The ankle pressure index is a non-invasive diagnostic method, thanks to which the doctor obtains information about the ratio of arterial pressures in the upper and lower limbs. It is the most reliable way to detect ICHDK. At the Primary CareCongress, Ondřej Sobotka, MD, spoke with the managing director of Compek Medical Services, Ltd., which offers GPs an effective tool for this examination.

Today I would like to welcome our next guest, Petr Čermák from Compek.

Thanks, bye.

I have a soft spot for devices and I've used a lot of things in my office, but I don't have an "A-Be" in there yet. I wanted to ask you if you could tell us what the Ankle Brachial Index is, what the device does, and why I should get one as a practitioner?

It's a simple screening for lower extremity ischemic disease. "Sciatica" doesn't hurt, and if it's found late, the patient usually already has a very short claudication distance and then it's about some necessary interventions. If it is found early, it is generally better for everyone and our device can help a lot.

Do you have any numbers or studies to show that it's medically worthwhile?

There was one study on this, run in collaboration with the Czech Society of Angiology and the Society of General Medicine. It started around 2008, ran until 2012, and was the basis for the later establishment of the procedure code 12024. In that study, there was I think a 13.5% detection rate of IHDK in a cross-sectional population over 50. It was originally called My ICHDK, but Associate Professor Karetová got it accepted into an impacted journal and with that it was renamed The Czech ABI Project. The numbers are certainly traceable and I think it came out very nicely. I can still remember Dr. Karetová running from one lecture to the next around our booth during the cardiac congress and saying, guys, it worked out well, I'll stop by. Those are the things that stick with you.

I like how technology is helping us detect different diseases earlier and earlier.

When the MOET ICHDK project started, they used handheld dopplers for diagnosis. However, this proved to be absolutely useless in the practitioner because it takes time. I remember a workshop with an angiologist, Dr Much. A local doctor invited a patient who completely wrecked the workshop. He was a gentleman with an AB index of I think somewhere around 0.3-0.4, which is severe IHDK, and by the time the doctor measured him with the Doppler, the workshop was over, because the examination took maybe half an hour.

That's really not applicable to a practitioner.

There was a Get ABI study running in Germany and it turns out that dopplers are not the way to go there either. Professor Diehm partnered with Boso and together they developed the first device called the Boso ABIStop. We're talking about 2007, 2008 or so. And then there was a long way to go, roughly seven years, before the code that has existed since January 1, 2014, was even created.

You mentioned Germany. What is the experience with this examination abroad? Is it carried out, is it part of any standard examination?

We were the first country to have a performance code. Thanks to the Czech Society of Angiology and the Association of General Practitioners of the Czech Republic, where Dr. Šonka was behind it. In Germany, it's standard for general practitioners. I know that Boso sells a lot of its devices in the Nordic countries as well, so I think it is a widely used examination in Europe in the last ten years. It used to be done as well, but probably only in specialist clinics.

Is it a test that can be performed by a general practitioner?

I would correct you, a doctor can do it too, of course, but it's an examination that a trained nurse can easily do.

And how long does it take?

The examination takes one or two minutes at most. It's simple, quick, four cuffs are put on the four limbs and the nurse presses a button to measure all four pressures. And the machine or the operating software calculates everything.

So you get a report out of it?

It comes out as a report, AB index right, AB index left. And there are clearly defined limits. What's above 0.9 is physiological, what's below 0.9 is pathological, and the machine determines the possible levels of ICHDK - mild, moderate, severe. According to that, the doctor will proceed and send the patient to a specialist.

Your company sells a device to measure the AB index. Is there any competition?

Of course, in the time since Boso developed and manufactured this device, there have been several competing devices that are already sold on the Czech market today.

I would be interested to know, in a general way, what is the purchase cost of such a device?

We offer the device in two variants. One is a basic ABI, the other variant is with pulse wave velocity measurement, which is not yet very popular in the Czech Republic. But I think it's a shame, because that's another cardiovascular risk factor that would fit very well into the whole screening. The basic machine costs around 60,000, the more expensive one around 90,000.

That's doable. You mentioned that insurance is already covering the procedure at the moment. What do I need as a practitioner to get the procedure?

In order to schedule procedure code 12024, you need proof of device charge, a statement of compliance, and an application to send to the health insurance company.

You'll supply me with the first two. I have to write the application. Don't you want to supply that with the application?

