CONTACTS
SUBJECTS
CBC Lab WBC VA No Results
2003 -
2003 - ..
2004 - Summary/Objective
2005 -
200501 - Follow up ref SDS 75 0000. ref SDS 74 0000.
200502 -
200503 -
200504 -
200505 -
200506 -
200507 -
200509 - ..
2006 -
2007 -
2008 - Background
2009 -
200901 - On 131016 1632 submit letter for agenda meeting to review lab results
200902 - scheduled 131017 1000. ref SDS 40 X45G
200904 - ..
200905 - On 140131 0815 ordered another lab - cbc, electrolytes, lipid with NMR
200906 - - from Labcor to get LDL-P. ref SDS 50 X45G
200908 - ..
200909 - On 140201 1159 had full lab with NMR lipid panel drawn at John Muir
200910 - Hospital on Treat, and by Labcorp. ref SDS 51 RP4N
200912 - ..
200913 - On 140203 1147 had partial lab drawn at VA in Martinez. ref SDS 52
200914 - KK9M
200916 - ..
200917 - On 140507 0857 ordered another full lab from Labcorp with NMR lipid
200918 - panel. ref SDS 58 OO5G
200920 - ..
200921 - On 140508 1133 lab blood daw at Labcorp with John Muir Medical Center
200922 - on Treat Blvd in Concord. ref SDS 59 445G
200924 - ..
200925 - On 140514 0950 VA partial lab at Medical Center in San Francisco.
200926 - ref SDS 61 X45G
200928 - ..
200929 - On 140518 0920 letter to VA submits consolidated blood tests from
200930 - Labcorp on 140508 and the VA on 140514, to prepare for the meeting on
200931 - 140519. ref SDS 63 1V6M Advise that VA has not ordered follow up lab
200932 - to check Electrolytes (Chem Profile) requested by Doctor Egan to
200933 - assess previously elevated potassium (K) 5.6, that cause electrical
200934 - problems for the heart. ref SDS 63 DV4M Medication side effects of
200935 - dizziness have subsided. ref SDS 63 DV50 Dry mouth and urination have
200936 - increased. ref SDS 63 DV56 Peripheral neuropathy related to elevated
200937 - bilirubin has recurred. ref SDS 63 DV59
200939 - ..
200940 - On 140518 0920 at 2244 received letter from Doctor Alba notifying not
200941 - to get blood draw at lab prior to meeting with medical team tomorrow
200942 - morning. ref SDS 63 RW7O
200944 - ..
200945 - On 140520 0732 background and planning for getting supplemental labs
200946 - on electrolyte (Chem Profile), and EPC. ref SDS 65 X45G
200948 - ..
200949 - On 140520 0732 at 0743 letter requests VA order electrolyte (Chem
200950 - Profile) lab order today. ref SDS 65 YW4H, and include lab for EPC.
200951 - ref SDS 65 4U46 Doctor Sandhu notified that medical team in San
200952 - Francisco discusses increased urination indicates possible prostate
200953 - issues. ref SDS 65 4U95 During meeting on 140519, decided that mild
200954 - symptoms peripheral neuropathy possibly due to statin treatment does
200955 - not justify ending statin tratement, because treatments have been
200956 - effective managing lipids. ref SDS 65 4U4F
200958 - ..
200959 - On 140520 0732 at 0812 letter from VA advises Doctor Alba will order
200960 - Chem Profile lab when she arrives at the hospital. ref SDS 65 4V5H
200962 - ..
200963 - On 140520 0732 at 1017 VA partial lab at Medical Center in San
200964 - Franciso for electrolyte (Chem) panel that was omitted on lab 140514.
200965 - ref SDS 65 KK9M Glucose, sodium, potassium declined, with potassium
200966 - (K 5.2) still at high end of range for Labcorp and slightly above VA
200967 - range, ref SDS 65 ZG5O; bilirubin declined dramatically. ref SDS 65
200968 - 015M
200970 - ..
