loss of motor control on one side of the body versus the other, loss of speech ability, and loss of vision in one eye versus the other.  Stroke symptoms do not cause pain, and vague symptoms such as dizziness and vertigo are not typical of strokes (unless it occurs in a certain area of the brain that control balance).

The typical risk factors for carotid artery disease are the same as for other cardiovascular diseases, namely cigarette smoking, high blood pressure, high blood sugar, high cholesterol, age and family history. Age and family history you are stuck with.  If Dad or Mom had heart disease and strokes at an early age, then unfortunately you are probably at a higher risk.  But the other risk factors are able to be controlled with medication if needed, or diet and exercise and smoking cession.

Most people with carotid artery disease never have symptoms.  In general, the higher the degree of narrowing, the greater the risk of symptoms.  Sometimes, you can have what is called a Transient Ischemic Attack (TIA) or mini-stroke, and at other times you might have a full blown stroke.  The difference between the two is that a TIA resolves within 24 hours, while a stroke last greater than 24 hours.  We don’t know which event is going to occur, if it does occur. We just know if you have a TIA, and you have significant carotid artery narrowing, your risk for a full blown stroke is a lot higher.

Most patients with carotid artery stenosis do not need surgery.  We emphasize controlling the risk factors, as well as smoking cessation.  I advocate an anti-platelet agent such as Plavix or aspirin, and close follow-up.  We used to be much more aggressive with carotid stenosis in terms of surgical management years ago.  However, in the era of anti-platelet agents such as Plavix, as well as statin drugs to control cholesterol level, and much better management of diabetic patients by our family practice and medical colleagues, the role for carotid artery intervention has diminished.  The options for management of carotid stenosis include carotid surgery where the blockage is cleaned out versus carotid artery stenting where the blockage is essentially reopened with a stent.  There is an ongoing debate about which technique is better for patients.  I suspect the answer is going to be dependent on the patients age, and anatomy, as well as other cardiovascular issues such as heart disease.

I dont think there is any doubt that if you have a TIA or a stroke with good recovery, and you have severe carotid artery narrowing on the side of the stroke, that you would benefit from carotid artery intervention to reduce further strokes.  What is less settled to me in the modern era is what should be done for patients with moderate to severe carotid artery disease (greater than 60% narrowing) who do not have symptoms of TIA’s or strokes.  There are carotid stents or carotid surgeries being performed for that condition (so called asymptomatic carotid stenosis), but the data is not clear in my mind of the benefits of the intervention versus the risks.  Thats what this whole business is about, balancing the risks versus benefits of every intervention we do.

Eating Right

I was trained the same way most physicians are trained in nutrition, and I suspect the same way that most other people in the health care industry are indoctrinated.  For years, I thought the equation for weight was simple.  Input equals output.  If your input in terms of calories are greater than your output, then you gain weight.  If your output was greater than your input, you lost weight.  Simple.  I recited the food pyramid to my patients diligently, and suspected that most people who thought they were following the correct diet and who did not lose weight were really not as strict as they thought.  If they only counted calories, they would lose weight.  I was the typical 35% cards, 35% protein, 30% fat diet guy.  When I started to hack my own diet and exercise, I discovered that at least for me, what I had been taught was all wrong.  Now I eat at least 50% of my calories from fat, and approximately 30-35% protein, with the rest being carbs.  I don’t eat bread or pasta.  I eat sweet potatoes only on a leg or back workout day (large muscle groups).  I have lost body fat, my waist size is less than 30 inches, and I am 56 years old (soon to be 57). Turns out there is new science validating some of this information.  As we get older, the body does not like to let go of fat.  You have to trick it into thinking there is lots of fat around.  It really works.  If you are a male in your 40’s or older, change the way you eat.  Combine it with variations of high intensity interval training.  You will feel better, and you will lose the body fat.  I should add I suspect the situation is more complex for women.

Peritoneal Dialysis

Another option that has been around for a long time, but is gaining increasing traction is peritoneal dialysis (PD).  PD is a method of cleaning the body of the toxins and waste products that are normally eliminated by the kidneys.  PD depends on diffusion, or the exchange of material along concentration gradients.  PD depends on the large surface area of the peritoneal cavity.  The peritoneal cavity is the space under your abdominal muscles and chest that hours the intestines and other organs.  In order for a patient to do PD, we have to insert a PD catheter into the peritoneal cavity and begin it out of the side of the abdomen.  This is an outpatient surgical procedure that takes about 45-60 minutes to perform and is not a very painful surgery.  The incisions are allowed to heal for about 2 weeks prior to the PD catheter being used or dialysis.

In essence, a large volume of dialysis fluid is placed into the abdominal (peritoneal) cavity, and allowed to dwell form some time, usually overnight.  During that time frame, due to the difference in the difference in concentration of electrolytes and other substances in the fluid as compared to the body, there is an exchange of products.  The fluid that was placed into the peritoneal saps a lot of the bad products that the kidneys would normally remove. This fluid is then drained out the next morning, resulting in “cleaning of the blood”, much like regular hemodialysis.

The good thing about PD is that is is much more physiologic than hemodialysis, meaning that it is gentler on your body because of the slower nature of the exchange.  The downside is that you have a piece of plastic tubing hanging out of your body, and you have to make adjustments to your lifestyle for it.  The other major risk of a PD catheter is the chance of infection.  An infection of the peritoneal cavity is called peritonitis, and can sometimes be treated with antibiotics in the dialysis fluid.  If the infection is severe, particularly if it s fungal infection, the catheter needs to be surgically removed in order to clear the infection.

PD requires  specialized training by peritoneal dialysis education centers, because it needs to be done correctly in order to reduce the chance of infection and other potential complications.  Patients who are significantly overweight, or who have had multiple pelvic or abdominal surgeries generally do not do as well with PD.