The first segment of a five-part virtual series for attending physicians, fellows, and allied health professionals, Dr. Craig Walker, Dr. Chris LeSar, Dr. Sreekumar Madassery, and Dr. Timothy Yates discuss the State of the Art in PAD and CLI, the importance of telehealth during the COVID 19 Era, and discuss the important focus of quality of life in reducing rates of PAD-related amputation.
The five-part course focuses on optimizing algorithms to improve clinical outcomes and advancing multidisciplinary collaboration in peripheral arterial disease and critical limb ischemia care. Content includes clinical and scientific discussions on the efficacious utilization of interventional therapies and the critical role imaging plays in case planning and improving outcomes, as well as the three panel-moderated live cases that provide multidisciplinary perspective and real world takeaways for endovascular procedures.
you know, this is PhD awareness month. And so um I think it's appropriate to kick this off and talk about P. A. D. And C. L. I. In the state of the art um for uh for this disease process and especially in the covid 19 area and how it impacts patients management quality of life when we look at ph d um you know, master positions throughout the country in the world um put together things that allow us to understand relationships between disease disease process and we know that ph d affects patients directly with communication where they can't walk where they rest pain or gangrene or possibly embolization. Um but it also affects and causes polly vascular disease so it can affect the schema to the kidneys, rheumatism, tariff or possibly uh formation of aneurysms or stroke issues with Kurata disease and in coronary heart diseases related um as well. And we know that there's a strong correlation between ph d. And smoking and lung cancer and smoking. So this is our patient population that we deal with. But there's an important distinction about coronary disease that I wanted to point out. And and the fact is that the first sign of someone having polly vascular or possibly coronary artery disease very well may just be clarification. So this is a systemic disease um That is um that is affecting a for for disease is uh effects approximately 8.5 million americans. Um And um has significant because of the significant prevalence and cardiovascular risk implications. Only 25% of PhD patients are undergoing treatment at the time of when we discover them. Ph. D. Is a marker for systemic atherosclerotic disease. And persons with ph D. As compared to those without having 4 to 5 times higher risk of dying from cardiovascular event. Um and the 2 to 3 times higher risk of mortality. Um In and compared to the people without ph. D. African american ethnicity is a strong and independent predictor for P. A. D. And they have a higher prevalence um than than than than whites. Consequently they have higher amputation rates and death rates associated with this disease process. And the risk factors include smoking and diabetes, hypertension, high cholesterol and lack of physical activity. Critical limb ischemia is the end stage of PH. D. Is generally involving the infra papa till vessels. Um The involves a chronic ischemia with rest pain, ulceration, skin green and patients are the greatest risk for amputation. Um For diabetic patients with ulcers, inadequate profusion can also lead and prevent healing for these patients. And for these patients, typical plants are foot artists are frequently involved. Cli affects two million americans who are risk for amputation of the of the lower extremities and mortality of ci paste typically exceeds 50% in five years. The red for classification of four or five and six, help us understand um Rest pain, minor tissue law. Some major tissue loss. When we look at a PhD population over 50 years of age. Um and categorize them, patients will present with either communication in only 10 to 35% of patients. So that means that that 50 20 to 50% of patients are asymptomatic. And um other patients are presented with a typical symptoms walking pain or walking difficulty, shuffling of their feet, low energy of the extremities. But despite that at five years, mortality for this cohort will be anywhere from 15 to 30% and uh 20% will have had a heart attack or stroke with these problems. If you look at ph D and cli when it presents a cli at one year, amputation occurs at 25% of the time and cardiovascular mortality of 25% of time. So it's a very different cohort and it seems to be about a five year difference between um ph D. And the cli group. To put it in perspective, you know, the five year mortality rate for the diagnosis of P. A. D. If we compare that to the common thing that we look at is cancers. And if we look at the top, we see that pancreatic cancer, we all know this is a very highly lethal cancer. Um And the this is fortunately very fairly low. Um And we and we see that over to the right side. Breast cancer, however, is more prevalent, but it only has a very low death rate. And we look at um Cli the incidents of cli is fairly high in the mortality risk with cli is very high. And so at five years more people die from cli than from the cancer is that we commonly hear about, except for of course lung cancer, which is its own special entity. Next please. Mhm. Next. Um if you look at diabetes and ph d uh foot ulcers are a major health problem throughout the world, 350 million people have have have diabetes. We think it's about 6.6% of the major populations. We think in the U. S. Is probably closer to 10% currently with about 3% of the patients just undiagnosed. And in 2025 we think there's gonna be about 65 million patients with diabetes is the leading cause of foot ulcers are the leading cause of hospitalizations. Any amputation in diabetic patients and 40% of the health care resources are spent on diabetes are related to feed problems of all. Um diabetic patients, 85% of amputations are preceded by a foot ulcer which subsequently got worse affected and in game green and then lead to amputation. Next please we look at long term prognosis of diabetes and patients with cli. Um if they go on to major amputation compared to endovascular therapy or bypass therapy and we look at survival, we see a natural declination of survival for endovascular and bypass surgery. But there's a dramatic difference with the survival curve for the primary imputation group. And so amputation suggested significantly decreased survival. And many studies are starting to elucidate this period. Next, when we look at diabetes renal disease and add cli to the mix, we see that 20% of dialysis patients have critical ischemia. You add diabetes and kidney disease and the mortality rates for for those people at one year is about 50%. So it's a stairway to amputation. They developed diabetes and neuropathy, chronic kidney disease, which leads to vascular impairment, alteration, infection and ultimately limb loss. Next please, when we're looking at temporal trends in geographic variation. Next, next slide, what we see is a large swath of the south having significant amounts of uh, this coordinate amputations compared to other parts of the country. Next, when we look, not only, um, in the United States, when we look inside specific states, this is north Carolina and what we see in the very dark areas are very underserved, totally underserved areas. The light rare, partially underserved and the actresses are where vascular surgeons are present. Um, there's a 29% incidents or uh or 29% increase in odds for amputation if you live in the wrong county. And it's surprising in modern modern day times that that could be the case, but where you live can predict a lot that