We'll supply it with the training report. They might want you to do that, too.

What's the approximate fee at the moment?

We're talking March 2024, the reimbursement is 159 points. Times the value of the points you have as a GP. And at that reimbursement, the payback is roughly 380 examinations.

Can you tell by eye how long it will take me to recoup my investment in the machine?

If you have plus or minus 2,000 patients on your circuit, it's easily a year.

Are there any other costs associated with the operation?

It's an electrical device, so obviously power. Plus, the ABI measures pressure, so it's a set gauge. Every two years you need to do a safety inspection and metrological verification of the accuracy of the pressure measurement. This task costs about 2500,-. And so you don't have to send the instruments out of the office, we have technicians who go to the offices and do the BTK and metrology on the spot. You just always need to get to the office to get it.

Well, that can be a problem.

The time management can be quite complicated.

You'll have to try to get an appointment at the office through Emmy.

Well, that's what I'm running out of. That would be the solution. But that would require Emmy to have 100% market coverage. Then it would be good.

You can make it happen. You mentioned two types of devices, the basic one and the pulse wave one. What type of scan is that? What does it give us and what is the output?

The output is two numbers. One on the right limb, one on the left. They show the rate of blood flow in the vascular system. It has its limits. When the aortic wall is stiff, blood flows faster here. The faster it's going, the stiffer the wall, and the more risky the patient's condition.

Is this the first sign of atherosclerosis?

The patient may have a beautiful ABI because they will have pressures in the lower upper extremities very similar. But it's from the velocity of blood flow that we can tell that the wall is stiff and pick up another marker of risk.

Are there any values already set?

When it comes to carotid femoral pulse velocity, there's a limit of 10 meters per second. And if it's the brachialis anguli, it's 14.5 meters per second. When it's over the limit, it needs to be taken into account given the patient's overall condition.

And so the output is some index, a number that expresses some increased risk of atherosclerosis. For me as a practitioner, that should mean being more stringent in the treatment of hypertension, diabetes, hyperlipidemia.Are there already any "guidelines" for this, or are they not yet set in the Czech Republic?

In Slovakia they already have a performance code for hypertension care. And there is automatically ABI plus pulse wave velocity. In the Czech Republic there is code 11112, which is an internal medicine procedure code. But it is not yet shared with general medicine specialty, only with angiology codes, or with angiology or cardiology specialty.

My question was aimed more at whether there are guidelines already set. That is, if the value of this index is somehow elevated, the velocity of that pulse wave would be higher, does that mean that I have to be stricter in such a patient, for example, in the administration of a statin, or to reach even lower values with the treatment of the pressure, because there are already initial signs of atherosclerosis?

Personally, I don't think it's entirely pressure related because the ABI can be really nice, there can be equal pressures in the lower and upper extremities, but by making that wall stiffer, there's probably going to be more susceptibility to mediocalcinosis. Or it's going to be a patient who's maybe already approaching some diabetes and so on. That's for you as a doctor to treat, I'm a technician. Here in the Czech Republic, pulse velocity is a cinderella. So far I know that the code exists, it is made on a slightly different machine, but in Slovakia let's say 95% of the machines are pulse wave. Here in the Czech Republic, about 40-50 doctors have pulse wave, here it is really not enough yet. But people are asking about it. In addition, we had an experience during the installation of the device that we tested a volunteer within the staff we were training, the ABI came out beautiful, but the pulse wave was out of tolerance.

Oh well, a healthy patient is just a poorly examined patient. So, of course, when we try things on ourselves, we find out things. I have to say, you've got me pretty tempted, and I think if I were considering the "Abe", I'd consider the pulse wave option right away.

It's probably a similar situation to ultrasounds today. Those who want to increase the credit of the ambulance will get an ultrasound, even if the insurance company won't pay for it, but they will do something extra for their patients. And it won't require as much unsolicited care.

Of course, the sooner I catch the patient, the sooner I can start treating and the more likely they won't end up with an intervention. Sounds good. Peter, thank you. That was interesting. You can't keep up with all the trends. And especially with technology, we don't see everything. That's why I'm glad that we're also meeting people from companies at conferences, and that you're going to give us a lot of insight from a technician's perspective. Maybe it will also inspire some colleagues and make them think if ABI makes sense for them in the office.

Thank you for inviting me. It was my first interview and it was enjoyable. Thank you