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• W3022851483 abstract "Although to those sitting in the audience the traditional gratitude toward the society, mentors and family can seem at times hackneyed and repetitive, I can tell you that it is by no means so. In preparing for this talk, which has frankly been one of the more difficult endeavors of my career, gratitude and humility are a constant accompaniment. I am grateful to the New England Society for Vascular Surgery for helping nurture my early academic and clinical career and for introducing me to an outstanding group of professional colleagues of the highest caliber, many of whom I cherish as personal friends. The honor of having been elected to serve on the Executive Committee as Secretary, and now as I reach the end of my Presidential year, will serve as my highest professional achievement. When I look at the list of those who have held those offices before, I am grateful and humbled. I count many individuals as critical mentors over the years, and acknowledging each would take us into the early morning hours, but I wish to single out a few, all of whom, ironically, had ties to New England vascular surgery before I even contemplated a move here. As a third-year medical student on a Navy scholarship, I spent two clinical rotations at Portsmouth Naval hospital, where my love of surgery and my passion for vascular surgery were cemented. I had the honor of working on the Vascular Surgery Service, whose attending was a bright, energetic, inquisitive, and skilled surgeon who had just completed his fellowship at the Peter Bent Brigham Hospital, Past President Andy Whittemore (Fig 1). His influence through example has attended my entire career. I obtained fellowship training at the University of Cincinnati under the leadership of Dick Kempczinski (Fig 2), a Harvard-trained surgeon who was making a mark in academic vascular surgery but never lost his Massachusetts General Hospital roots. He taught me precision and perfection in technique, a rigorous adherence to scientific method, and a strict intellectual honesty, even when subsequent investigations called into question theories we thought we had proved. As many of you know, he was the victim of an unfortunate bodysurfing injury that left him paralyzed in 1994. We remain in touch, but it is the memories of his presence in the operating room and in the laboratory that continue to shape my thinking. When I accepted a faculty appointment at Brown in1991 and began my academic career at the Miriam Hospital, I met Past President Bob Hopkins (Fig 3), whose unfortunate passing this year is commemorated in your program. Bob was a compendium of Brown and Rhode Island surgical history, a true gentleman, and shared my love and interest in the vascular laboratory and hemodynamics. He is the only surgeon I know who would recalculate the velocity obtained in a stenosis if he felt the insonation angle theta was incorrect. He is sorely missed. Brown does not have a fellowship program, but we have a robust medical school and surgical residency, and I have been privileged to work with some incredibly bright and challenging students and house staff over the years. We have placed many in some of the most prestigious training programs in the country, and it always gives me pleasure to hear of their success from their program directors, fellow faculty, and partners. My family and extended family, children, and grandchildren, which Patty and I have brought together in a far flung and constantly evolving opera, are a constant source of pride, wonderment, and joy. In particular, my daughter Kate and her husband Mike, living in D.C. and raising Sebastian and Natalie through the wonder years, and Charles and his wife Leslie, moving most improbably to New Orleans, where he pursues a residency in plastic and reconstructive surgery, keep me grounded and honest. Patty's daughter Jesse and her husband Robb get the family award for farthest traveled, having come from North Carolina to attend. My wife Patty is the most amazing person I know—loving, humble, firm, intelligent, professional, and most of all, tolerant of her continuous improvement project, me. As you learned from Roger's overly complimentary introduction, I was an English major during my undergraduate years at Emory, with a particular interest in 18th and 19th century British and American authors. Thus I turned to some of my favorites for inspiration. With a direct descendant of Melville as our 24th Society President, it would be inappropriate to use Moby Dick as a template. Middlemarch is too obscure, and although a Tale of Two Cities is a useful metaphor for the difference between cardiac surgery and vascular surgery, that also seemed too facile. Therefore, I have turned to Jonathan Swift, and more specifically to his brief essay, “A Modest Proposal” (Fig 4) for my theme. Swift published the tract, the full title of which is “A Modest Proposal for Preventing the Children