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Recommendations for the referral and treatment of patients with lower limb chronic venous insufficiency

In the current issue of Phlebology, the Venous Forum of the Royal Society of Medicine presents ‘Recommendations for the referral and treatment of patients with lower limb chronic venous insufficiency (including varicose veins)’. The rationale for this undertaking is based on the fact that ‘few of the many existing referral guidelines are evidence-based, and ‘localism’ (in the UK) in decision making perpetuates the injustice of the ‘postcode lottery’’. The postcode lottery is a term used to explain the variations in the provision and quality of public services from district to district, which don’t appear to be explained by social or patient factors. The RSM points out that ‘explicit and implicit rationing by purchasers and General Practitioners (GP) has led to a decrease in the number of interventions performed for CVI by the NHS’. The aim of the guidelines is an admirable one, ‘to offer an evidence-based, expert view as to how NHS resources made available for the treatment of CVI might be used in the most clinically and costeffective manner’. Supported by ample published evidence, these guidelines assert that conservative and interventional treatment of chronic venous insufficiency (CVI), in properly selected patients, will result in significant improvements in quality-of-life (QoL) the prevention of CVI complications and be ‘a highly cost-effective use of NHS resources’. The guidelines recommend referral to a vascular surgeon for clinical and duplex ultrasound assessment and intervention if deemed appropriate in patients with significant venous disease. This applies to patients with C1–C3 disease and significant lower limb symptoms that impair QoL; patients who have not responded to conservative therapy; or those with significant oedema. They state, ‘it is anticipated that most such patients will benefit from and should receive treatment aimed at the eradication of superficial venous reflux’. Endorsing the National Institute for Health and Clinical Excellence referral guidelines, those of the RSM also support urgent referral for patients with superficial thrombophlebitis, bleeding from varicosities or complicated (C4–6) disease. Further, they recommend that all C4 patients as well as all patients with a history of suspected chronic venous ulceration (C5 patients) should be referred for a full clinical and duplex ultrasound assessment supported by other diagnostic tests as deemed appropriate. Finally, the guidelines suggest ‘all patients with a break in the skin below the knee that has failed to heal within 2 weeks (potential C6) should be referred urgently (within 2 weeks)’. The guidelines specifically recommend referral to a vascular surgeon in all cases. New concepts and innovations in Duplex imaging and in the diagnosis and treatment of common vein disorders have created heightened interest by physicians across a broad range of specialty backgrounds. Primary care physicians, general surgeons, interventional radiologists, dermatologists and physicians can now do many vein procedures in an office setting via percutaneous or simple surgical procedures from other specialty backgrounds. In the USA, the American Board of Phlebology (ABPh) was created in response to the concern that there exists no residency devoted to training physicians in the field of phlebology, that the level of training in venous procedures is very diverse across existing training programmes, including vascular surgery, and that many physicians in those specialties have had little or no training in phlebology during their residency or fellowship programmes. The ABPh is designed to advance specialized care for patients with venous disease by providing a certification that rigorously evaluates whether a physician has the necessary knowledge, skills and abilities to provide high-quality care for venous disorders. As of February 2011, the ABPh has 477 Diplomates with specialty backgrounds that include vascular surgery, general surgery, interventional radiology, family practice, internal medicine, vascular medicine, dermatology, plastic surgery and gynaecology. Approximately 100 physicians have applied to sit for the 2011 certification exam. The evidence-based expert guidelines of the RSM are welcome and reasonable, ones that would help balance the burden of venous disease and limited health-care resources. It should be noted that in many countries physicians from backgrounds other than vascular surgery have provided competent care as well as important contributions