Original Article
Heterogeneity in venous disease practice patterns amongst primary healthcare practitioners
Vascular 2015, Vol. 23(4) 391–395 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1708538114552011 vas.sagepub.com
Anahita Dua1,2, Sapan S Desai3 and Jennifer A Heller4
Abstract Introduction: This study aimed to describe the practice patterns of primary healthcare practitioners who diagnose and manage venous disease to determine differences in clinical evaluation of disease, recognition of venous ulcers, and referral patterns. Methods: A survey was distributed at the August 2011 Primary Care Medical Conference (Pri-Med) in Baltimore, Maryland. Pri-med is a medical education company that caters to the continued professional development needs of a variety of physicians. Results: A total of 305 surveys were completed. Of the respondents, 91% were physicians and 9% were advanced level practitioners. In all, 93% prescribed compression stockings as first-line treatment. Heterogeneous referral patterns were reported with 81% referring to vascular surgery, 25% to a vein clinic, 10% to interventional radiology, and 3% to interventional cardiology. Up to 35% responded that they met resistance (did not have their referral accepted) when attempting referral to a vascular surgery colleague. There was substantial variation when asked about the treatment of deep vein thrombosis with 88% starting anticoagulation therapy, 54% prescribing compression stockings, 40% doing a thrombophilia workup, and 25% referring for lytic therapy. Conclusion: Diagnosis and management aptitude of venous disease is highly variable. Further grassroots education is required to improve diagnosis and treatment in patients with chronic venous disease.
Keywords Venous disease, thrombophlebitis care, superficial thrombophlebitis, management of venous disease
Introduction Venous insufficiency impacts more American than do coronary artery disease and peripheral vascular disease combined and is one of the most common pathologies seen by a primary care physician. Varicose veins, chronic venous disease (CVD), deep vein thrombosis (DVT) and venous thromboembolism (VTE), and venous ulceration make up the majority of venous disease in the USA. While estimates of the prevalence of varicose veins globally vary widely from 2% to 56% in men and from 1% to 60% in women, these variations are a reflection of diversity of study populations including age, race and gender, methods of measurement, and disease definition.1–3 In the USA, up to 23% (20–25 million) of people are impacted by varicose veins with 6% (1.5–2.5 million) of this cohort presenting with more advanced CVD. CVD is associated with debilitating symptoms
such as chronic skin changes, phlebitis, and ultimately, venous stasis ulceration which affects approximately 0.3% of the adult population in the USA.1–4 1 Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA 2 Center for Translational Injury Research (CeTIR), Department of Surgery, University of Texas-Houston, Houston, TX, USA 3 Department of Vascular Surgery, Southern Illinois University, Springfield, IL, USA 4 Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Center, Baltimore, MD, USA
Presented as an oral presentation at the American Venous Forum annual meeting 24th Annual Meeting, February 8–11, 2012, Orlando, Florida, USA Corresponding author: Anahita Dua MD, MS, MBA, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA. Email: [email protected]
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Debilitation from CVD results in a direct medical cost estimated between $150 million and $1 billion annually.5–7 DVT and VTE together are responsible for over 100,000 deaths in the United States annually and venous ulcer care costs exceed 3 billion dollars per year in the USA alone. The ability to treat venous disease is made possible by accurate, prompt diagnosis and appropriate early intervention. Hence, expertise in vein care and prompt interventional therapy are the key to ensuring optimum outcomes with venous disease. Since 2013, the treatment of venous disease has been primarily procedural as medications are seldom effective and conventional compression stockings only provide symptomatic relief. Given that venous disease may involve any body part either in the deep or superficial system, comprehensive knowledge and procedural skills are required for a practitioner managing venous disease to feel comfortable treating the scope patients may present within.8 However, in the USA, the majority of patients with venous disease initially presents to practitioners that may not be specialized in vein care and have evolved from primarily nonprocedural specialties including family medicine, internal medicine, dermatology, nursing, or cardiology.7,8 This may lead to substantial variation in care and can ultimately impact the patient if best practice is not being employed. This study aimed to describe the practice patterns of primary healthcare practitioners in the USA who are the first to diagnose and manage venous disease to determine differences in clinical evaluation of disease, recognition of venous ulcers, referral patterns, and perception of vascular surgeons.