of Poor People From Being a Burthen to Their Parents or Country, and for Making Them Beneficial to the Publick” anonymously in 1729.1Swift J. A modest proposal for preventing the children of poor people from being a burthen to their parents or country, and for making them beneficial to the publick. J. Roberts, Dublin1729Google Scholar In it he outlines several logical proposals to deal with the plight of the starving Irish, population control, economic hardship, and improving the lot of the upper class. Along those lines, and in keeping with my lifelong professional interest in the management of claudication, I have reviewed what I see as the current state of affairs in the treatment of patients with claudication, also known as the assault on the superficial femoral artery (SFA). We have been inundated by numerous strategies to deal with that pesky vessel—drug-eluting balloons and stents for stenoses, lasers, atherectomy devices, crossing wires for chronic total occlusions, retrograde pedal access for the most stubborn lesions. And for what? Patency rates of 73% at 1 year and 64% at 3 years, with a dismal 33% at 7 years.2Stavroulakis K. Torsello G. Manal A. Schwindt A. Hericks C. Stachmann A. et al.Results of primary stent therapy for femoropopliteal peripheral arterial disease at 7 years.J Vasc Surg. 2016; 64: 1696-1702Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Early reintervention rates for secondary patency of 38%, amputation rates as high as 8%.3Kayssi A. Al-Atassi T. Oreopoulos G. Roche-Nagle G. Tan Kong T. Rajan Dheeraj K. Drug-eluting balloon angioplasty versus non- stenting balloon angioplasty for peripheral arterial disease of the lower limbs.Cochrane Database Syst Rev. 2014; 10: CD011319Google Scholar For a patient who has undergone laser recanalization of a chronically occluded SFA, followed by atherectomy with a distal protection device, balloon angioplasty in preparation for drug-eluting balloon therapy, with a drug-eluting stent as a bailout for dissection, all guided by intravascular ultrasound imaging, the cost of such a primary procedure in devices alone exceeds $10,000.00. A study from our own Vascular Study Group of New England by Jones et al4Jones D.W. Schanzer A. Zhao Y. MacKenzie T.A. Nolan B.W. Conte M.S. et al.Growing impact of restenosis on the surgical treatment of peripheral arterial disease.J Am Heart Assoc. 2013; 2: e000345Crossref Scopus (51) Google Scholar found an increase in secondary revascularization because of a failed previous endovascular intervention for claudication from 13% in 2003 to 22% in 2011. These were associated with higher rates of graft failure, morbidity, and mortality than the initial (primary) revascularization. This may underestimate the true rate of revascularization after a failed intervention, because patients presenting with critical limb ischemia after an initial procedure for claudication are included in a different category. The authors suggest indirect evidence of a “treatment trap,” where an initially liberal application of percutaneous intervention for claudication results in an escalating number of secondary procedures with increasingly poor outcomes. Swift's proposed solution for the ills he addressed was simple and elegant—to sell 1-year-old children, properly fattened and maintained, to be roasted by the wealthy as a delicacy. “I have been assured by a very knowing American of my acquaintance in London a young healthy child well nursed, is, at a year old, a most delicious nourishing and wholesome food, whether stewed, roasted, baked, or boiled; and I make no doubt that it will equally serve in a fricassee or a ragout.” Along those lines, I suggest we substitute this expensive and, some would suggest, futile approach to the SFA with a simple, and economically sound approach—primary below-knee amputation. Clearly, you approach this suggestion with alarm, because we all know the poor outlook of major amputation in our elderly, debilitated population, but those numbers come from patients with critical limb ischemia, failed attempts at limb salvage, and the unfortunate few who suffer major amputation as the endgame of interventions initially performed for claudication. But consider the high success rates of amputation healing and rehabilitation for nonvascular, elective procedures or for trauma in otherwise healthy patients, which better reflects the population of patients with intermittent claudication who, without the burden of previous interventional therapies, have a high likelihood of primary healing and prosthetic ambulation, with complete and final resolution of their symptoms. From the American Orthopedic Foot & Ankle Society website (http://www.aofas.org/footcaremd/treatments/Pages/Below-Knee-Amputation.aspx), “Patients are often able to return to the level of activity they had prior to amputation. An amputation may even allow a higher level of activity such as brisk walking or even running.” With modern prosthetics they may even