200971 - On 140520 0732 at 1028 VA letter Doctor Alba requests clarification of
200972 - scope for EPC lab. ref SDS 65 654J Called to explain scope of EPC
200973 - lab, but encountered poor connection using cell phone. ref SDS 65 U63N
200975 - ..
200976 - On 140520 0732 at 1609 VA letter - Doctor Alba ordered EPC lab, she
200977 - advises EPC lab requires approval by lab staff of doctor's
200978 - justification. ref SDS 65 AF5L
200980 - ..
200981 - On 140520 0732 at 1617 letter to VA submits justification for doctor
200982 - to submit with order for EPC lab that saves lives, time, and money.
200983 - ref SDS 65 JP8O
200985 - ..
200986 - On 140522 1052 letter to Doctor Egan at Martinez submits results of
200987 - labs on Electrolyte Chem Profile showing Potassium, which Doctor Egan
200988 - requested. ref SDS 66 X45G
200990 - ..
200991 - On 140529 0942 letter to Doctor Alba at VA Medical Center in San
200992 - Francisco adise placed order with Release of Information Department to
200993 - submit Progress Notes for meeting on 140519, so no need for Doctor
200994 - Alba so submit. ref SDS 67 X45G Recommend correcting errors in prior
200995 - notes so they are carried forward in Progress Notes for meeting on
200996 - 140519. ref SDS 67 QF6T Recommend Progress Notes cite patient support
200997 - to improve lipid labs past 6 months, ref SDS 67 QF67, referencing the
200998 - lab report on 140514 0950, ref SDS 61 W25L, which also presents
200999 - extended exercise, weight loss, and diet changes. ref SDS 61 I17G
201000 - Asked about progress getting approval for EPC lab. ref SDS 67 QG3U
201001 - Request VA order coronary CT angiography with calcium score to
201002 - evaluate regression of athersclerosis, as a result of good labs from
201003 - medication and extended exercise the past 6 months. ref SDS 67 QG38
201005 - ..
201006 - On 140610 0930 letter asks again about publishing Progress Notes for
201007 - meeting at the VA on 140519. ref SDS 68 X45G Reminds to order EPC and
201008 - coronary CTA tests. ref SDS 68 LJ61 Customer offers to order EPC and
201009 - coronayr CTA tests in order to save time for the VA. ref SDS 68 LJ6L
201010 - Report peripheral neuropathy and urination symptoms have again
201011 - subsided. ref SDS 68 LJ6Y
201013 - ..
201014 - On 140610 0930 at 1115 letter from Doctor Alba advising that Progress
201015 - Notes for meeting on 140519, were completed last week. ref SDS 68 W84I
201017 - ..
201018 - On 140610 0930 at 1114 letter asks Doctor Alba about progress ordering
201019 - EPC lab and coronary CTA with calcium score, ref SDS 68 KH3O, repeating
201020 - request in the letter earlier this morning, ref SDS 68 LJ61, but not
201021 - discussed in Doctor Alba's letter received at 1115. ref SDS 68 W84I
201023 - ..
201024 - On 140612 1048 VA letter notifies refuse order coronary CTA to test
201025 - for level of atherosclerosis because history of CABG surgery on
201026 - 091022, shows coronary artery disease, which VA relies upon to
201027 - speculate plaques remain in arteries, therefore, CT angiography, is
201028 - not going to add any value to your current diagnoses or treatment.
201029 - ref SDS 69 X45G
201031 - ..
201032 - On 140626 1652 letter notify VA commend Doctor Alba correcting errors
201033 - in Progress Notes in prior meeting so they are not replicated in
201034 - Progress Notes for meeting on 140519. ref SDS 71 X45G Commend VA
201035 - timely prescription refill on Ezetibime and Atorvastatin. ref SDS 71
201036 - MY9Y Offer to defer lab on EPC to assess prospects for regression of
201037 - atherosclerosis, since EPC should be favorable based on increased
201038 - exercise that has increased WBC 50%. ref SDS 71 MY45 Review VA refusal
201039 - to order coronary CTA aligns with prior experience at Kaiser ordering
201040 - CT testing to evaluate pulmonary embolism. ref SDS 71 MY51 VA grounds
201041 - for refusing CTA testing that results will not aid care for patients
201042 - with CABG surgery, conflicts with the record showing CTA is commonly
201043 - performed to assess recovery from atherosclerosis who have undergone
201044 - CABG surgery. ref SDS 71 MZ33 Request recommendations for 2nd opinions
201045 - on CTA testing. ref SDS 71 MZ82
201047 - ..