Methods An 11-question survey with comprehensive questions regarding management of venous diagnosis and management strategies facing the primary care provided was provided to all practitioners who attended the Primary Care Medical Conference (Pri-Med) mid-Atlantic meeting in August 2011. Pri-med is a medical education company that caters to the continued professional development (CPD) needs of a variety of physicians.
Question development and administration We developed an 11-point questionnaire consisting of closed-ended questions in multiple-choice and true-false format. Care providers (physicians and advanced-level practitioners) were asked to complete the survey that included all patients who presented for treatment of superficial or deep venous disease as the primary diagnosis. Question included data about education level, geographic practice location, years in practice, type of practice, and the following questions:
. Large symptomatic varicose veins are a cosmetic problem – True/False . How often do you encounter symptomatic varicose veins? . Where do you refer your patients with symptomatic varicose veins? . Do you meet resistance to treat from your vascular surgeon colleagues? . When do you prescribe compression stockings? . In a case scenario with a 50-year-old patient with a 2-month history of a left medial malleolar ulcer and normal pedal pulses with no risk factors for peripheral artery disease, what is your next step? . What is your treatment algorithm for lower extremity DVT? . Would you attend a 1-day training session on the diagnosis and management of venous disease for the primary care practitioner? All Pri-med attendees who were designated as primary healthcare providers (family practice physicians, internists, physician assistants, nurse practitioners) were surveyed voluntarily via printed, anonymous surveys. Potential participants were given the survey with no monetary incentives. All response data were collected anonymously and grouped according to predefined analyses. Individual responses were kept confidential and questionnaire completion was voluntary.
Statistical analysis Statistical analysis was performed with descriptive statistics to determine practice patterns amongst practitioners.
Results There were 305 US practitioners with 91% (277) physicians and 9% (28) advanced-level practitioners (nurse practitioners, physician assistants). There was a 97% (297) response rate for the surveys distributed. Most healthcare providers (298) practiced in the Mid Atlantic region (150, 50%), followed by the Northeast region (113, 38%), the remainder hailed from the South, West, and Midwest (12%, 35). The mean number of years in practice was 20.6 years (SD 11.8). In all, 302 practitioners responded to the question regarding type of practice with the majority of participants (260, 86%) practicing in a community setting, 12% (36) in an academic setting, 4(1%) in both academic and community settings, and 2 (0.7%) practitioners responding as other. Only 3% (9) claimed not to encounter venous disease in daily practice. From 297 responses, 67% (200) said that large symptomatic varicose veins were a cosmetic problem.
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The following Figure 1 depicts the percentage of symptomatic varicose veins encounter in practice by the practitioners surveyed (Figure 1). Figure 2 depicts referral patterns of primary care practitioners in our cohort (Figure 2). Of the group surveyed, 35% felt they met with resistance when attempting to refer patients with varicose veins to their vascular surgeon colleagues. In regard to management, 93% of responders prescribed compression stockings as a first line of therapy. When given the scenario of a 50-year-old male with a 2month left medial malleolar ulcer and normal pulse exam there was substantial heterogeneity in management strategies; Figure 3 represents the next step in management for this patient (Figure 3)
Figure 1. The percentage of symptomatic varicose veins encounter in practice by the practitioners surveyed.
Management strategies for lower extremity DVT was also heterogeneous with practitioners marking multiple strategies for their initial step in DVT management. Of the total group (277), 88% (244) would prescribe anticoagulation, 25% (69) would refer for lytic therapy, 40% (110) would do a thrombophilia workup, and 54% (149) would prescribe compression stockings. The majority (84%) of those surveyed would attend a 1-day local course on the diagnosis and management of venous disease for the primary care practitioner.