achieve feats previously unattainable by them. And from the position of the surgeon, we substitute a relatively brief and stress-free operation with optimal relative value unit reimbursement for a sometimes lengthy procedure that places us at risk for radiation-induced injury and stress injury from lead aprons, which, in a setting outside of the dreaded office-based laboratory, pays very little. In addition, a major unilateral amputation for claudication would likely discourage a patient from seeking intervention for the other limb, resulting in further cost savings to our cash-strapped health care system. I have neither the wit nor the ability to sustain the irony achieved by Swift, whose real suggestions for a solution were outlined in a paralipsis, in part: “Therefore let no man talk to me of other expedients: Of taxing our absentees… Of utterly rejecting the materials and instruments that promote foreign luxury: Of curing the expensiveness of pride, vanity, idleness, and gaming… Of introducing a vein of parsimony, prudence and temperance: Of learning to love our country… Of quitting our animosities and factions…” Instead, I will take a more serious tone, and actually outline a true modest proposal for managing claudication in the 21st century. Exercise therapy, offered and reimbursed. I believe the first published extensive investigation of the natural history of claudication was by Boyd5Boyd A.M. Obstruction of the lower limb arteries.Proc R Soc Med. 1962; 55: 591-593PubMed Google Scholar in 1962 in the Proceedings of the Royal Society of Medicine, reviewing the natural history of claudication in 1508 patients, with a remarkable complete 10-year follow-up of 1476. A reading of this treatise is interesting and prophetic. It emphasizes how far we have come in the interventional management of arterial disease, as bypass was in its infancy, lumbar ganglionectomies and a few tenotomies of the tendo Achillis were primarily used, and patients aged >65 years were deemed unsuitable for a major operation. He did, however, recognize the implications of associated diseases of atherosclerosis, with a 5-year mortality in different age groups of 10% to 60% and a 10-year mortality of 23% to 100%, with 84% due to atherosclerotic complications (myocardial infarction, stroke, aneurysm rupture). He speculates on the need for multiple operations to maintain “normal” circulation, and states “The net result is that eliciting the help of the surgeon to fight the ravages of increasing age is a chancy business.” An observational study by McAllister6McAllister F.F. The fate of patients with intermittent claudication managed nonoperatively.Am J Surg. 1976; 132: 593-595Abstract Full Text PDF PubMed Scopus (90) Google Scholar reported in 1976 that 100 patients with arterial disease, predominantly with claudication but some with more advanced symptoms, had improvement or stability of symptoms at 6 years of 78%, with only seven amputations (six in patients with diabetes). Past President Cronenwett reported a less favorable outcome in 91 Veterans Affairs patients monitored for 2.5 years,7Cronenwett J.L. Warner K.G. Zelenock G.B. Whitehouse W.M. Graham L.M. Lindenauer S.M. et al.Intermittent claudication. Current results of nonoperative management.Arch Surg. 1984; 119: 430-436Crossref PubMed Scopus (155) Google Scholar with 60% reporting worsening symptoms and an annual intervention rate of 9%. He noted, however, that major daily exercise was associated with stable claudication. Fowl et al,8Fowl R.J. Gewirtz R.J. Love M.C. Kempczinski R.F. Natural history of claudicants with critical hemodynamic indices.Ann Vasc Surg. 1992; 6: 31-33Abstract Full Text PDF PubMed Scopus (13) Google Scholar from my fellowship alma mater, evaluated a more challenging population of patients with claudication as their sole complaint despite noninvasive vascular studies consistent with critical limb ischemia. Even with objective hemodynamic evidence of severe disease, >50% never progressed beyond claudication as a complaint, with an amputation rate of 8% caused by progression and failure of limb salvage surgery. And with regard to the patent's greatest fear, major amputation, the lifetime risk of amputation with untreated claudication is 2% to 4% So, with a relatively benign natural history with regard to progression to limb-threatening ischemia, what alternatives are there for relief of the symptoms that can range from annoyance to debilitating, as seen through the eyes of our patients? I will not go into pharmacologic therapy, which has had some modest, if variable, success, or the intriguing but rarely offered intermittent pneumatic limb compression,9Porter J.M. Pneumatic limb compression: a free lunch?.J Vasc Surg. 2000; 31: 821-822Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar but will direct your attention to exercise therapy. The first published article I have found investigating the use of exercise therapy for treatment of intermittent claudication was by Larsen and Lassen10Larsen A. Lassen N.A. Effect of daily muscular exercise in patients with intermittent claudication.Lancet. 