happens to you next. Sometimes one of the problems is a concept of uh when were consulted, many of us are consulted for um for amputation of for these particular problems. But I think the hospitalist consult is wrong. It shouldn't be for amputations should be more for limb limb preservation. Next. Sometimes advanced elderly grandma has a small little uh gangrene on the, on the fifth toe. Does that necessitate? And above knee amputation? Every single time? I think not. I think things should be changed how we do this Or if someone has contractors. Uh is that an automatic amputation? Is that is that the next best thing for that person? Or can I actually walk Like we see in in this gentleman right here. Next, of course I'm not a nihilist. I'm a surgeon. There are times we need to do surgery where there's osteomyelitis or infected joint or this poor gentleman that lost um lost part of his foot. Next I think the philosophy philosophy should be no amputation for the diagnosis of ta be alone. Next. When we look at cost effective care in this paper, we saw a 10 year period of different various management strategies. And what they found was that revascularization and limb preservation attempts appear to be less costly and provide more health benefits than wound care alone or primary primary amputation alone. Um even among patients with marginal functional status at baseline and those are most of my patients, that's we look at the cli amputation and mortality rates. We see that they increase with disease that would be expected next. And also the cost burden increases with increasing increasing presentation for rougher class for interventional cardiac cardiac care versus uh cli. There's about a 1.5 factor difference in cost. So it's a very significant issue. That's however, it's surprising I think to many people. The amputation actually costs more than revascularization strategies and this has been shown in numerous studies Next the cli conundrum. Well, here's the problem. I live in the south is about 42% of all the amputations occur in Southern states and this is in the face of no attempt for revascularization is made in 60 to 73% of the cli patients. No angiogram is performed in 51 to 73% of patients, despite a 90% odd production for amputation reduction with intervention. So the solution for this multifactorial conundrum must be found by understanding the problem. And the cli conundrum is that ph d is under recognized and therefore undertreated. And so patients that have cli presents with um years of untreated medical risk factors and so they have very best disease. The other problem is the amputation is the gold standard and has been since the civil War for major limb trauma infection or gangrene. And that has been the answer for this problem. And I think that needs to change systemic ineffectiveness is um systems that don't work. The the the ability for hospitals to give the right type of equipment that you need need or the trouble of getting between position position offices or getting to see a specialist in time. And so these problems can also lead to hi amputation rates. One of the other problems, there's just not enough critical and specialists and people who are interested in this. I would encourage you to to learn this and live this. It's been it's been great for our patients and you must remember that we have to have a comprehensive cli program. You can't just be plumbers. It's not just about fixing the pipes. You've got to deal with the medical risk factors and their diabetes that are that's out of control next, please. So this is a unique challenge. The paradigm will only change when interventional care improves in the notion of no amputation allowed for the diagnosis of PTSD or CLI alone becomes routine. We have to foster vascular reconstructive knowledge for limb preservation in the bipac, in the vascular surgeon community with their material bypassing and property of the people bypassing interventional community for for trans collateral reconstruction and pedal luke reconstruction. Next please. In the era of covid 19 we've all seen early case cancellation and elective procedures being put off. But I think a bigger problem that we're all experiencing right now is the delayed interventions the patients not seeking medical care for the last six months. And then the fallout that happens right now with advanced disease. We have been seeing increased arterial thrombosis personally. I've talked to many colleagues around the world world and this is uh disturbing and prevalent in this in this community. Next place. Cli affects two million americans who are at risk for amputation. Um The this represents a unique interventional challenge with the fewest multi level arterial involvement and the infra Patil and below ankle. Um arteries, interventional success relies on relieving pain, healing wounds, in preventing amputations and having an amputation prevention program can reduce the occurrence of amputations and improve survival for your patients. And that is what we find next. Please, I'll leave you with this if you're interested in cli. No more. No more amputations. Thank you Philip. Next thank you so much, Doctor Lazar. So I'm curious, you know, and again I welcome the attendees to you can chime in a question um that we can, you know, we can always answer or we can always hold to the end if we don't get to all of them, but before we move over to dr walker, um you know, just that map that you put up with with north Carolina and the lack of providers in certain areas. Um you know, what do you do to try to reach out to those areas? Um that may not have the specialist, you know that that's there for those patients to go see. So is that something that that the four of you are are actively trying to do? How do you approach that? Well, it's a good it's a great question and it's it's quite real. We look at public health in general. We can look from a company or a countrywide perspective, which we showed that first draft and then you can look at the state level. Um, but we're also looking in my own county, um, within the county itself where you live, depends on on what care you are offered or given. So, one of the things that you would try to do is broader based educational events, um, uh, teaching of, of of the nurse practitioners and phds in the region, as well as primary care, what to look for, how to be involved. Um, and then general, um, you know, uh, any type of advertising we do for our group or is almost always tied with education and trying to get the awareness, um, that there are problems out there. And one of the things we do is something called flow. It's F. L. O. W. Feeling of pain in your extremities, loss of sensation. Open source that don't heal or wounds um that are present. Um If you have flow problems you need to see somebody. And so we try to get that educational piece out. That's how you deal with that. All right, thank you. So 11 question and then we will turn over to dr walker. Can you explain how it is that amputation costs more and leads to increase mortality over a vascular intervention? Well, I think as as an interventional list, one of the main things I'm trying to do as a surgeon is to get people to walk the active. If you can't walk and be active, you can't maintain normal cardiac health and overall health. And so I think walking in the active is critical to why we do things. Um amputations cost more because there's a number of factors that go with it. It's not just losing a leg, it's the cost of the prosthesis, it's the cost of multiple interventions sometimes where you have to redo surgery. Um, it is getting a wheelchair ramps and the loss of economic viability for these patients. So it's not just $40,000. If