Discussion The objective of this study was to determine if heterogeneity in practice patterns exist amongst practitioners in the community who are the first to diagnose and treat patients with venous disease. Our study showed that the practitioners who are the first to see venous stasis ulcer disease are not providing care in a uniform way. The attendees of this conference who completed this survey were physicians and advanced level practitioners from large demographic areas from all parts of the USA (covered multiple states); hence the subset accurately reflects the primary care practice in the US. While compression stockings are noninvasive and safe, they are beneficial only in patients who manifest mild or uncomplicated venous disease.7,8 In our practitioner sample, up to 93% were prescribing this therapy as first-line intervention. Venous ulcers are costly to treat and up to 48% recurred by the fifth year after healing.9 Furthermore, while venous ulcers are classically small initially, if undertreated they can progress to larger ulcers that are associated with more serious complications
Figure 2. Referral patterns of primary care practitioners in our cohort.
Downloaded from vas.sagepub.com by guest on July 28, 2015
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Figure 3. The next step in management for patients.
requiring more complex treatments. Without proper care, the ulcer may get infected leading to cellulitis or gangrene and eventually amputation of the part of limb.9 Given the fact that venous disease is so prevalent in the community, it is not feasible or cost-effective to have all patients with venous disease present to specialists directly. Primary care physicians serve as an excellent ‘‘gate-keeper’’ resource through which patients can be screened, initially managed, and then referred to the appropriate place depending on the pathology. However, in order to provide optimum, evidencebased, standard treatment to this large patient population, there needs to be a standard of care that all primary care practitioners adhere to regardless of geographical location, practice setting, or education level (MD versus NP or PA). Our data show that primary care practitioners demonstrate a variable fund of knowledge resulting in a heterogeneous approach to venous disease in the USA. Furthermore, up to one-third of this cohort did not perceive vascular surgeons as a friendly resource likely resulting in inappropriate referrals to other practitioners and possibly a delay in care. DVT and VTE if mismanaged can also result in dire consequences including death. While our data did show variability in practice patterns, we found that the majority of primary care physicians acknowledge this and are willing to engage in educational opportunities related to the diagnosis and management of venous disease. Comprehensive knowledge can be acquired via instructional courses, textbooks, online study, by all practitioners who manage vein disease.8 However, the procedural skills required to treat complex venous disease should involve an
advanced fellowship training in a procedure-driven specialty such as vascular surgery, interventional radiology, or interventional cardiology.8 The Intersocietal Accreditation Commission Vein Treatment Facilities (IACVTF) develops standards determined by published evidence with accreditation based on adherence to standards and risk-adjusted outcomes.8 This consortium is composed of eight sponsoring organizations: the American College of Phlebology (ACP) (two directors), American Venous Forum (AVF) (two directors), Society for Vascular Surgery (SVS) (two directors), Society for Vascular Medicine (one director), Society for Vascular Ultrasound (one director), Society of Interventional Radiology (two directors), American College of Surgeons (one director), and Society for Clinical Vascular Surgery (two directors), all focused on ensuring optimum care for patients with venous disease.8 These groups provide grassroots education that is needed to improve the primary care practitioners ability to identify and act upon venous insufficiency. Further engagement with the primary care community by these groups may yield positive results in terms of patient care.
Limitations This study was limited by the fact that data were generated through utilization of the survey method given the absence of clinical data and this has inherent limitations. Furthermore, there are competing recommendations and occasionally conflicting guidelines that have been developed and implemented by various societies that target specific specialties (Society of Vascular Surgery [SVS], Society of Radiology [SIR], American Heart Association [AHA] etc.) which may account for
Downloaded from vas.sagepub.com by guest on July 28, 2015
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variations in management preferences. This study did not document which guidelines/societies practitioners were members of in our survey regarding DVT management and treatment. This may impact treatment practices substantially and impact patient selection. For example, recent data have supported the use of compression therapy that may be best for selected patients with post-thrombotic syndrome but the allpublished guidelines are yet to appropriately delineate the specific patient group that would benefit from treatment.