201048 - On 140629 1921 report side effects of prescribed care metatasalgia
201049 - causing sore feet. ref SDS 73 UZ64 Efforts to resolve without medical
201050 - care have not been effective. ref SDS 73 U13R Request referral to
201051 - Podiatry for consultation. ref SDS 73 U14H
201053 - ..
201054 - On 140703 1938 letter from Doctor Alba at VA in San Francisco Medical
201055 - Center reports detailed discussion among medical team leading and
201056 - refused to order EPC lab. ref SDS 74 X45G The doctor recommends
201057 - getting 2nd opinion from Doctor Egan at VA Cardiology Clinic in
201058 - Martinez on CTA testing for regression of atherosclerosis. ref SDS 74
201059 - H233 Doctor Alba further recommends requesting from Primary Care at
201060 - VA Clinic in Martinez, referral to Podiatry to resolve metataslagia
201061 - side effects from implementing Plan of care in Progress Notes on
201062 - 140213. ref SDS 74 H240
201064 - ..
201065 - On 140703 1938 at 2023 letter to Doctor Alba at VA in San Francisco
201066 - Medical Center, requests details of discussion among medical team on
201067 - EPC issue. ref SDS 74 6X3V Notify VA customer will pay for cost of EPC
201068 - and CTA testing, request assistance - need doctor to order tests.
201069 - ref SDS 74 6X40 Advise VA Medical Center in San Francisco that during
201070 - a meeting on 140430, Doctor Egan at VA Cardiology Clinin in Martinez,
201071 - was consulted on CTA to evaluate regression of atherosclerosis, and
201072 - seemed to indicate it is impossible. ref SDS 74 6X43 Present research
201073 - showing expert opinion that regression of atherosclerosis occurs under
201074 - conditions of elevated EPC and HDL. ref SDS 74 6X46 Present benefits
201075 - of doing CTA test for regression of atherosclerosis. ref SDS 74 6X5G
201077 - ..
201078 - On 140703 1938 at 2023 letter to Doctor Alba at VA in San Francisco
201079 - Medical Center notfies have been unable to perform Plan of Care for
201080 - continuing physical activity prescribed in Progress Notes on 140213
201081 - 0830, ref SDS 55 E34O, hiking 11 miles per day due to metatarsalgis
201082 - side effects, and will implement recommendation to discuss referral to
201083 - Podiatry with Primary Care at VA Clinic in Martinez. ref SDS 74 6X57
201085 - ..
201086 - On 140710 1348 letter from Doctor Alba offering to follow up if Doctor
201087 - Egan in Cardiology at VA Clinic in Martinez is unable to order EPC and
201088 - CTA test for regression of atherosclerosis. ref SDS 75 X45G
201090 - ..
201091 - On 140710 1348 at 1353 letter to Doctor Alba with copy to Doctor Egan
201092 - in Cardiology at VA Clinic Martiniz, and submitting Doctor Alba's
201093 - letter earlier today, and asking Doctor Egan to order EPC and CTA
201094 - tests for regression of atherosclerosis. ref SDS 75 DX7K
201096 - ..
201097 - On 140710 1348 at 1353 letter to Doctor Alba with copy to Doctor
201098 - Sandhu in Primary Care at VA Clinic Martiniz, and notifying that feet
201099 - pain from metatarsalgia preventing hiking 2 weeks (actually 3) caused
201100 - weight increase. ref SDS 75 CA5F Request Doctor Sandhu make referral
201101 - to Podiatry to resolve metatarsalgia; cite CVD risk without hiking,
201102 - and Half Dome hike in jeopardy. ref SDS 75 CM68
201104 - ..
201105 - On 140710 1348 at 1353 letter to Doctor Alba advises will notify the
201106 - doctor of results requesting support from VA Clinic in Martinez.