you look at these patients over a year, it's hundreds of thousands of dollars. It's a it's a lost potential, but it's also how do we deal with someone who cannot walk? It's the care issue. So it's it's a bigger, bigger, bigger piece of the pot. Great, thank you. So, in the interest of time, we we got another question and I would like the other faculty to chime in. But in the interest of time we'll move on to dr walker and then again, well, we can have more discussion and questions at the end. So we do have another polling question um to launch before he starts his presentations. If we could launch that polling question and this was on telehealth. So, you know, perhaps this is one of the ways that you could reach out to some of these underserved areas. So we would like to know, are you using telehealth today? Did you use it before? Covid are using it now, not using it or are you considering it devon? Who are you asking? Uh the audience? The audience. I know our panelists actually can't shine them in. We were blocked. We're not allowed to answer the polls, but if our audience will chime in, I see it, wow. And if we can go ahead and give dr walker control and show those results interesting. So it kind of gives us a little bit of some information of our of our background, of the post joining is made doctor, you should have control of the screen if you'd like to drive the sides and if if it doesn't work for you I can I can right. There you go. Great, well thank you very much devon and thank you to phillips for what I think is a really important practice and that is extending education out to healthcare providers. I deliberately did not chime in on that last question because I think that the way that we reach out to underserved areas is going to be a function of telehealth and I think it's going to be something that allows us to deliver better care, cheaper care and reach for more people. Now. Just to give you an idea when I started C. I. S in 1983 it was one young doctor, I don't know who the hell this guy is. We had two employees total and one little tiny location in this blue building. And as of uh april of 2019, we've already grown to 68 cardiologists, 45 nurse practitioners, 860 employees, 19 clinic locations. And by this point had nine tele cardiology programs. You can see a lot of patient visits and where these came from and a lot of hospital procedures. Uh Now we have bigger numbers than this but I don't have those most recently tabulated. So this shows you where our practice is in Louisiana and Mississippi right now and on the right you see a robot that we've used in some hospitals and we'll speak a little bit more about that. Now when I moved back home to start the CIA's program I wasn't very busy to start with. I have plenty time. And one of the things I wanted to do was I wanted to set a moral compass for our group. So I wrote a mission statement and this mission statement still stands in our building and it stands in each of our exam rooms and it stands in each of our physicians offices and each of our nurse practitioners offices. It is our idea that if we follow this plan and this pledge that we have to our patients that we could grow and achieve success. Now in sticking to this, we've had pretty good patient satisfaction. This is ranked based on organizations with a 50 to 100 employees. You can see that in the first quarter of 2020 we had a slight decrease in patient satisfaction. There were many factors involved in this, which included moving into some other buildings. There were some issues with that, some glitches in appointments, but in our most recent quarter, we're back up to the 100th percentile in terms of patient satisfaction. Our core business, in addition to what we do in the hospital consists of outpatient clinic, diagnostics, hospital, co management, research, education, virtual care. And uh now we have a nobel in S. C. Now we have recently seen tremendous changes in health care and certainly the coronavirus pandemic has been a big stimulus here, and many have talked about this saying we must change the way we deliver health care based on this. And others have come out and said maybe this could really help improve health care. And I think I might agree with both of these. And now there's a debate about how Covid 19 is changing health care. Covid is forcing our industry, the medical industry to reimagine health care delivery and say, can we do things better cheaper, please patients better. And I think telemedicine is important part of that now for those who believe that we're just beginning this change. Uh, that's just not the case. Medicine has changed CBS health and Aetna created a multibillion dollar merger to be able to start treating patients walmart uh, informs were saying you might go to walmart to see your doctor in the near future. Usa today talks about the new electronics involved in health care delivery, in how best buy is the source of that. Each of these articles talks about the fact that big business is looking at medicine saying, can we do it better cheaper with better patient satisfaction. So, there are many challenges that are creating these changes. Medicine is too expensive. There's too much friction between different departments and referrals and other problems and it's difficult sometimes for patients to come in. And so we're starting to see disruption from the outside. And the other thing that's happened. Certainly many specialties, we just simply don't have enough providers. And we're seeing burnout of providers who with you, medical record systems, et cetera. Just simply said, you know, I don't know if I want to keep practicing and we've seen many physicians retired in this area era. Now this slide had really caught my attention in the past and I said, you know, we have to do something about this, my practices all cardiologists, but you can see that which physicians burn out the most cardiologists are pretty high in this list. And when we looked at, why do people get burned out? You can see these things. And I think all of us can agree these are issues and certainly anything that we can do the lesson physician burnout. It is very important so that we can deliver health care. And specifically, we looked at too many bureaucratic task could we improve that spending too many hours at work. This affects our family and ultimately our health and happiness and increasing computerization of practice, the electronic health records. Can we do a better job? Can we achieve doing these with less time spent by a physician? So we decided we wanted to start a virtual practice. We didn't start this with Covid. Our plans for this began more than four years before Covid and our goals were quadruple. In terms of what we were hoping to achieve, we thought we could reach our goals and our mission statement by improving access to patients so that when a patient calls our group there immediately, speaking to a health care provider rather than a secretary who has to create a contact in another weathers. I'm lost that we could impact cost that we can improve quality because this increased access would help and at the same time help to prevent physician burnout. And we decided that virtual care was part of this solution. So we started a multimillion dollar project in the past. And this was our initial concept of how virtual care center would work. It would serve as the hub with spokes including clinic support service, tell a cardiology where the management bundled payment uh management so that we could make sure that we can lessen healthcare costs and patients undergoing things such as pacemakers or things such as um coronary interventions so that we could perform remote cumin and monitoring remote patient