1966; 288: 1093-1095Abstract Google Scholar in 1966, a randomized controlled trial of 14 patients, seven of whom were prescribed daily exercise to tolerance and the other seven given a placebo tablet without further instructions. The exercise group experienced a 300% improvement in objective treadmill walking, while the placebo group had no discernible change. Tellingly, a discussant for the paper noted that in the 3 years after conservative therapy for intermittent claudication was instituted at his own institution, the rate of operations dropped to 10% of the preceding 3 years, and that “seldom is there any need for surgery… a painful concession for a surgeon.” Numerous studies of medically supervised exercise have been performed over the years, with surprisingly consistent results given the increasing age and frailty of the population with peripheral arterial diseases. The most recent meta-analysis of supervised exercise included 28 randomized controlled trials of supervised exercise compared with at least one other modality.11Gommans L.N. Saarloos R. Scheltinga M.R. Houterman S. De Bie R.A. Fokkenrood H.J. et al.Editor’s choice - The effect of supervision on walking distance in patients with intermittent claudication: a meta-analysis.Eur J Vasc Endovasc Surg. 2014; 48: 169-184Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Comparing levels of intervention (none, medical advice, home-based exercise, and medically supervised therapy), they concluded that increasing levels of supervision resulted in significant improvement in objective performance. Interestingly in the meta-analysis, home-based exercise improvement at 6 months of follow-up approached that of supervised exercise, with the caveat that the degree of support and intervention for the home-based programs in these studies was variable, and in some instances, intensive. Which leads us to examine the role of alternatives to supervised programs. In his recent review of exercise therapy, Gardner12Gardner A.W. Exercise rehabilitation for peripheral artery disease: an exercise physiology perspective with special emphasis on the emerging trend of home-based exercise.Vasa. 2015; 44: 405-417Crossref PubMed Scopus (21) Google Scholar analyzed contemporary randomized controlled trials of minimally supervised home-based exercise programs and found, with a single exception, that the most recent controlled studies demonstrate significant improvement over controls in various measures of walking ability and quality of life. Interestingly, Gardner and Poehlman13Gardner A.W. Poehlman E.T. Exercise rehabilitation programs for the treatment of claudication pain. A meta-analysis.JAMA. 1995; 274: 975-980Crossref PubMed Google Scholar found in another study that the home group performed better on the 6-minute walk test than the supervised group, suggesting that treadmill training may not translate as well to community walking, an observation I have made in the clinical provision of supervised exercise. In our own program,14Patterson R.B. Colucci A.M. Braun C.M. The current role of a supervised exercise program as therapy for arterial claudication.Adv Vasc Surg. 1999; 7: 147-166Google Scholar we encouraged our patients to supplement their supervised exercise with community walking, but found that because they were “going to the gym,” the patients had little enthusiasm to add extra dedicated exercise outside the facility. Arguably the most ambitious and comprehensive attempt at providing high-quality outpatient exercise therapy in the community is evolving in Denmark,15Lauret G.J. Gijsbers H.J. Hendriks E.J. Bartelink M.L. de Bie R.A. Teijink J.A. The ClaudicatioNet concept: design of a national integrated care network providing active and healthy aging for patients with intermittent claudication.Vasc Health Risk Manag. 2012; 8: 495-503Crossref PubMed Scopus (23) Google Scholar where they have instituted a program called ClaudicationNet, a charitable foundation (www.claudicationet.nl) started in 2011 to initiate regional care networks between specially trained physical therapists, central caregivers, and vascular surgeons. After initiation of a network, general practitioners and vascular surgeons are able to use the network's infrastructure. They rely on physical therapists who obtain special training in supervised exercise as well as risk factor modification and “motivational interviewing.” Numerous studies have attempted to compare exercise therapy with intervention, many with results favoring exercise.16Creasy T.S. McMillan P.J. Fletcher E.W. Collin J. Morris P.J. Is percutaneous transluminal angioplasty better than exercise for claudication? Preliminary results from a prospective randomised trial.Eur J Vasc Surg. 1990; 4: 135-140Abstract Full Text PDF PubMed Scopus (180) Google Scholar, 17Perkins J.M. Collin J. Creasy T.S. Fletcher E.W. Morris P.J. Exercise training versus angioplasty for stable claudication. Long and medium term results of a prospective, randomised trial.Eur J Vasc Endovasc Surg. 1996; 11: 409-413Abstract Full Text PDF PubMed Scopus (192) Google Scholar The most recent, tightly controlled trial, Claudication: Exercise vs Endoluminal Revascularization (CLEVER),18Murphy T.P. Cutlip D.E. Regensteiner J.G. Mohler E.R. Cohen D.J. Reynolds M.R. et al.Supervised exercise, stent revascularization, or medical therapy for claudication due to aortoiliac peripheral artery disease: the CLEVER study.J Am Coll Cardiol. 