Conclusion Primary care physicians diagnosis and manage the vast proportion of venous disease in the USA initially. Our study found that there is substantial variability in the way these practitioners manage patients with venous insufficiency. However, as primary care practitioners are amenable to education, further outreach to this population by vascular groups such as the AVF, ACP, and SVS is warranted. Spearheading this effort will demonstrate our willingness as vascular surgeons to treat venous insufficiency in a multi-disciplinary fashion, ensuring optimum patient care in a timely fashion. Grassroots education may lead to earlier intervention thereby decreasing the incidence of venous stasis ulceration in the United States.
Consent
Conflict of interest No conflicts of interest or financial disclosures.
References 1. Kaplan RM, Criqui MH, Denenberg JO, et al. Quality of life in patients with chronic venous disease: San Diego population study. J Vasc Surg 2003; 37: 1047–1053. 2. Gloviczki P, Comerota AJ, Dalsing MC, et al; Society for Vascular Surgery and American Venous Forum. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011; 53: 2S–48S. 3. Robertson L, Evans C and Fowkes FG. Epidemiology of chronic venous disease. Phlebology 2008; 23: 103–11. 4. Beebe-Dimmer JL, Pfeifer JR, Engle JS, et al. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol 2005; 15: 175–184. 5. Smith JJ, Garratt AM, Guest M, et al. Evaluating and improving health-related quality of life in patients with varicose veins. J Vasc Surg 1999; 30: 710–719. 6. Korn P, Patel ST, Heller JA, et al. Why insurers should reimburse for compression stockings in patients with chronic venous stasis. J Vasc Surg 2002; 35: 950–957. 7. Heller J. Treatment of chronic venous insufficiency: how current technology is changing our approach. Endovascular Today October 2011. 8. Elias S and Almeida JI. Who should treat vein disease? Defining higher standards for vein specialists. Endovascular Today July 2012. 9. Brem H, Kirsner RS and Falanga V. Protocol for the successful treatment of venous ulcers. Am J Surg 2004; 188: 1–8.
There were no patients involved in this study and hence consent is not applicable. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Downloaded from vas.sagepub.com by guest on July 28, 2015
Heterogeneity in venous disease practice patterns amongst primary healthcare practitioners
Vascular 2015, Vol. 23(4) 391–395 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1708538114552011 vas.sagepub.com
Anahita Dua1,2, Sapan S Desai3 and Jennifer A Heller4
Abstract Introduction: This study aimed to describe the practice patterns of primary healthcare practitioners who diagnose and manage venous disease to determine differences in clinical evaluation of disease, recognition of venous ulcers, and referral patterns. Methods: A survey was distributed at the August 2011 Primary Care Medical Conference (Pri-Med) in Baltimore, Maryland. Pri-med is a medical education company that caters to the continued professional development needs of a variety of physicians. Results: A total of 305 surveys were completed. Of the respondents, 91% were physicians and 9% were advanced level practitioners. In all, 93% prescribed compression stockings as first-line treatment. Heterogeneous referral patterns were reported with 81% referring to vascular surgery, 25% to a vein clinic, 10% to interventional radiology, and 3% to interventional cardiology. Up to 35% responded that they met resistance (did not have their referral accepted) when attempting referral to a vascular surgery colleague. There was substantial variation when asked about the treatment of deep vein thrombosis with 88% starting anticoagulation therapy, 54% prescribing compression stockings, 40% doing a thrombophilia workup, and 25% referring for lytic therapy. Conclusion: Diagnosis and management aptitude of venous disease is highly variable. Further grassroots education is required to improve diagnosis and treatment in patients with chronic venous disease.
