“It’s not what you look at that matters, it’s what you see.” Henry David Thoreau No Disclosures Should we change the color font consistent with the remaining slides or is this ok? Armen Roupenian, MD, FACS, FACPh RVT, RPhS, RPVI Alaska Center for Venous and Lymphatic Medicine Alaska Regional Hospital Anchorage, Alaska

Incorporating Lymphedema into your vein practice

Does it make sense for your practice? Advantages of an outpatient independent medical practice What is the future of a “vein” practice? Is it enough to say “I am a specialist in the treatment of superficial veins” and expect that to have sustainability? Ask the question. How many of you have independent vein practices So many advantages to practicing in an office setting. Chronic venous insufficiency will not go away. Non hospital based. Is it sustainable Favorable reimbursement for what may be considered

Recent change in the specialty board designation from “Phlebology” to the American Board of Venous and Lymphatic Medicine. That change reflects the understanding that there is one venous-lymphatic system “The venous and lymphatic systems are one inseparable system connected by capillaries at the tissue level in order to transport venous blood and lymph fluid. When one of the two systems loses its normal function this mutual interdependence can result in the overburdening of the other” Partsch H , Lee B. Phlebology and lymphology--a family affair. Phlebology. 2014 Dec;29(10):645-7

The Board is in the process of expanding Fellowship With that understanding the ABVLM has developed a Core Content for training in venous and lymphatic disease The Board is in the process of expanding Fellowship Training Programs in Venous and Lymphatic Medicine that has as its foundation the Core Content This will result in an ever increasing number of specialty trained physicians in the field of venous and lymphatic medicine They will be your competition

So what will it take to incorporate lymphedema into your practice? Commitment In expanding your knowledge base and understanding of the pathophysiology treatment of: Primary and secondary lymphedema Acute and chronic edema Lipedema

Commitment: From you and your staff: In dealing with a unique subset of patients who can express sadness, anger and even look at the established medical community with some suspicion. They have commonly been pushed aside, frequently told there is nothing can be done for them You need

Commitment: In venous ultrasonography: Superficial venous exam is inadequate Lower Extremity Venous Duplex for Thrombosis and Patency (IAC Standard 4.7.1B) Infrapopliteal imaging RVT RVS Don’t assume they understand venous diseasse Pursue further training and education and credentialing in vascular ultrasonography Employ vascular ultrasonographer: RVT, RVS Most of these patient will need a study that the Intersocietal Accreditation Commission defines as “Thrombosis and Patency”

Commitment: Capital investment

Commitment Understanding of compression needs and options unique to this patient population Elastic compression Flat knit Compression short stretch multilayer wrapping Inelastic adjustable Velcro® compression Role of pneumatic compression Fitting, education in donning techniques and troubleshooting compression

Should you incorporate a certified lymphedema therapist into your practice and is it essential to provide CDT (Complete or Complex decongestive therapy) in your office setting? Manual lymphatic drainage Compression (not just multi layered bandaging) Patient education Skin care and therapeutic exercises

Numerous schools of lymphedema training with varying degrees of educational requirements: Vodder Földi Norton Klose Online training programs

Physical therapists Occupational therapists Massage therapists RN’s Lymphology Association of North America (LANA®) Certification should be mandatory

Advantages of Certified Lymphedema Therapist: Emphasizes the team approach Assume those aspects of lymphedema care that you as a venous specialist may not feel comfortable with Brands and adds credibility to your Center Depending on the business model there may be a financial benefit Independent practitioner Employee

Develop relationships with: Tertiary care specialists and surgeons who specialist in lymphedema procedures Vascular surgery or interventional radiology Certified Lymphedema Therapist Bariatric surgery If patients are admitted continuity of care Compression: durable medical goods Occupational and Physical Therapists

Does it make sense for your practice? You will open up and entirely new referral base not predicated on your being a “vein doc” but truly a specialist in the care of a complex group of patients in whom primary care providers desperately need assistance Ask the question. How many of you have independent vein practices So many advantages to practicing in an office setting. Chronic venous insufficiency will not go away. Non hospital based. Is it sustainable Favorable reimbursement for what may be considered

Does is it make sense for your practice? Two things I do know: Open your doors and these patients will come They desperately need your help!

“The best interest of the patient is the only interest to be considered.” 1910 Dr. William J. Mayo

If you claim to be an expert in the treatment of venous disease then by default you claim to be an expert in lymphedema The most common etiology of secondary lymphedema is malignancy and its treatments Phlebolymphedema secondary to multifactorial venous hypertension is the most common source of secondary lymphedema Superficial venous disease Post thrombotic deep venous disease Calf muscle pump dysfunction Positional and intra-abdominal venous hypertension from obesity Cal

Does is it make sense? Successful outpatient practice will consist: Treatment of superficial venous disease Diagnosis and management of acute and chronic deep vein thrombosis Assessment and management of post thrombotic venous hypertension Evaluation and management of lymphedema and limb edema So many advantages to practicing in an office setting. Chronic venous insufficiency will not go away. Non hospital based. Is it sustainable Favorable reimbursement for what may be considered