201107 - ref SDS 75 CM72
201109 - ..
201110 - On 140731 1048 letter to Doctor Alba with Endocrinology, Diabetes and
201111 - Metabolism Department at VA Medical Center in San Francisco, report
201112 - results work plan on 140710 - Doctor Egan in Cardiology VA Clinic
201113 - Martinez has not responded to request for ordering EPC and CTA testing
201114 - to assess regression of atherosclerosis related to CVD risk.
201115 - ref SDS 0 X45G Request Doctor Alba support order for EPC and CTA,
201116 - ref SDS 0 WL7K, as noted in the doctor's letter on 140710 1348.
201117 - ref SDS 75 X45G
201119 - ..
201120 - On 140731 1048 letter to Doctor Alba with Endocrinology, Diabetes and
201121 - Metabolism Department at VA Medical Center in San Francisco, notified
201122 - unable to hike last 4 weeks due to rising metatarsalgia side effects.
201123 - ref SDS 0 WL6H Weight has increased without hiking; past 3 days was
201124 - able to hike trying new shoes and orthotics. ref SDS 0 WL70
201126 - ..
201127 - On 140731 1048 letter to Doctor Alba with Endocrinology, Diabetes and
201128 - Metabolism Department at VA Medical Center in San Francisco, notified
201129 - Primary Care VA Clinic in Martinez has not had time to issue referral
201130 - for Podiatry to resolve rising metatarsalgia side effects. ref SDS 0
201131 - WL6M
201133 - ..
201134 - On 140731 1048 at 1421 letter from Doctor Alba with Endocrinology,
201135 - Diabetes and Metabolism Department at VA Medical Center in San
201136 - Francisco, repeats recommendation to obtain support from Doctor Egan
201137 - ordering EPC lab and CTA test for regression athersclerosis.
201138 - ref SDS 0 QU4F The doctor complains she cannot order EPC and CTA
201139 - tests, because she does not understand them, ignoring plan for
201140 - collaborating with a doctor who has this understanding for placing the
201141 - order. ref SDS 0 0V75
201143 - ..
201144 - On 140731 1048 at 1421 letter from Doctor Alba with Endocrinology,
201145 - Diabetes and Metabolism Department at VA Medical Center in San
201146 - Francisco, proposes making referral to podiatry for resolving
201147 - metatarsalgia side effects of care for regression of atherosclerosis
201148 - to lower risks of CVD. ref SDS 0 OV90
201150 - ..
201151 - On 140731 1048 at 1537 letter to Doctor Alba with Endocrinology,
201152 - Diabetes and Metabolism Department at VA Medical Center in San
201153 - Francisco, notifies Doctor Egan was notified twice about need for EPC
201154 - and CTA tests to assess regression of atherosclerosis to lower CVD
201155 - risk. ref SDS 0 GY4K Propose defer EPC test because metatarsalgia
201156 - side effects have prevented extended exercise, so cannot get valid
201157 - test until metatarsalgia resolved. ref SDS 0 4164 Propose defer CTA
201158 - because VA has not had time to order test paid for by patient.
201159 - ref SDS 0 4167
201161 - ..
201162 - On 140731 1048 at 1537 letter to Doctor Alba with Endocrinology,
201163 - Diabetes and Metabolism Department at VA Medical Center in San
201164 - Francisco, thanks the doctor for making referral to Podiatry,
201165 - ref SDS 0 4230, and requests referral provide link to patient history
201166 - on extended exercise that caused matatarsalgia, and requests
201167 - submission of language in the referral. ref SDS 0 4233
201168 -
201169 -
201170 -
201171 -
201173 - ..
2012 -
2013 -
2014 - Progress
2015 -
201501 - Letter to Doctor Alba at VA saying...
201502 -
201503 - 1. Subject: VA Order EPC Lab and Coronary CTA with Patient Billed
201504 - Date: 2014-07-31 11:05
201511 - ..
201512 - 2. As you requested, today following up letter on 140710.