2015; 65: 999-1009Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar has reported 18-month results that continue to support the durability and success of supervised exercise. Fakhry et al19Fakhry F. Rouwet E.V. Den Hoed P.T. Hunink M.G. Spronk S. Long-term clinical effectiveness of supervised exercise therapy versus endovascular revascularization for intermittent claudication from a randomized clinical trial.Br J Surg. 2013; 100: 1164-1171Crossref PubMed Scopus (64) Google Scholar reported 7-year outcomes of a randomized trial of supervised exercise vs intervention first and found no difference in functional performance or quality of life, Although 53% of the group initially randomized to exercise underwent a subsequent intervention, the intervention-first cohort underwent a significantly greater number of both endovascular and surgical primary and secondary procedures. Of note, the only major amputations (3 of 75) occurred in the intervention-first group. Exercise combined with intervention was prospectively studied by Lundgren and Dahllöf,20Lundgren F. Dahllöf A. Intermittent claudication-surgical reconstruction or physical training? A prospective randomized trial of treatment efficiency.Ann Surg. 1989; 209: 346-355Crossref PubMed Scopus (194) Google Scholar who found the combination to be superior to exercise or intervention alone. More recently, Fakhry et al21Fakhry F. Spronk S. van der Laan L. Wever J.J. Teijink J.A. Hoffmann W.H. et al.Endovascular revascularization and supervised exercise for peripheral artery disease and intermittent claudication.JAMA. 2015; 314: 1936-1944Crossref PubMed Scopus (158) Google Scholar reported the 12-month findings of the Endovascular Revascularization And Supervised Exercise (ERASE) study, a prospective randomized trial of exercise alone or intervention and exercise combined. Not surprisingly, at 12 months they found the combination therapy patients had better performance in walking distance and quality of life measures. The accompanying editorial by McDermott22McDermott M. Erasing disability in peripheral artery disease: the role of endovascular procedures and supervised exercise.JAMA. 2015; 314: 1921-1923Crossref PubMed Scopus (7) Google Scholar cautions against too much enthusiasm for this approach with only 12-month follow-up, because the parameters began to merge at that time period, and warned about the potential “downstream effects” of late failure of intervention. No current discussion of therapies can ignore the escalation of health care expenditures, much of it attributable to implant expenses (Fig 5), as well as the recognition, long acknowledged by surgeons, that quality of outcome is as critical as cost. Numerous studies have evaluated the costs of supervised exercise compared with both usual practice and intervention. Investigating supervised exercise vs unsupervised exercise using an extensive review of the available literature with a Markov model, Bermingham et al23Bermingham S.L. Sparrow K. Mullis R. Fox M. Shearman C. BradburyA et al.The cost-effectiveness of supervised exercise for the treatment of intermittent claudication.Eur J Vasc Endovasc Surg. 2013; 46: 707-714Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar demonstrated in 75% of simulations that supervised exercise had a cost of £711 to £1608 per quality-adjusted life-year (QALY) gained and would be considered highly cost-effective by policy makers worldwide. They also imputed health benefits beyond claudication relief to their exercise model, an interesting argument that is lacking in studies focused on claudication alone. When compared with supervised exercise, “go home and walk” advice is much less effective, but not surprisingly substantially less costly, and the benefit of supervised exercise is dependent on the willingness to pay threshold.24van Asselt A.D. Nicolai S.P. Joore M.A. Prins M.H. Teijink J.A. Cost-effectiveness of exercise therapy in patients with intermittent claudication: supervised exercise therapy versus a “go home and walk” advice.Eur J Vasc Endovasc Surg. 2011; 41: 97-103Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar When compared with percutaneous intervention, however, the differences are substantial. Using a very robust Markov modeling, van den Houten et al25van den Houten M.M. Lauret G.J. Fakhry F. Fokkenrood H.J. van Asselt A.D. Hunink M.G. et