Getting Kypho Referrals

[deadhead2]

Hey all,

Long-time lurker and infrequent poster. Really appreciate everything I have learned from this forum and would appreciate any advice I can get on this.

I am a new grad working in a hospital-employed group. My group does some kypho, but I am starting out of 2 new locations without any established pain physicians or set referral sources. One location is attached to a small, rural non-trauma hospital and the other is associated with a busy level 3 trauma center. There are no spine surgeons or neurosurgeons in either location, for what it's worth.

I would like to figure out the best way to get referrals for kypho. The Stryker and Medtronic reps tell me that nobody is doing any kypho in either location, so there is no real competition.

For those who do a lot of kypho (@lobelsteve, @BobBarker, I'm sure there are others), how do you get referrals? Meet with PCPs, ER, hospitalist, and trauma? Do you take any inpatient call or see these patients if they are admitted? I am definitely willing to put in the work to get these referrals, but I would appreciate any tips on the best way to go about it.

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[BobBarker]

You can visit with the ED Docs and give them your cell phone number. Get the patient in the next day for consult.

 

[unchockey21]

Talk to ED docs and urgent care. If there’s no IR guys doing them either, talk to the imaging centers.

 

[paindoc007]

PCPs and EDs. Mind you, you’ll be getting a lot of old fractures in the referral mix as well. But still good injection candidates.

 

[lobelsteve]

I am in a pcp centered office with an urgent care. And I manage osteoporosis.

 

[deadhead2]

Awesome, thanks everyone. I'll definitely swing by the ED to meet the docs and visit some PCPs too.

 

[agolden1]

Awesome, thanks everyone. I'll definitely swing by the ED to meet the docs and visit some PCPs too.

I'll be interested to hear your experience with this. I had the practice I just joined give me a list of referring docs and practices. In the weeks leading up to starting, I called a bunch of them to let them know by there was a new provider in town and offered to swing by and say hello/have lunch.

Absolute radio silence from every kind of practice.

Maybe I sound funny on the phone...

 

[RoloTomassi]

I'll be interested to hear your experience with this. I had the practice I just joined give me a list of referring docs and practices. In the weeks leading up to starting, I called a bunch of them to let them know by there was a new provider in town and offered to swing by and say hello/have lunch.

Absolute radio silence from every kind of practice.

Maybe I sound funny on the phone...

What do you mean radio silence? They had to respond somehow to your offer

 

[agolden1]

What do you mean radio silence? They had to respond somehow to your offer

Spoke to alot of practice managers/receptionists.

“Oh yea. We will pass that along to the docs and let you know if/when there’s a good time.”

Then ghosted afterwards.

 

[Status Sciaticus]

Spoke to alot of practice managers/receptionists.

“Oh yea. We will pass that along to the docs and let you know if/when there’s a good time.”

Then ghosted afterwards.

did you follow up with them afterwards?

 

[lobelsteve]

PCP call while I am in OR. Lots of pain. Can I log in and look at imaging and work him in. Yea. Yes. Yes.

 

[DrMDAware]

May I ask what leads you to want to more kyphos? I’m genuinely curious.

My friend told me they brought in lots of money. I told him they weren’t worth it financially speaking unless done in office. He didn’t believe me when I said not much $$$ and lots of fluoro. My impression was they at one time paid well but not anymore.

Maybe others have had different experiences.

 

[DubVille]

May I ask what leads you to want to more kyphos? I’m genuinely curious.

My friend told me they brought in lots of money. I told him they weren’t worth it financially speaking unless done in office. He didn’t believe me when I said not much $$$ and lots of fluoro. My impression was they at one time paid well but not anymore.

Maybe others have had different experiences.

They pay well in the office and tend to get better. I'd still say I wait out 90% of fractures I see

 

[nvrsumr]

No one has time to meet anymore. Covid didn’t help. The door to the back office is permanently closed at many practices now

 

[DrMDAware]

They pay well in the office and tend to get better. I'd still say I wait out 90% of fractures I see

Maybe it’s just a minor subset in my anecdotal experience but these patients sometimes are older, sicker, and more frail. After I do the kypho they say that it didn’t work because now they have SI joint pain, hip pain from walking more, or were admitted to the emergency room for an infection from their COPD. They tell my staff that it didn’t work though. And they also tell their PCP it didn’t work because they’re not able to stand up straight yet like before.

 

[lobelsteve]

Maybe it’s just a minor subset in my anecdotal experience but these patients sometimes are older, sicker, and more frail. After I do the kypho they say that it didn’t work because now they have SI joint pain, hip pain from walking more, or were admitted to the emergency room for an infection from their COPD. They tell my staff that it didn’t work though. And they also tell their PCP it didn’t work because they’re not able to stand up straight yet like before.

Your results are different than mine. One of the most rewarding things we do. 90% of the patients get off the table and pain is gone.

 

[MD87]

What is the most recent data on adjacent level fractures after kyphoplasty?

 

[DrMDAware]

Your results are different than mine. One of the most rewarding things we do. 90% of the patients get off the table and pain is gone.

That’s great. How soon after the fx are you seeing them? Perhaps mine are too late and too deconditioned?

 

[lobelsteve]

Fx and cancer pain get 48hr work ins. So usually they broke within a week.