201513 - ref SDS 75 DX7K Have not heard from Doctor Egan, Cardiology in
201514 - Martinez on ordering EPC lab and coronary CTA with calcium
201515 - score (at patient expense) to evaluate regression of
201516 - atherosclerosis, planned in the meeting with you and Doctor
201517 - Feingold on 140519. Recall this test is justified by 130% rise
201518 - in HDL 67 with concomitant fall in TG reported in most recent
201519 - lab on 140514, (see lipid history line 760656, ref SDS 61 W25L,
201520 - compared to labs when CABG was performed to resolve 4 blockages
201521 - 5 years ago on 091022. ref SDS 4 PQWU
201523 - ..
201524 - [...below on 140731 1048 at 1421 letter from Doctor Alba
201525 - proposes asking Doctor Egan again to support EPC and CTA
201526 - testing for response to treatment achieving regression of
201527 - atherosclerosis, ref SDS 0 QU4F; seems to ignore report in
201528 - the letter today that Doctor Egan has not had time to take
201529 - action, per above - and so presents a loop. ref SDS 0 X45G
201531 - ..
201532 - 3. The past 4 weeks have not been able to hike due to
201533 - metatarsalgia side effects of extended exercise to raise HDL
201534 - and EPC, and lower TG through weight loss, which together may
201535 - drive regression of atherosclerosis, also shown with lab report
201536 - on 140514 (see line 760574. ref SDS 61 I17G
201538 - ..
201539 - 4. As well, Doctor Sandhu, Primary Care at the VA in Martinez, has
201540 - not had time for referral to podiatry to resolve metatarsalgia.
201542 - ..
201543 - This follows up letter to Doctor Alba with copy to Doctor Sandhu on
201544 - 140710 1348. ref SDS 75 CM68
201545 -
201546 - [...below on 140731 1048 at 1421 letter from Doctor Alba
201547 - requests notice for her to make referral to Podiatry.
201548 - ref SDS 0 OV90
201550 - ..
201551 - Letter to VA continues...
201552 -
201553 - 5. Without hiking, weight has increased. After many trials, new
201554 - shoes and orthotics enabled resumption of hiking the past 3
201555 - days, beginning on 140728; vitals still look okay (see line
201556 - 107952. [...referencing case study on 120101 0900. ref SDS 18
201557 - T56H
201559 - ..
201560 - 6. Your letter on 140710, discussed making inquiries about
201561 - ordering EPC lab and coronary CTA with calcium score from an
201562 - outside vendor paid by the patient (see your letter on 140710
201563 - 1348. ref SDS 75 X45G). Since there doesn't seem to be another
201564 - way to get this done, please let me know if you can help.
201565 -
201566 - [...below on 140731 1048 at 1421 letter from Doctor Alba
201567 - proposes asking Doctor Egan again to support EPC and CTA
201568 - testing for response to treatment achieving regression of
201569 - atherosclerosis, ref SDS 0 QU4F; seems to ignore report in
201570 - the letter today that Doctor Egan has not had time to take
201571 - action, per above - and so presents a loop. ref SDS 0 X45G
201573 - ..
201574 - Background on EPC issue....
201575 -
201576 - Doctor Egan did not respond.................... 140731 1048, ref SDS 0 X45G
201577 - Patient requests support Doctor Egan........... 140710 1348, ref SDS 75 DX7K
201578 - VA refuse order EPC suggests ask Doctor Egan... 140703 1938, ref SDS 74 H167
201579 - Request progress ordering EPC lab.............. 140626 1652, ref SDS 71 MY45
201580 - VA still pending answer on order EPC lab....... 140612 1048, ref SDS 69 Y68L
201581 - Follow up on ordering EPC lab.................. 140610 0903, ref SDS 68 LJ61
201582 - Follow up on ordering EPC lab.................. 140529 0942, ref SDS 67 QG3U
201583 - Doctor Alba responds........................... 140520 0732, ref SDS 65 AF5L
201584 - Follow up letter............................... 140520 0732, ref SDS 65 4U46
201585 - Confirm request in meeting on 140529........... 140520 0732, ref SDS 65 4U46
201586 - Request EPC lab................................ 140515 2043, ref SDS 62 YM61
201587 - Research EPC enables regression atherosclerosis 131125 0005, ref SDS 46 6O9M
201589 - ..