management will speak more about that as it relates to peripheral disease. Nocturnal call for our patients. So all call all nocturnal calls first. Go into our virtual care center. And what we have found is in about 80% of those calls are people who are on that night can handle the call really tremendously lessening the burden to our physicians on call. We've wanted to have virtual visits for patients who couldn't come in or many of our patients come from really far away so that we could reach them at any time. And finally, we wanted business intelligence. We wanted to understand how are you doing with this and get feedback? So this was our initial plan and I'll show you how this rolled out. So we decided to establish a comprehensive cardiovascular virtual care center. And we wanted a virtual care center prompted by high patient demand. So we have 17 clinics with all of which are busy. We wanted to improve efficiency and increased patient access. Um, We spent a lot of money doing this. Uh But I'll tell you when the time that covid came around, we were very happy we had done this because we did not see the same drop in patient volume that appears across the country did within one year. We were having 30,000 patient contacts per month out of 300,000 total patient visits across the system. And that's increasing ever since that time. And we can see that the virtual care centers staffed by five nurse practitioners, 34 are ends LP in telemetry tech. And these provide 24 7 care. And we use Ai algorithms to help us more in staffing. Nurse practitioners provide care remotely to nearly all patient requests. In 17 clinics we perform prescription refills, surgical clearance and certain allows us to take many of the things that take physicians time that really shouldn't and what we've seen with a 90% reduction in the time to respond to a patient problem, which of course patients like this now to pay for this, our individual clinics contribute to supporting this now. Uh we have 24 7 nursing an appointment access for patients, prescription refills, prior authorizations, patient problem handling, re surgical clearances. And we set up the patient appoint. You can see that with our telehealth system. We have multiple locations. We have nine hospital locations and we have our physicians who share call behind the nurse practitioners and we reach out to underserved areas. You can see here bastard winds berg the north of our state prairie ville galliano down on the gulf. These are smaller hospitals and via our robots that you see here in the telehealth system. We saved countless lives because we've expanded cardiology and cardiovascular expertise into these areas. There are many uses of tele cardiology as I see it. One of supporting rural hospitals that have limited cardiology coverage. Here's an example of the one I told you galley and our Lady of the Sea Hospital. Uh It's a very nice hospital, but it's very small. It does not have cardiology expertise and when patients come in with chest pain or other problems, the question is, must we transfer those patients right away and they invested in the robot and work with us with this. And how has it worked for them? Well, it resulted in them being able to keep eight out of 10 of the patients that they were contemplating transferring. It helped increase that small hospitals financial performance and it helped increase patient satisfaction. And that's certainly always a goal of ours. It also helps us in helping health systems better utilize bed capacity. So often we see hospitals that are on the verge. And one of a large major tertiary centres is Lafayette General Medical Center in Lafayette Louisiana. And we have smaller clinics. We end hospitals that we work with in Breaux Bridge in Crowley in Kaplan and L. G. M. C. Is constantly on the version. Can we help that with this? When we can 84% of the patients that were consulted on, get to remain in their local community, 16% transfer and when they do, we have pretty much easy transfer into the hospital, not just because it's not full because in first grading these patients, they know that they're getting someone that must be there. Other ways that it can help as it provides outpatient services and underserved markets with some specialty care. We provide surgical clearances for hospitals with limited cardiology coverage. We leverage telemedicine equipment to other services and allows us to beat by beat, look at what's happening to our critically ill patients. 24 7 and it dramatically improves physician quality of life. Made us travel much less now. What's happened with our tell a cardiology outcomes? Well, 45% of these come from emergency rooms, 55 from in patients. Eight hospitals, 830 consult and most of those stay in those hospitals for this program. Before Covid came up, we were given the telehealth leadership award several years back now in leveraging virtual care center, we wanted to determine what can we do without patients see and impatient to see as these are services which are now being bundled and often people exceed the bundled payment because if a patient goes home and calls his primary care doctor with shortness of breath, which maybe from ver Lanta or discomfort in the chest, which may be many things other than ischemia. There often sent emergency urgently into an emergency room. Often those are admitted tonight and of course costs spiral by having a cardiovascular specialists as the first person they contact and making that the path of least resistance. We've been able to dramatically less than those costs. And this year we were asked to speak to the A. C. C. Because our virtual care center working with our bundle care payments syndrome uh system had allowed us to achieve the number one ranking in that system in terms of limiting health care costs. Out of this, there were 700 patients and it saved almost $1.3 million for CMS. So what about leveraging this in peripheral vascular disease? We've started to do this. We'll use this to screen to determine the urgency of the problem. We get patients in from really all over the world and certainly all over the United States. It is important to note must we see that patient immediately? Do we have a week? Do we have a mouth? Very important when the patient comes? What are the appropriate diagnostic tests prior to the visit? So that the patient, if they're coming in particular from far away, you're not having to spend a week getting the test where we have those up front and can answer questions and with the procedures, making sure patients on the appropriate medicines prior to the intervention. This is very important and we have a virtual care call every patient before interventions and before diagnostic procedures. What we've found is often they're on medicines. They should not be, often they're not taking medicines they should be. And by changing this, it's improved that. It's helped by having 24 7 patient access to answer questions. We use this to follow wound healing management and if a patient has any issues, we have an app that allows them to take pictures, send them to us and we can do this in uh in a way that we do not violate medical rules. It ensures appropriate follow up testing. If we put in coverage stents, we make sure these stations have appropriate duplex ultrasound at appropriate intervals and make sure that we don't let anyone fall through the cracks, ensures appropriate medicines post as well as pre and it ensures that we achieve appropriate visit. So without a doubt, I'm convinced. Based on our experience with telemedicine, it's going to play an ever increasing role. I think this is one of the first things that we have dealt with. It not just improves care but really lures the cost of