Keywords Venous disease, thrombophlebitis care, superficial thrombophlebitis, management of venous disease
Introduction Venous insufficiency impacts more American than do coronary artery disease and peripheral vascular disease combined and is one of the most common pathologies seen by a primary care physician. Varicose veins, chronic venous disease (CVD), deep vein thrombosis (DVT) and venous thromboembolism (VTE), and venous ulceration make up the majority of venous disease in the USA. While estimates of the prevalence of varicose veins globally vary widely from 2% to 56% in men and from 1% to 60% in women, these variations are a reflection of diversity of study populations including age, race and gender, methods of measurement, and disease definition.1–3 In the USA, up to 23% (20–25 million) of people are impacted by varicose veins with 6% (1.5–2.5 million) of this cohort presenting with more advanced CVD. CVD is associated with debilitating symptoms
such as chronic skin changes, phlebitis, and ultimately, venous stasis ulceration which affects approximately 0.3% of the adult population in the USA.1–4 1 Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA 2 Center for Translational Injury Research (CeTIR), Department of Surgery, University of Texas-Houston, Houston, TX, USA 3 Department of Vascular Surgery, Southern Illinois University, Springfield, IL, USA 4 Division of Vascular Surgery, Department of Surgery, Johns Hopkins Medical Center, Baltimore, MD, USA
Presented as an oral presentation at the American Venous Forum annual meeting 24th Annual Meeting, February 8–11, 2012, Orlando, Florida, USA Corresponding author: Anahita Dua MD, MS, MBA, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA. Email: [email protected]
Downloaded from vas.sagepub.com by guest on July 28, 2015
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Debilitation from CVD results in a direct medical cost estimated between $150 million and $1 billion annually.5–7 DVT and VTE together are responsible for over 100,000 deaths in the United States annually and venous ulcer care costs exceed 3 billion dollars per year in the USA alone. The ability to treat venous disease is made possible by accurate, prompt diagnosis and appropriate early intervention. Hence, expertise in vein care and prompt interventional therapy are the key to ensuring optimum outcomes with venous disease. Since 2013, the treatment of venous disease has been primarily procedural as medications are seldom effective and conventional compression stockings only provide symptomatic relief. Given that venous disease may involve any body part either in the deep or superficial system, comprehensive knowledge and procedural skills are required for a practitioner managing venous disease to feel comfortable treating the scope patients may present within.8 However, in the USA, the majority of patients with venous disease initially presents to practitioners that may not be specialized in vein care and have evolved from primarily nonprocedural specialties including family medicine, internal medicine, dermatology, nursing, or cardiology.7,8 This may lead to substantial variation in care and can ultimately impact the patient if best practice is not being employed. This study aimed to describe the practice patterns of primary healthcare practitioners in the USA who are the first to diagnose and manage venous disease to determine differences in clinical evaluation of disease, recognition of venous ulcers, referral patterns, and perception of vascular surgeons.
Methods An 11-question survey with comprehensive questions regarding management of venous diagnosis and management strategies facing the primary care provided was provided to all practitioners who attended the Primary Care Medical Conference (Pri-Med) mid-Atlantic meeting in August 2011. Pri-med is a medical education company that caters to the continued professional development (CPD) needs of a variety of physicians.
Question development and administration We developed an 11-point questionnaire consisting of closed-ended questions in multiple-choice and true-false format. Care providers (physicians and advanced-level practitioners) were asked to complete the survey that included all patients who presented for treatment of superficial or deep venous disease as the primary diagnosis. Question included data about education level, geographic practice location, years in practice, type of practice, and the following questions:
. Large symptomatic varicose veins are a cosmetic problem – True/False . How often do you encounter symptomatic varicose veins? . Where do you refer your patients with symptomatic varicose veins? . Do you meet resistance to treat from your vascular surgeon colleagues? . When do you prescribe compression stockings? . In a case scenario with a 50-year-old patient with a 2-month history of a left medial malleolar ulcer and normal pedal pulses with no risk factors for peripheral artery disease, what is your next step? . What is your treatment algorithm for lower extremity DVT? . Would you attend a 1-day training session on the diagnosis and management of venous disease for the primary care practitioner? All Pri-med attendees who were designated as primary healthcare providers (family practice physicians, internists, physician assistants, nurse practitioners) were surveyed voluntarily via printed, anonymous surveys. Potential participants were given the survey with no monetary incentives. All response data were collected anonymously and grouped according to predefined analyses. Individual responses were kept confidential and questionnaire completion was voluntary.
Statistical analysis Statistical analysis was performed with descriptive statistics to determine practice patterns amongst practitioners.
