Updated: Mar 11, 2019
Developing a steady referral network can be one of the most challenging parts of picking up a new procedure. Prostatic artery embolization (PAE) experts Dr. Ari Isaacson and Dr. Sandeep Bagla share how they built up benign prostatic hyperplasia (BPH) referral from urologists and primary care physicians.
The BackTable Brief
Urologists and primary care physicians tend to be the most opportune referrers of benign prostatic hyperplasia (BPH) patients.
To secure referrals early on, it’s important to articulate the differentiated value of prostatic artery embolization (PAE) in patients with hematuria, very large prostates, coagulopathy, and other contraindications to transurethral resection (TURP).
Keeping your local urologist involved with pre- and post-procedure management can help solidify your BPH referral network.
Individuals with BPH may also self-refer to interventionalists offering PAE, seeking alternatives to TURP. These patients tend to be more inquisitive and seek to understand the advantages of PAE over alternatives.
Disclaimer: The opinions expressed by the participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
The Importance of Partnering with Your Local Urologists
Now, Ari, when I was a fellow, when we had these patients, we would do most of the pre-procedure workup and the follow-up, but I was really impressed with this system that you all developed at UNC. This collaborative partnership with urology, it's both innovative and it seemed to be ideal for both patients, and physicians.
Could you share with us how that works, how it got started, and how you guys as a team managed the patient before and after the procedure?
Yeah, absolutely. From the very beginning, I didn't want my interest in PAE to be a threat to urology, I wanted to try to approach it in a collaborative way, and get them on board, so they could see the benefit of it for them in the long run. From the very beginning, when I started the clinical trial, I asked one of the urologists to be my co-investigator. I had every patient who we enrolled in the trial, see urology for about four or five visits, associated with the trial, including a cystoscopy. They're getting a good volume of business from this trial.
That made it a legitimate treatment in their eyes, and they got to see firsthand the results of it. When patients did better, they were coming in and seeing urologists ... It's hard to be skeptical when you're seeing the patients yourself.
Then, I was able to present all the data, and the background on the procedure, at Urology Grand Rounds, at UNC. That helped spread it as well. Since then, they've become believers, in the sense that they've seen the data, they've seen the patients, so they understand the value of it, and have started sending patients my way.
I also thought you made an interesting point that this allows urologists to retain patients, who otherwise might have been lost to follow-up, so they really get to keep their patient population.
Acquiring BPH Patients in a Private Practice Setting
Getting across this bridge with urology has been my greatest challenge, since I'm not doing any clinical trials, and I’m private practice. Do you have any recommendations for how to approach a urology practice, to push this as a collaborative partnership?
I think Sonny could probably speak to this a little better, because he functions out of private practice. But, I think the key when you're starting out, is to really emphasize the holes you can fill with the procedure.
You don't wanna approach urologists, and say, "I have a treatment that's far better than anything else you can offer for BPH.", but rather, you'd wanna say, "I have a treatment that can treat hematuria. I have a treatment that can treat very large prostates, that you may not want to TURP. I have a treatment that can be useful in the setting of coagulopathy, or being on medications."
I think that's the emphasis you wanna go with. Sonny could probably speak to that a little more.
Yeah. I'd love that, Sonny. I'd also like to hear, for the patients that you do get from primary care physicians, if you are having them see urology before the procedure.
Sure. Couple things. Similar to Ari, we've launched our clinical trial back in 2011. We did the same exact thing. Urology was involved, in terms of being an investigator. Not only on the clinical study, but actually seeing and evaluating every patient that we were enrolling, and even screening, for that fact.
Similarly, now, almost invariably, all patients who come to us, even through primary care, have been evaluated by urology in some form or another. I think that is important. I wouldn't say that it's an absolute. The same goes for anything that we do, as interventional radiologists, we often times sell ourselves short, as not being able to, say, manage clinical medicine.
With, say, for example, a urologic patient, depending on the community you're practicing in, many urologic disorders, specifically BPH for example, are managed wholly by internal medicine physicians, and primary practice physicians, and really only referred to urologists when there is a need for surgical intervention.
Whether it's a medical management workup evaluation, et cetera, it is important for interventionalists to really feel comfortable, and knowledgeable, about the entire BPH spectrum, and how to manage the patient, whether it be watchful waiting, whether it be lifestyle modification. I think that the more you feel comfortable managing a BPH patient as a whole, the less you may rely on a patient to see a urologist. That doesn't imply that there should not be a collaborative network, or framework, for how you build a PAE practice.
What's important to take away from that, is that interventional radiologists are capable of managing these patients, both independently, and with the help of both urology, and primary care. I think that's an important concept for interventionalists to really get a hold of.
Differentiating the Utility of Prostatic Artery Embolization in Unique Patient Populations
Now, Sonny, is there a typical type of patient that you see pretty frequently? The ones that get referred to you for this procedure.
Yeah. The ones that typically get referred, are the ones, like Ari mentioned, that we go out and promote to be their urologist, or primary care doctors, that we should be seeing. Those are the patients, like Ari mentioned, who had a recent MI, they're on Plavix, for example, they're not gonna get a transurethral procedure for that reason. The patients have a very large prostate, or have some contraindication to surgery general anesthesia, et cetera. Those are the types of patients, who I think are very typical from the referred patients. The patients that other doctors are seeing, and say, "Hey this would be great for PAE.", because their traditional transurethral surgery may not be ideal for them.
The other patient population that comes to interventionalists, and I think as the procedure becomes more widely recognized, will be directly referred patients. Those patients who come direct to interventionalists ... They're a different patient population, because they themselves are seeking out an alternative option, which is very different from someone, of course, who comes by way of their physician. That type of patient population, is someone who's much more inquisitive, asks numerous questions, would love to have comparative data, and/or a good understanding at how PAE compares to former typical procedures. They're a much more inquisitive bunch. How to handle these two different patient populations is an important skill to learn.
Dr. Sandeep Bagla is a practicing interventional radiologist with the Vascular Institute of Virginia.
Dr. Ari Isaacson is a practicing interventional radiologist with the UNC Department of Radiology in North Carolina.
Dr. Michael Barraza is a practicing interventional radiologist with Radiology Alliance in Nashville.
Cite this podcast:
BackTable, LLC (Producer). (2017, November 27). Ep 17 – Prostate Artery Embolizations [Audio podcast]. Retrieved from https://www.backtable.com/podcasts
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