health care. Pre screening has become our practice now to decrease risk of infection spread, particularly with Covid. But now as we have started to use it here if patients have aggressive infections, we see them actually in another area that we can keep clean to lessen the risk of infection spread at our clinics. This has resulted in dramatically better patient satisfaction. Clearly much better patient access. It allows us algorithmic follow up on certain issues to make sure we need guidelines of management of cholesterol blood pressure. Other items such as drugs and patients should be on. It has drastically improved our physician quality of life to improve the hospital utilization. It's improved outcomes. And my only thing that I wish to tell the audience is you must be HIPPA compliance if you're going to do this. But I'm certain this represents a huge part of the future of medicine and the future of peripheral vascular medicine. And with that I'm happy to answer any questions that we may have out there. Thank you so much. Doctor walker. I do have one question on where you see, you know, and this is really kind of a hypothetical question. Um um but where you see, kind of, what's next for PhD with telehealth and you know, wearables, um is that going to come into play that we can really kind of monitor um blood flowed into the flight? Yeah, that's that's a great question. That future is kind of here is not right now with some of the new tools that we have, but, you know, even tools as simple as taking a picture can tell us an awful lot about urgency of situation, but is a wound healing, et cetera. Being able to speak to the patient or making sure there is communication. You know, we have many patients who call whenever there's anything that they feel. But there are many patients who don't call, even if things are getting terrible. Uh, what this does this allows us to stay in touch. There are many programs being looked at by many big companies now to actually let us look at blood flow to the foot. I think we'll see some of that in the future. We don't have that now in the hospitals. The we have access to every major test in those hospitals that we can see in real life time via the robots that we're using. It's really short of being able to palpate. We can do almost any other part of the physical exam that we would typically do with those patients. Oh, well, I have had the privilege of seeing your virtual care center firsthand tonight and it is, it is something I think people have to see to believe, kind of state of the art and how far ahead you are getting that in place. Um But you know, I've also had the privilege of going down to Dr Lazar Center. I haven't been to the Yates and dr Yates, the ambassador center to rush um much, but you know, so I know doctors or you're using telehealth and in some capacity as well. Um and I wonder from our other panelists just kind of, you know, how else you're using it did. Um So I don't know, it's just a quick, quick minute before we, before we segue into the next presentation of. So I think the uh it was very, very clear, it was it was a covid related event. Um and we um you know, we still care for a lot of people in this kind of broad region. Um And we we've done a lot more with telehealth in the last um really six months than we have had before. I think dr walker has had a lot of foresight in many different things. Um And and telehealth is definitely here for the future. It's the patients in like it they enjoy it, they get their questions answered um and they don't have to you know drive for an hour and a half and sit in the doctor's office and wait for the doctor to show up. So um it can be scheduled, it's pretty pretty standard routine and it seems to be more in line with what people are wanting. So I I think we're going to see definitely see more of this like dr walker said, I think it's the modern day home call that older doctors used to go into homes and visit patients. This is the way that we can make house calls in today's world. Virtual house calls completely agree. Yeah, that's great. Well, on that note, you know, so thinking about virtual house call, you know, virtual health calls and what might help patients and their quality of life. Well, we'll transition and switch gears over to dr Yates and Dr medicine very for their conversation and discussion. And I will preface this um their presentation by saying you'll see in their presentation there are moments where they're encouraging interactive chat. So please do you get your chaps can open and we really appreciate those, your opinions to chime in here. So with that I'll turn it over to you guys and I'll run your sites for you. Thank you so much today, Evan and phillips. Doctors ASAR and walker excellent talks is always uh captivating audience attention and really starting a wonderful discussion uh, and it's really a great privilege for me to be able to give this talk with an absolutely phenomenal interventional, also a good friend, Dr Kumar Monastery. So with that we'll try to respect your time here, but we did want to focus on some more thought provoking topics tonight and that uh, that of quality of life for our patients uh, in patients who do have a limited lifespan and significant impairment as well as the quality of life for a physician who have dedicated their life to the care of these patients. So next slide, it's okay, we can go forward. Next slide. So we've all had the Cape that's gone wrong and this is a gentleman that I had relatively recently and these are the cases we don't talk about at the conference is these are the cases we don't share with people, but I think it's very important for everyone in the audience to have that moment to realize that everybody has, these things happen to them. This is a 44 year old HIV positive gentleman, long term, highly active antiretroviral therapy as well as prior end stage renal disease, hemodialysis, then went to a kidney transplant, pre existing severe vascular disease that had gone sort of uncharted, complicated by his HIV. He presented to me and dire straits with severe gangrene in his both of his feet, the left horse in the right preferred by podiatrist. They had severe outflow obstruction failed people. Plants are loop reconstruction, failed, even a deep venous arterial ization. He had no bypassed target and unfortunately went on to require below the amputation and despite this being about 89 weeks ago has been very slow to heal his BK still is not on the prosthesis. So this is a very uh alive and very functional person. Very active gentleman. His life has been irreparably changed by his disease and unfortunately he also doesn't really have any insight into how he can alter his his disease management of diabetes et cetera hasn't really accepted it. So for both the patient obviously this has resulted in severe lifestyle restrictions but also for a position trying to take care of a patient as dr walker adequately said to do no harm. First this can be a big challenge. Next five. So a couple of just quick questions that we will bring up now and what resurface at the end of the first question where are the areas in your practice where you've seen the most negative impacts the quality of life and managing the P. D. Or critical impatient and what areas or what practices have you implemented in your office or hospital to most profoundly positively impact quality of life. Just keep those in the back of your mind and go ahead and comment as we move forward next life. So as we look a little bit at the what's been written about this topic, we're going to see some disparate results. The partners uh study was one that's often quoted uh and in the uh in this segment of the study they looked