Results There were 305 US practitioners with 91% (277) physicians and 9% (28) advanced-level practitioners (nurse practitioners, physician assistants). There was a 97% (297) response rate for the surveys distributed. Most healthcare providers (298) practiced in the Mid Atlantic region (150, 50%), followed by the Northeast region (113, 38%), the remainder hailed from the South, West, and Midwest (12%, 35). The mean number of years in practice was 20.6 years (SD 11.8). In all, 302 practitioners responded to the question regarding type of practice with the majority of participants (260, 86%) practicing in a community setting, 12% (36) in an academic setting, 4(1%) in both academic and community settings, and 2 (0.7%) practitioners responding as other. Only 3% (9) claimed not to encounter venous disease in daily practice. From 297 responses, 67% (200) said that large symptomatic varicose veins were a cosmetic problem.
Downloaded from vas.sagepub.com by guest on July 28, 2015
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The following Figure 1 depicts the percentage of symptomatic varicose veins encounter in practice by the practitioners surveyed (Figure 1). Figure 2 depicts referral patterns of primary care practitioners in our cohort (Figure 2). Of the group surveyed, 35% felt they met with resistance when attempting to refer patients with varicose veins to their vascular surgeon colleagues. In regard to management, 93% of responders prescribed compression stockings as a first line of therapy. When given the scenario of a 50-year-old male with a 2month left medial malleolar ulcer and normal pulse exam there was substantial heterogeneity in management strategies; Figure 3 represents the next step in management for this patient (Figure 3)
Figure 1. The percentage of symptomatic varicose veins encounter in practice by the practitioners surveyed.
Management strategies for lower extremity DVT was also heterogeneous with practitioners marking multiple strategies for their initial step in DVT management. Of the total group (277), 88% (244) would prescribe anticoagulation, 25% (69) would refer for lytic therapy, 40% (110) would do a thrombophilia workup, and 54% (149) would prescribe compression stockings. The majority (84%) of those surveyed would attend a 1-day local course on the diagnosis and management of venous disease for the primary care practitioner.
Discussion The objective of this study was to determine if heterogeneity in practice patterns exist amongst practitioners in the community who are the first to diagnose and treat patients with venous disease. Our study showed that the practitioners who are the first to see venous stasis ulcer disease are not providing care in a uniform way. The attendees of this conference who completed this survey were physicians and advanced level practitioners from large demographic areas from all parts of the USA (covered multiple states); hence the subset accurately reflects the primary care practice in the US. While compression stockings are noninvasive and safe, they are beneficial only in patients who manifest mild or uncomplicated venous disease.7,8 In our practitioner sample, up to 93% were prescribing this therapy as first-line intervention. Venous ulcers are costly to treat and up to 48% recurred by the fifth year after healing.9 Furthermore, while venous ulcers are classically small initially, if undertreated they can progress to larger ulcers that are associated with more serious complications
Figure 2. Referral patterns of primary care practitioners in our cohort.
Downloaded from vas.sagepub.com by guest on July 28, 2015
394
Vascular 23(4)
Figure 3. The next step in management for patients.
