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L. Nelson "Nick" Hopkins III, MD -- Part One

Angioplasty.Org recently talked with Dr. L. Nelson "Nick" Hopkins, Chairman of Neurosurgery, Professor of Radiology, and Director of the Toshiba Stroke Research Center at the University at Buffalo, State University of New York. Truly one of the pioneers in the treatment of stroke, as well as the non-surgical therapies developed to treat both stroke and carotid disease, Dr. Hopkins provides a unique perspective into the growing area of cross-specialty and multidisciplinary collaboration between and among medical specialities.

This three-part interview covers a range of topics:

  • Part One discusses the diagnosis and treatment of stroke;
  • Part Two deals with carotid artery disease;
  • Part Three discusses how imaging may impact future treatment, and how reimbursement questions must be resolved for this field to move forward.



L. Nelson "Nick" Hopkins III, MD
L. Nelson Hopkins, MD
University of Buffalo

Q: Where do you see hopes of the future of this field in terms of imaging and treatment of neuro procedures, etc?
Dr. Hopkins: We work predominantly in the neuro field anywhere from the upper chest on up, so anything in the brachiocephalic circulation is for us an area of focus. I think this field is progressing at a very rapid rate. I believe that more and better non-invasive imaging is helping us greatly. I believe that less-invasive procedures are gradually going to replace the more invasive procedures as we are able to make them safer and better. In the meantime, we just need to make sure we get good judgment when we have a patient with carotid stenosis. It’s really all about judgment at this point; it’s making the right choice for each individual patient. So I think the field is fascinating and exciting and the future is I think more and more going to be less and less invasive. That would be my take.

Q: The growth of the cross-disciplinary approach seems to be a model that’s going to grow. Are there incentives or a model can be used?
Dr. Hopkins: I think that there are opportunities for that to grow. I think there are models beginning to pop up where there interdisciplinary teams working together. And I think that hopefully is the future. We have to get people to put turf aside and realize that there are so many patients out there with vascular disease. There’s a role for everyone in all the disciplines that are focused on this area. And the more we work together, I think the better job we’re going to do.

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Millard Fillmore Gates Circle Hospital, Buffalo NY

We’re working on developing a multi-disciplinary vascular center here in Buffalo, and we’re doing a lot with just cross-training. Right now we have this artificial division between open surgery and interventional procedures, and I think that distinction is gradually going to go away.

I think more and more people in all these disciplines are going to find that people who take care of patients with vascular disease are going to be those who can perform both surgery and interventional procedures or best medical therapy. So we are gradually moving towards that; it’s going to take time.

I think the other very difficult thing is that Medicare is becoming more and more difficult as a partner, because if a device is safe and if it’s proven effective, the FDA tends to approve it. Then Medicare turns around and says, “Well, that doesn’t matter to us. What matters is to us is what they call reasonable and necessary,” so that they require what appears to be a much higher level of evidence in order for them to begin to pay for a procedure. So, we have to get FDA and CMS together. I think CMS is probably being a little short-sighted at this point because the less invasive procedures are going to be more effective and cost less in the future, but right now they’re still having problems accepting FDA approval as a condition for reimbursement. That makes it tough on everybody.

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Q: Recently Medicare changed parameters for carotid stenting, and another issue with reimbursement for imaging. There are some who say that more non-invasive imaging will lead to more and possibly unnecessary procedures.
Dr. Hopkins: Well, I think that it’s incumbent upon us to utilize imaging in the most effective way. I think that we are constantly learning more about imaging, and I think multi-modality imaging is always better in terms of giving you the total picture of a patient’s given vascular situation.

If you make a mistake in the treatment of a patient with vascular disease, the price you pay is extremely high. Like for example, a stroke. If you don’t have adequate imaging and therefore you end up having a stroke because you weren’t able to learn everything that could’ve helped you, that’s a penny-wise pound-foolish decision to turn down legitimate requests for imaging.

I think it is reasonable to turn down requests from people who don’t normally know how to deal with those images. To think that primary care docs would be ordering CT angiograms and MR angiograms routinely, I can understand why Medicare would balk somewhat at that because they don’t normally use those modalities as much as the people who are treating the patients. So I think that limiting imaging studies to those who are capable of using the imaging a little better might be reasonable. But to deny the imaging I think is potentially hurting the patient. And if you hurt the patient and the patient has a stroke, it’s going to cost the federal government a fortune compared to the cost of that imaging study. So I don’t think it makes sense to kind of limit non-invasive vascular imaging at this point in time, we’ve got a lot to learn and every month we learn something new that helps us.

Q: Thank you, Dr. Hopkins.

For the latest news and information about imaging, visit Angioplasty.Org's Imaging and Diagnosis Center.

(return to Part One)

This interview was conducted by Burt Cohen of Angioplasty.Org.