at health care health related quality of life between ph. D. Patient and compared those two other cardiovascular disease patients who didn't have for criteria disease. And one of the major take home point is that patients just with a diagnosis of materials do have as significant a disease burden and restriction of quality of life is that which we see and patients with cardiovascular and coronary and other through the vascular disease, a dramatic very National library. Thanks to, you know, great to have dr Lessard after walker and everybody else here. I kudos to phillips for putting this together. We're gonna keep this going here next slide. So, you know, what they look at in continuation of these articles is there's a lot of disregard incongruity between what the physician thinks is going with the patient versus what uh in terms of the clinical status versus what's the quality of life for that patient? I think all of us who treat these complex diseases, we kind of get tunnel vision into what we're doing and what we're treating. And we don't really see the impact on the quality of life for that patient. We see the clinical outcome. But what this kind of study from 2000 and six kind of realizes that the physician may be concerned with the physiological anatomical abnormality. While the patients really looking at the overall quality of life and I think that's something for us to take into consideration as we kind of progress here next slide please. Additionally, uh the study from a. M. A. Go back one. There we go. Sorry. Uh so looking here from JBs actually looking at the quality of life in terms of what the patient gets out of it from a physical mental evaluation for PhD. Um this was kind of, the separation was like, this was best predicted by what their function the physical function was. There wasn't really based on markers of PhD severity or co morbid conditions and what this kind of led to the the conclusion was that really are intervention should try to focus on what will improve the patient's quality of life um, next lead. And so in terms of patient's quality of life, what we need to understand is that we're going into a generation or another era of uh more and more elderly population. This is not going to decrease. We're going to see a lot more of the baby boomer generation. We're seeing a huge increase into our population patients that need better care. So the question becomes, what are we going to kind of look for? We're gonna look for immediate successes, or are we going to focus on the long term benefits these patients to improve their quality of life as we focus on keeping these patients alive and functioning better. So, I don't think our goal should be just immediate results is what's the long term results of what we do? So it's not always as much as what can we do is maybe when should we not do something that could negatively impact their life? I think that's where the goal of this is continuing on uh tim Yates. Perfect for the next slide. So another, another bit from this article from the American Medical Associate General of Ethics, the same exact article looked at some other factors that affect our patients and one of the key points that they brought up was that um oftentimes our interventions that are, and the way that we treat those patients really can't impact positively the underlying social familial and economic conditions that truly are limiting the patient's ability to heal poverty, nutrition, housing issues and family support structure can significantly alter an influence the post op period. Uh you know, we often see these patients, we treat them and send them home and everything's going to be great, but if they don't have the appropriate care, it's actually control uh in a way to get back and forth between appointments and to take their post particular medications. Ultimately, these will often fail. So, you know, some of these issues are going to be out of our ability to appropriately influence them next life. Another thing that we've seen this is from the european journal vascular surgery, looking at critical limb ischemia more specifically than ph d. Looking at amputation, I think Dr Schweitzer and dr walker appropriately talked about the severe restriction of quality of life, and these patients amputees have reported in there in the survey from this particular study, significantly more overall problems, those mobility, social isolation, lethargy, pain, sleep, and even emotional disturbances outside of their control. They found that their overall quality of life scores were significantly poor and the largest restricting factor was the inability to move so rehab. At the take home point from this article suggested that amputation patients should have a focus on attempts to improve ability in order to improve their subsequent quality of life forward. On the next line, another study, a systematic review looking at similar treatment modality actually resulted in the best outcomes that compared prospectively endovascular surgical revascularization, amputation or conservative therapy and found that overall any treatment was better than none, but that endovascular surgical revascularization ended up most positively affecting overall scores and quality of life. Uh And one of the points that they brought in from outside studies and their and their references was that overall quality of life. Uh scores tend to lack from a lot of our studies were focused on primary potency, secondary assisted pregnancies, etcetera, and superior or devices. Uh The patient element is often left out next life dr Madison if you want to continue their. So, in terms of, you know, discussing the quality of life, the questions we need to kind of address. Our depositions have responsibility not only to extend the life, but also improve their overall social circumstances that give the patient a better quality of life, not just the life. What is that life value for them? Uh Should we refrain when we know that their existence may not be a life worth living? I don't think we have that frank conversation enough with patients and their family members. I think as we as we try to get better at this, that's something we need to probe. So just example your patient, elderly patient demented patient alterations, infections to Cubans, ulcers in a nursing home with marginal resident conditions and care. What are we doing by improving just the wound and getting back to the same environment to have this recurring futile cycle. Um And then these drug eluting therapies and patients and rampant disease if they don't have the social economic understanding to obtain the actual post procedure medications that help extend the life, you know, what is the benefit of this? So there's some questions to ponder here as we move to the next slide please. At the same time, we gotta evaluate what about the physicians were taking on this burden. We all, as we've said before, we dedicate our lives. As we saw dr walker talk about how they're finding new ways to implement care to reach other people. This is what we all strive for. And as the slides were shown previously, you know, we're getting into burnout phases and a lot of specialties, all of us with all what we're inundated with. Next slide, please. So we look at this, the study looked at work life balance and you know when you look at this altogether. Ph. D. And C. L. A. Has obviously a poor prognosis worse for cli just like oncology and we call this arterial cancer. Death rates are high. Um And this puts a toll on the patients their family. But also all of us who deal with this because we want good outcomes. We want good results. That's not often going to be the case for some of these patients. But this requires keeping up with the integrity and duty while we do all these things. Um uh in families and homes currently unlike other generations there's two people working sometimes single caretakers. We all tend to choose. Work over family is often and we need to kind of re address that before we burn out completely. And we are the big gatekeepers for our patients for socially. So I think getting that balance is saying we need to work for a little bit better. Nothing that we were taught in med school properly. When you were a quiet life in medicine, surveys of physicians is 15,000 patients and many specialties. Um you know, it's not great. 