requiring more complex treatments. Without proper care, the ulcer may get infected leading to cellulitis or gangrene and eventually amputation of the part of limb.9 Given the fact that venous disease is so prevalent in the community, it is not feasible or cost-effective to have all patients with venous disease present to specialists directly. Primary care physicians serve as an excellent ‘‘gate-keeper’’ resource through which patients can be screened, initially managed, and then referred to the appropriate place depending on the pathology. However, in order to provide optimum, evidencebased, standard treatment to this large patient population, there needs to be a standard of care that all primary care practitioners adhere to regardless of geographical location, practice setting, or education level (MD versus NP or PA). Our data show that primary care practitioners demonstrate a variable fund of knowledge resulting in a heterogeneous approach to venous disease in the USA. Furthermore, up to one-third of this cohort did not perceive vascular surgeons as a friendly resource likely resulting in inappropriate referrals to other practitioners and possibly a delay in care. DVT and VTE if mismanaged can also result in dire consequences including death. While our data did show variability in practice patterns, we found that the majority of primary care physicians acknowledge this and are willing to engage in educational opportunities related to the diagnosis and management of venous disease. Comprehensive knowledge can be acquired via instructional courses, textbooks, online study, by all practitioners who manage vein disease.8 However, the procedural skills required to treat complex venous disease should involve an
advanced fellowship training in a procedure-driven specialty such as vascular surgery, interventional radiology, or interventional cardiology.8 The Intersocietal Accreditation Commission Vein Treatment Facilities (IACVTF) develops standards determined by published evidence with accreditation based on adherence to standards and risk-adjusted outcomes.8 This consortium is composed of eight sponsoring organizations: the American College of Phlebology (ACP) (two directors), American Venous Forum (AVF) (two directors), Society for Vascular Surgery (SVS) (two directors), Society for Vascular Medicine (one director), Society for Vascular Ultrasound (one director), Society of Interventional Radiology (two directors), American College of Surgeons (one director), and Society for Clinical Vascular Surgery (two directors), all focused on ensuring optimum care for patients with venous disease.8 These groups provide grassroots education that is needed to improve the primary care practitioners ability to identify and act upon venous insufficiency. Further engagement with the primary care community by these groups may yield positive results in terms of patient care.
Limitations This study was limited by the fact that data were generated through utilization of the survey method given the absence of clinical data and this has inherent limitations. Furthermore, there are competing recommendations and occasionally conflicting guidelines that have been developed and implemented by various societies that target specific specialties (Society of Vascular Surgery [SVS], Society of Radiology [SIR], American Heart Association [AHA] etc.) which may account for
Downloaded from vas.sagepub.com by guest on July 28, 2015
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variations in management preferences. This study did not document which guidelines/societies practitioners were members of in our survey regarding DVT management and treatment. This may impact treatment practices substantially and impact patient selection. For example, recent data have supported the use of compression therapy that may be best for selected patients with post-thrombotic syndrome but the allpublished guidelines are yet to appropriately delineate the specific patient group that would benefit from treatment.
Conclusion Primary care physicians diagnosis and manage the vast proportion of venous disease in the USA initially. Our study found that there is substantial variability in the way these practitioners manage patients with venous insufficiency. However, as primary care practitioners are amenable to education, further outreach to this population by vascular groups such as the AVF, ACP, and SVS is warranted. Spearheading this effort will demonstrate our willingness as vascular surgeons to treat venous insufficiency in a multi-disciplinary fashion, ensuring optimum patient care in a timely fashion. Grassroots education may lead to earlier intervention thereby decreasing the incidence of venous stasis ulceration in the United States.
Consent
Conflict of interest No conflicts of interest or financial disclosures.
References 1. Kaplan RM, Criqui MH, Denenberg JO, et al. Quality of life in patients with chronic venous disease: San Diego population study. J Vasc Surg 2003; 37: 1047–1053. 2. Gloviczki P, Comerota AJ, Dalsing MC, et al; Society for Vascular Surgery and American Venous Forum. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011; 53: 2S–48S. 3. Robertson L, Evans C and Fowkes FG. Epidemiology of chronic venous disease. Phlebology 2008; 23: 103–11. 4. Beebe-Dimmer JL, Pfeifer JR, Engle JS, et al. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol 2005; 15: 175–184. 5. Smith JJ, Garratt AM, Guest M, et al. Evaluating and improving health-related quality of life in patients with varicose veins. J Vasc Surg 1999; 30: 710–719. 6. Korn P, Patel ST, Heller JA, et al. Why insurers should reimburse for compression stockings in patients with chronic venous stasis. J Vasc Surg 2002; 35: 950–957. 7. Heller J. Treatment of chronic venous insufficiency: how current technology is changing our approach. Endovascular Today October 2011. 8. Elias S and Almeida JI. Who should treat vein disease? Defining higher standards for vein specialists. Endovascular Today July 2012. 9. Brem H, Kirsner RS and Falanga V. Protocol for the successful treatment of venous ulcers. Am J Surg 2004; 188: 1–8.
There were no patients involved in this study and hence consent is not applicable. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Downloaded from vas.sagepub.com by guest on July 28, 2015