201590 - Background on CTA issue...
201591 -
201592 - Doctor Egan did not respond.................... 140731 1048, ref SDS 0 X45G
201593 - Patient requests support Doctor Egan........... 140710 1348, ref SDS 75 DX7K
201594 - VA recommends 2nd opinion from Doctor Egan..... 140703 1938, ref SDS 74 H233
201595 - Request referral for 2nd opinion on CTA........ 140626 1652, ref SDS 71 MY51
201596 - No grounds refuse CTA assess atherosclerosis... 140626 1652, ref SDS 71 MZ33
201597 - CTA for CABG common assess atherosclerosis..... 140626 1652, ref SDS 71 MZ54
201598 - VA no grounds failure order CTA assess plaques. 140612 1048, ref SDS 69 Y68L
201599 - Follow up on ordering CTA atherosclerosis...... 140610 0903, ref SDS 68 LJ61
201600 - Request CTA assess atherosclerosis plaques..... 140529 0942, ref SDS 67 QG38
201601 - Justification coronary CTA order............... 140520 0732, ref SDS 65 VQ48
201602 - Request EPC lab predicate to CTA............... 140515 2043, ref SDS 62 YM61
201603 - Research CTA test regression atherosclerosis... 131125 0005, ref SDS 46 N73K
201604 -
201605 -
201613 -
201614 -
201615 -
201617 - ..
2017 -
2018 -
2019 - 1421
2020 -
202001 - Received letter from Doctor Alba at VA Medical Center San Francisco
202002 - and saying...
202003 -
202004 - 1. Subject: RE: VA Order EPC Lab and Coronary CTA with Patient Billed
202005 - Date: 2014-07-31 12:53
202012 - ..
202013 - 2. I really recommend that you obtain second opinion from Dr
202014 - Eagan. You should discuss the utility of a CTA and calcium
202015 - score. As discussed before, we consider that there is no
202016 - utility for you, since we are already know you have coronary
202017 - artery disease and CABG, as well as elevated cholesterol and
202018 - you are currently on therapy. Also, you have to take into
202019 - account the concern for exposure to unnecessary radiation.
202021 - ..
202022 - Background on CTA issue is listed above. ref SDS 0 CM64
202024 - ..
202025 - Doctor Alba responds to the letter this morning requesting support for
202026 - EPC and CTA testing, because Doctor Egan has not had time to provide
202027 - assistance, per above, ref SDS 0 X45G and ref SDS 0 WL7K, and by
202028 - repeating recommendation on 140710 to obtain support from Doctor Egan,
202029 - ref SDS 75 X45G - thus the VA is in a loop, refusing to perform. VA
202030 - assertion that testing for regression of atherosclerosis to assess
202031 - care for managing CVD risk is "without utility" because the patient
202032 - has a history of atherosclerosis is inherently conflicting with
202033 - standard of care to test for results of medical interventions, and
202034 - further ignores prior analysis in the record on 140626 1652.
202035 - ref SDS 71 MZ33
202037 - ..
202038 - VA citing concern that CTA test presents exposure to unnecessary
202039 - radiation, as grounds to refuse testing, conflicts with standard of
202040 - care to test for results of treatment. The patient has been treated
202041 - for 5 years to recover from atherosclerosis, beginning with CABG x4 on
202042 - 091022 0700. ref SDS 4 PQWU CTA is standard of care for CABG with
202043 - sources cited in letter to VA on 140626 1652. ref SDS 71 MZ54 An
202044 - obvious question is what effect have post CABG interventions yielded,
202045 - since 091022, including medications and extended exercise training
202046 - prescribed in VA Progress Notes on 140519 0800? ref SDS 64 OW76 CT
202047 - testing is well settled standard of care for response to treatment.