23% of physicians are neutral to unhappy. That's not good to have a quart of your workforce in that situation. Look at this 2015 of a million patients. Uh 250,000 physicians are unhappy. That's not good. And dr walker uh touched on some of this earlier as well. Next slide please. Additionally, um when you talk about family relationships, 85% of physicians were married or in a committed relationship. Uh 7% signal, 6% divorce is just as physical analysis. Next slide please. Um and then also 84% of position. State of their marriage is good to very good, which is good to hear and actually better than um what the national polls for for non physician. So that's at least somewhat comforting. But I think we need to keep that consideration um, and dr gates will take over the rest here. Okay, So we can get perfect. So we found that about half of patients uh, that were a few, the providers that are working healthcare actually have a partner who's in health care. So there may be a correlation with the ability to live with a busy physician who has this sense of vocation uh, can go forward. And additionally, the majority of physicians surveyed in the 2019 Medicaid survey actually did. It's about some religious beliefs or spiritual beliefs, so that there may be a common thread uh, that uh, that we see among the patients, the physicians who are sort of making it through next line. Um When we look at time spent in the hospital or time spent outside of the practice, Over three quarters of physicians in the U. S. Spent up to no more than four weeks vacation per year in 2017. The meantime spent on vacation by physicians in the U. S. Was only 17 days next slide. And interestingly substance and alcohol abuse we do see in all specialties, all industries, all professions. Uh in this particular survey, only two out of three physicians reported drinking two or less drinks of alcohol per week. So uh whether or not you choose to believe those numbers as another point of contention, but uh next life um and uh interestingly physical activity, weight control, diet control. Uh been shown in multiple uh profession successful business people. Up to 50% of the physicians uh surveyed in this particular study were actively trying to lose weight. Well three of them were trying to maintain their weight and about 60% were reported working out at least 2 to 3 times per week trying to fit with that C. D. C. Recommendation of moderate to vigorous activity spent weekly next live. So what are some of the other things that we that we see? I think Dr barker hinted toward this are some of the managerial bureaucratic things that physicians get bogged down in and sort of some of the details and not the higher level thinking. I think it can take a toll. So one of the most common complaints we heard in this study actually was looking at that of administrative documentation activities. Um And when surveyed the practices that had ancillary services described services or other telemedicine services that help to augment the patients, physicians ability to get those sort of side tests done uh significantly improved their their uh happiness through throughout the course of their work. So the ability to say no and delicate responsibilities may help to improve productivity itself, satisfaction. Doctor matters here, you can take the next slide. Yeah, necessary please. So in terms of strategies for success, when you're trying to navigate the situation, um I think we have to think about how demand always outweighs the ability to perform and what the success is gonna be defined by us individual operator. A couple things they talk about for strategies to to work on this balance is do things that try to remind you of why you're doing this? Like what was your goal in getting this? What's your goal in treating patients with this? Um I think something that we really are not good at is time management, uh, that kind of helps you be more efficient and not waste your time on things that kind of take away from the precious time you do have. Prioritizing is something you have to do and you have to decide what is important, what's not. And I think as you get older and you progress, you're able to kind of execute that little better and reassess your life goals here and it kind of, that goes hand in hand, we'll figure out what your life goals were and how can you adjust, improvised? And I think the hardest thing we all have, we all have is to say no, I don't think any of us are good at that, especially on our stages. We say yes to everything because we want to help, we want to grow, we want to be available, but that's a hard lesson to understand. That's something we have to have next line. So, uh if anybody has questions in the chat regarding on this, what do you think is the single most important metric for quality of life and what has been most impactful in your practice? Um So, and thank you for that. I think there was a question, tim, I believe. Right? Yeah. So I think uh dr Bill julianna, fellow Floridian down here, has been a huge proponent for the outpatient practice in florida, has asked a couple of good questions, and I'm gonna try to start with the second question because I find it particular interesting. I think it made some very good points. Uh He says that uh HIV many of his HIV patients tend to have sort of weird ph d very advanced after sclerosis or strange arterial uh disease locations. Uh and uh you know, they're they're they're absorbed in their disease management with their antiretrovirals and just trying to keep those types of accounts under control are often completely unaware of how severe their vascular diseases. And so because of that and because we know that it's as providers and, for example, the case I presented, I presented for this exactly discussion, we have to do a better job of setting reasonable expectations with our patients to try to get them to have some insight into their disease whether or not they're aware of it, that sort of talk them through what they can expect. I think Dr Julian made a really great point that these are patients who have actually a significant risk of living off despite our intervention and we really want to make them aware of that risk before we intervene, so that we don't just look like the bad guy that was trying to be, you know, cowboy trying to help them. A lot of these patients are young and otherwise functional. So, you know, our our brain is set to be more aggressive on younger patients are functional, try to improve their quality of life. So doctors walker Lazar, what's been your practice? And how do you see an HIV affect peripheral disease and critical ischemia? Well, I have had a number of patients with HIV and I would agree, um, that there is a different pathology. There may be a vasculitis associated with this, maybe that's the wrong term, but something's definitely different about these patients and it's uh, it's a common were taken back and we're treating things again. And despite drug solution therapy, it doesn't work and we're doing it again. Um, so, you know, we we have a no quit motto here. We just don't