al.Cost-effectiveness of supervised exercise therapy compared with endovascular revascularization for intermittent claudication.Br J Surg. 2016; 103: 1616-1625Crossref PubMed Scopus (25) Google Scholar found intervention to be €91,600 more per QALY. In a prospective randomized study of exercise vs intervention with carefully documented costs extending beyond the initial therapy, Spronk et al26Spronk S. Bosch J.L. den Hoed P.T. Veen H.F. Pattynama P.M. Hunink M.G. Cost-effectiveness of endovascular revascularization compared to supervised hospital-based exercise training in patients with intermittent claudication: a randomized controlled trial.J Vasc Surg. 2008; 48: 1472-1480Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar found no significant difference in clinical outcomes at 12 months, but the mean incremental cost-effectiveness ratio was €231,800 per QALY favoring exercise. Reviewing the costs of a prospective trial of exercise, angioplasty, and combination therapy, Mazari et al27Mazari F.A. Khan J.A. Carradice D. Samuel N. Gohil R. McCollum P.T. et al.Economic analysis of a randomized trial of percutaneous angioplasty, supervised exercise or combined treatment for intermittent claudication due to femoropopliteal arterial disease.Br J Surg. 2013; 100: 1172-1179Crossref PubMed Scopus (36) Google Scholar found the most cost-effective per QALY was exercise (€6147.04) with combination therapy (€10,649.74) preferable to intervention alone (€11,777.00). For a United States perspective, the incremental cost of intervention vs exercise in the CLEVER trial was $122,600.28Reynolds M.R. Apruzzese P. Galper B.Z. Murphy T.P. Hirsch A.T. Cutlip D.E. et al.Cost-effectiveness of supervised exercise, stenting, and optimal medical care for claudication: results from the Claudication: Exercise versus Endoluminal Revascularization (CLEVER) trial.J Am Heart Assoc. 2014; 3: 1-11Crossref Scopus (27) Google Scholar The cost of supervised exercise per QALY remained preferable to stent therapy out to 10 years. With all of this evidence pointing to the efficacy of supervised exercise, why has it not been embraced by patients, physicians, insurers, and national health services? What barriers are there to the provision of medically supervised programs? In the United Kingdom, where the National Health Service controls the provision of care, there are still no National Health Service-funded supervised exercise programs available despite strong recommendations by the agency responsible for evaluating therapies. Several authors29Popplewell M.A. Bradbury A.W. Why do health systems not fund supervised exercise programmes for intermittent claudication?.Eur J Vasc Endovasc Surg. 2014; 48: 608-610Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 30Stewart A.H. Lamont P.M. Exercise for intermittent claudication. Supervised programmes should be universally available.BMJ. 2001; 323: 703-704Crossref PubMed Scopus (24) Google Scholar have addressed the impediments to establishing programs. They include concerns by payers regarding the design and applicability of studies to the general population, the desire for some patients to have a “quick fix” and not being able or willing to participate in a program, and particularly with a lack of funded and established programs, the perverse incentive to perform a reimbursable intervention rather than counseling. They suggest asking vascular surgeons and interventional radiologists to support it is like asking “turkeys to vote for Christmas” because their professional pride and income is threatened. In addition, the powerful device industry, whose profits depend on widespread adoption of intervention for vascular disease, influences care in many ways. Many if not all of these barriers exist in the United States health care system, yet as we careen toward insupportable health care costs with questionable benefits, provision of appropriate care will be threatened by the broad brush approach often taken by Centers for Medicare and Medicaid Services and insurers. It is incumbent on us in this era of personalized medicine to provide thoughtful, patient-centered care. However, Aetna in its recent policy review (http://www.aetna.com/cpb/medical/data/400_499/0458.html) “considers medical supervision of peripheral vascular rehabilitation programs experimental and investigational because the value of such supervision is not well documented by the available peer-reviewed published medical literature.” Withdrawal of funding sank a highly successful program in Wales,31Evans T. Roberts M. Lewis M. Re: “Why do health systems not fund supervised exercise programmes for intermittent claudication?”.Eur J Vasc Endovasc Surg. 2015; 49: 487Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar similar to my own experience of having to shut down a highly successful clinical program of 15 years that proved fiscally unsustainable during the financial crisis of 2008. Des" @default.
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