202048 - Millie had about 15 CT tests per year for 7 years, and never suffered
202049 - noticable effects. In this case the patient previously had a CT test
202050 - on 130117 0900. ref SDS 32 LM8K There was a previous CT the month
202051 - before on 121113 1100. ref SDS 28 4X5H The next prior test was 5
202052 - years earlier during evaluation of post CABG surgery issues on 091030
202053 - 0810. ref SDS 5 1N6L Accordingly, 1 more test in a 2 year period
202054 - presents minimal exposure to radiation, likely less than hiking
202055 - in the sunshine everyday for 5 years.
202057 - ..
202058 - Letter from Doctor Alba continues...
202059 -
202060 - 3. Regarding EPC - although I found data on the relation of EPC to
202061 - cardiovascular risk; we already know that you have a history
202062 - of coronary vascular disease, so again utility is not clear
202063 - and that is what I discussed with the lab medicine department
202064 - when I enquired about this test in the past. If I were to
202065 - order a test that I do not know how to interpret it, I am not
202066 - sure we can conclude that there is any benefit to you or your
202067 - current treatment.
202069 - ..
202070 - Background on EPC issue is listed above. ref SDS 0 H33O
202072 - ..
202073 - VA position conflicts with standard of care, reported above.
202074 - ref SDS 0 545J
202076 - ..
202077 - VA reliance on patient "history of coronary vascular disease" (CVD),
202078 - as grounds for failure to test for EPC, conflicts with research
202079 - showing EPC together with elevated HDL enable regression of
202080 - artherosclerosis, which is the best treatment for CVD, reported on
202081 - 131125 0005. ref SDS 46 6O9M Managing CVD risk requires testing EPC
202082 - and HDL, and CTA with calcium score, presented to VA most recently on
202083 - 140626 1652. ref SDS 71 MZ54 Testing is not to determine whether
202084 - patient has CVD, but whether the condition is improving, static, or
202085 - worsening, and in time to take effective action.
202087 - ..
202088 - Letter from Doctor Alba continues...
202089 -
202090 - 4. You have to understand that If I order a test, I am responsible
202091 - for the results and/or follow up. So I am sorry, but I do not
202092 - feel comfortable ordering these tests.
202094 - ..
202095 - This position seems to ignore patient proposal to pay for the cost of
202096 - EPC and CTA testing, as done with Lipid NMR test to determine LDL-P,
202097 - set out in the letter on, ref SDS 74 6X40
202099 - ..
202100 - Since testing is standard of care for evaluating response to
202101 - treatment, explained above. Seems likely the underlying reason for
202102 - refusing EPA and CTA testing is that VA has taken policy position not
202103 - to test, because few patients achieve regression of atherosclerosis,
202104 - and so the cost to suppor the few who do is not justified in relation
202105 - to simply prescribing medical drug treatment for atherosclerosis,
202106 - regardless of whether any plaques remain in the blood vessels to
202107 - treat.
202109 - ..
202110 - While no physician should be pressured to resist or otherwise ignore
202111 - hospital cost benefit policies, it is not clear why any hospital,
202112 - including the VA, should refuse to order testing for recovery from
202113 - atherosclerosis, when test results could justify reduced treatment,
202114 - cost, and wear and tear on patient health from side effects, and when
202115 - the cost is being paid by the patient, as set out in the letter to the
202116 - VA on 140703 1938. ref SDS 74 6X40
202118 - ..
202119 - Letter from Doctor Alba continues...
202120 -
202121 - 5. Since Dr Egan is your cardiologist, I think you should make an
202122 - appointment with him to further discuss the utility of the
202123 - tests.
202125 - ..
202126 - 6. I think you have an appointment coming up in September in the
202127 - endocrinology clinic, so if you have any more questions, you
202128 - can further discuss these issues then.
202130 - ..
202131 - 7. Let me know if you need the referral to podiatry, I can do that
202132 - for you.
202134 - ..
202135 - Offer to make referral to Podiatry responds to the letter this morning
202136 - notifying that increased side effects of metatarsalgia have prevented
202137 - for past 4 weeks rather than continue care with physical activity
202138 - prescribed in Progress Notes on 140213 0830. ref SDS 55 E34O and that
202139 - Primary Care at VA Clinic in Martinez has not had time to make
202140 - referreal, per above. ref SDS 0 WL6H
202142 - ..