quit until we we try to achieve for that patient. Um, but I think there's something true to Dr Julian's comment. He's on target with that. Yeah. Um We have another question from dr vargas, who says, do you refer end stage desert? Put patients with new revascularization options to palliative care. And when in your practice, who manages pain control and cli cases? What's the what's been the practice here, gentlemen? In terms of the Desert foot? If say diva is not an option. Yeah. Well, um, I deal with that as well. That's one of the main things we deal with in our our cli center. Um uh we're an Amputation prevention center. So we do offer, we try to do advanced endovascular therapy for the lower extremity material loop reconstructions, things like this. If you truly have a desert foot, uh and they're a viable candidate and they have, you know, they're just limited because of their leg, then we'll consider deep venous materialization. Um It's been effective in our practice for pain control wound healing. Um And then you have the patient that that truly um is not going to benefit from multiple procedures. You have to balance that. I think that you can operate too many times and lose a patient because you've had bad judgment. So, in some of those patients, it's a primary amputation and that's where we go, and that's that's their story. Um And then in patients where it's truly um uh you know, potentially abusive to that patient to continue to do surgery and treat them poorly, we get palliative care involved. And uh it maybe I've had patients where they have come out of palliative care because they're having horrible pain and you'll do the amputation to control pain. Um but, you know, you're not doing heroic kind of surgeries to try to um you know, fill quotas or do whatever, but you're really looking for that patient. Um the ultimate uh need of that patient. So proud of care can be very helpful, very good dr walker. Any additional points? Yeah, we have a very active pain management uh service in each of the areas that we are not not part of C. I. S. But these are people who can help, they can help with neural stimulators. They can manage the pain medications. You know, we really believe that relieving pain is a very crucial part of what we do. Quality of life is very important. So we take that part pretty seriously. So we do start patients that are having pain that nothing else can be done with medicines to help with pain. In addition, we really make sure that we've revved up everything we can from a medication perspective to make sure we're going to get slow in as best as we can. We ask patients to then cushion the foot to hopefully avoid skin breakdown and other issues, such as that. One of the things we also do is to encourage exercise even in the critical ischemic using their arms, not uh not legs, that's been shown to increase in the field growth factor and other things. And some of these patients sometimes achieve pain relief. So even in the most mormon patient, we often can get some substantial improvement by doing those. And, you know, we don't speak much about exercise therapy uh unless we see it in an editorial criticizing when it's not used, but by and large, uh upper arm work. And even in critical ischemic can help. And as I've said, certain clinical parameters have shown to be increased. But there are some patients who just have horrible pain. And towards that we have to take, take big bigger measures first pain management. And then if we cannot control things and sometimes that does require amputation, luckily it's seldom in our practice. Very good. Certain uh Dr monastery had to he actually called him from the hospital tonight and he texted that he had to um to go tend to an add on case a late case. But we did have a question um that I don't know if we quite address Dr Julian's first question about mobiles in the remote areas. Um, and, you know, with all of you having RBL based practices, I wonder if you could speak to that. I think I think actually, I think what I understood was a mobile office interventional suite. So a trailer with the ability to do cases is what I understood and dr Julian, please correct me if that's not the case. And I privately sent him a response. I think everyone here uh is very aware of the underserved communities and I think that this idea has probably occurred to each one of us here. I just don't know you know personally what the legal ramifications are in terms of coverage, hospital privileges, transfer agreements, et cetera, to be in all of these remote location. Uh dr walker's been in this game for some time, I don't know, craig and in uh Louisiana, you know, legislation different in florida. But how would you, how could you conceptualize something like this in Louisiana? Well, we thought about this in the past. The problem that I have is a cath lab is not just a doctor, it's a full team, it's a, it's a lot of people with great skill set, it's a recovery area that needs to be present and I think it's kind of tough to take some of this stuff on in the mobile fashion. In addition to that, I worked for a short time and some of the hospitals that we had with mobile labs as things were being brought in and typically imaging is is not quite of the same quality as I said that the space is a little less up. I'm disinclined to do that. We are reaching to these people to where we can manage problems if it is just for an intervention that they have to travel. I think that's a lot easier than an amputation. And so you know, I would tend to keep a real high quality, high volume center that can do things with a lot of equipment on standby, where you're not limited by what you have and you have perfect imaging all the tools that you need. I probably prefer that route well and maybe a potentially more economically viable approach to having the mobile lab with all of the, as you mentioned, dr walker, all the staff and ensuring quality as you're moving, maybe just setting up a program for transporting patients for that intervention, uh doing the rest of your care by telehealth, sort of limit their travel. As we know, they do have limited mobility that may be a more viable approach that keep the qualities same with each patient has come to your senses. We are doing that now, exactly what you just said and we think that's worked pretty well. It's patients like, yep. Yeah, well, again, thank you so much for all of your for all of your time and dialogue tonight. Um we don't have any more questions that have come in through the chat or the community at this point and we have, we have taken more of your time than we had originally scheduled. You know, we said we would stay on for a little a few extra minutes here, um, but if there aren't any more questions, um I will, I'll leave with this final thought that again, this was the kickoff session, um that this is a series throughout september and that all three of you will hopefully, you know, be joining us later in the month um with our our subsequent sessions and um live cases, more discussion on the utilization of different technology and you know, different settings and and morphology um and so it's certainly a a month long of learning. We're hoping during PhD awareness month this september and we just really appreciate all of your time and effort that you've put into tonight and again the rest of the month as well. So, um, I welcome any final comments from you, um, if you have any or if you want to say good night, but, but again, thank you so much from, from my part. Thank you Philips. Thank you for putting this on. This was this was very appropriate. I agree. Thank you so much. Thank you. Well, we'll see you next week. Come join us next week. Thank you. I'm