1. “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

2. Incorporating Lymphedema into your vein practice

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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”

9. Commitment:
Capital investment

10. 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

11. 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

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

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

14. 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

15. 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

16. 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

17. 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!

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

23. 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

24. 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