202143 - [...below on 140731 1048 letter to VA notifies Doctor Alba
202144 - to make referral to Podiatry. 1537 ref SDS 0 4230
202145 -
202154 -
202155 -
202157 - ..
2022 -
2023 -
2024 - 1537
2025 -
202501 - Sent letter to Doctor Alba saying...
202502 -
202503 - 1. Subject: Please Proceed Podiatry Referral
202504 - Date: 2014-07-31 16:13
202512 - ..
202513 - 2. Responding to your letter earlier today at 1253, shown above,
202514 - ref SDS 0 X45G, your recommendation to consult Doctor Egan on
202515 - ordering a coronary CTA test with calcium score was implemented
202516 - on 140430, ref SDS 57 2F6O, and again on 140710. ref SDS 75
202517 - DX7K Doubtless he's done all he can with a hectic schedule.
202519 - ..
202520 - 3. Please drop the EPC issue, and just assume I had a good number
202521 - OA 140514. EPC tests are not done often, because few customers
202522 - get to the point of testing for regression of atherosclerosis.
202523 - Since it is not a common test, it is likely expensive. While
202524 - best practice would test for elevated EPC and HDL, then test
202525 - for regression of plaques, since I have been unable to hike for
202526 - a month, EPC probably won't test well anyway at this time.
202528 - ..
202529 - 4. Coronary CTA with calcium score tests for results of therapy
202530 - treating atherosclerosis (CAD, CVD) with medication and
202531 - exercise, including weight loss. Favorable results can reduce
202532 - the cost of care, and further reduce wear and tear from
202533 - extended training, which reached critical mass last month. I
202534 - assume you have asked around and cannot find a direct, simple
202535 - way to get an order issued within the VA for the customer to
202536 - pay the cost of an outside lab, as done with NMR lipids.
202537 - Therefore, let's drop CTA issue at this time.
202539 - ..
202540 - This responds to Doctor Alba's notice that VA refuses to order CTA
202541 - paid by patient, because there is no "utility," ref SDS 0 QU4F; and
202542 - further resolves VA quandry about how to interpret EPC and CTA tests,
202543 - as causing hestancy ordering the tests, presented in her letter
202544 - earlier today, per above. ref SDS 0 0V75
202546 - ..
202547 - Since the VA is not paying for the test, there is no duty to interpret
202548 - results, and indeeed results need not be presented to the VA. There
202549 - has been no similar complaint about VA getting results of Lipid NMR
202550 - test results, which the VA refused to order, but which were paid by
202551 - the patient and submitted to the VA, shown in composite lab report on
202552 - 140514 0950. ref SDS 61 IM9N CT test results are interpreted by a
202553 - professional experienced with this work.
202555 - ..
202556 - Letter to Doctor Alba continues...
202557 -
202558 - 5. Thanks for making referral to podiatry. While some progress
202559 - has been made, work should be guided by professional medical
202560 - advice. A few weeks ago, seemed that Half Dome was not going
202561 - to be possible in September. Based on improvement the past few
202562 - days, I'm more hopeful now, even though had to stand down on
202563 - hiking today with sore feet again.
202565 - ..
202566 - This responds to Doctor Alba's letter today, with last paragraph
202567 - offering to make referral to Podiatry, per above. ref SDS 0 OV90
202569 - ..
202570 - Letter to Doctor Alba continues...
202571 -
202572 - 6. In making referral please provide patient history reporting
202573 - metatarsalgia, shown in case study on 120101 beginning line
202574 - 107952. ref SDS 18 T56H
202576 - ..
202577 - 7. Referral should remind that this is a big record, and so can
202578 - take 30 - 90 seconds to read into the browser. Naturally, I
202579 - will understand if no citation to the record is provided, and
202580 - remain very grateful for your referral to podiatry. Please
202581 - submit the precise language presented in the referral in order
202582 - to be prepared for the doctor's awareness of issues.
202584 - ..
202585 - 8. Thanks again very much for your help.
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