 

[DrMDAware]

Fx and cancer pain get 48hr work ins. So usually they broke within a week.

Oh yeah that’s probably why our results are different. Some HMOs I take require anywhere from a 6-12 week waiting period which doesn’t make sense to me.

 

[RoloTomassi]

Oh yeah that’s probably why our results are different. Some HMOs I take require anywhere from a 6-12 week waiting period which doesn’t make sense to me.

Are you getting good fills? That makes a big difference too

 

[DrMDAware]

Are you getting good fills? That makes a big difference too

Sometimes I don’t. Could be my technique. Don’t want to push it too much. Could be the bone has already started to harden given it is no longer acute. Is there a rough cutoff you have for a good fill? Looking to learn more.

 

[lobelsteve]

Sometimes I don’t. Could be my technique. Don’t want to push it too much. Could be the bone has already started to harden given it is no longer acute. Is there a rough cutoff you have for a good fill? Looking to learn more.

If more than 4 months has past, it is not kypho worthy.
Volumes are a Doug Bealle thing. Older literature supported 2 to 4.5cc was adequate fill for relief. Hoping Doug comes out with some good retrospective review data. Then teaches us all how not to spill it into adjacent disk, anteriorly through Fx line, or into the epidural space.

 

[BobBarker]

Doug disciples overfill and get themselves in trouble.

 

[deadhead2]

May I ask what leads you to want to more kyphos? I’m genuinely curious.

My friend told me they brought in lots of money. I told him they weren’t worth it financially speaking unless done in office. He didn’t believe me when I said not much $$$ and lots of fluoro. My impression was they at one time paid well but not anymore.

Maybe others have had different experiences.

The few cases I did in fellowship had great outcomes, so that is what got me interested. Plus, I enjoy doing kyphos and the balance of the evidence suggests that patients benefit from it. In my area, it is way underutilized.

I'm hospital employed (salaried with wRVU production bonus after year 2) so the money is not a primary motivator for me.

 

[buddababa]

I'll be interested to hear your experience with this. I had the practice I just joined give me a list of referring docs and practices. In the weeks leading up to starting, I called a bunch of them to let them know by there was a new provider in town and offered to swing by and say hello/have lunch.

Absolute radio silence from every kind of practice.

Maybe I sound funny on the phone...

Probably 'cuz you're not a provider, you're a physician.

 

[RoloTomassi]

Sometimes I don’t. Could be my technique. Don’t want to push it too much. Could be the bone has already started to harden given it is no longer acute. Is there a rough cutoff you have for a good fill? Looking to learn more.

I like to see spiculation from pedicle to pedicle and endplate to endplate. Volume depends on level, collapse, and spread. Bealls look like hockey pucks with tentacles. Seems excessive to me but he's done more than I'll ever do in a lifetime

 

[DrMDAware]

I like to see spiculation from pedicle to pedicle and endplate to endplate. Volume depends on level, collapse, and spread. Bealls look like hockey pucks with tentacles. Seems excessive to me but he's done more than I'll ever do in a lifetime

To get that kind of volume do you keep pumping up the VB? Move the cannula?

 

[RoloTomassi]

To get that kind of volume do you keep pumping up the VB? Move the cannula?

Yes keep filling in one spot if it's spreading up-down and sideways nicely without going anywhere it shouldn't. Move cannula if it stops going the direction you want

 

[BobBarker]

I agree with @RoloTomassi. I’m looking for pedicle to pedicle, top to bottom. I will do my best to accomplish that by moving the cannula. But I am not cavalier with overfilling and leakage. There is a happy medium which is safest.

 

[paindoc007]

Doug disciples overfill and get themselves in trouble.

Are you aware of actual cases like that, or is that just a general guess?

 

[BobBarker]

Yes, I have seen cases like that. Lungs, canal.

 

[RoloTomassi]

There's a study showing chance of pulmonary cement increases with volume

 

[paindoc007]

Yes, I have seen cases like that. Lungs, canal.

I’ve actually heard Beal say “I’ve never had a neurological problem that I’m aware of after a kyphoplasty”. I wonder if that’s true. You can’t be that aggressive and do that much without ever having an issue…

 

[gdub25]

I'll be interested to hear your experience with this. I had the practice I just joined give me a list of referring docs and practices. In the weeks leading up to starting, I called a bunch of them to let them know by there was a new provider in town and offered to swing by and say hello/have lunch.

Absolute radio silence from every kind of practice.

Maybe I sound funny on the phone...

You aren’t serious enough to go meet them in person so they aren’t taking you serious enough to call you back. That’s how they are thinking about it most likely I believe. I beat the streets regularly and show up in their waiting room, only kind of marketing I’ve ever done and it’s worked well for me and my partners. I also have personally visited ever ER in the surrounding area within 1 hour of my main office and given my cell number to every one of them. My advice is just get out there and hustle. It will work.

 

[RoloTomassi]

Spoke to alot of practice managers/receptionists.

“Oh yea. We will pass that along to the docs and let you know if/when there’s a good time.”

Then ghosted afterwards.

 

[Drd105]

It has been a long time since I’ve seen this but ay yi yi I am hoping this is some of his worst acting. Upsetting. But your use of the clip was great 👍