Rationing of Treatment for Varicose Veins and Use of New Treatment Methods: A Survey of Practice in the United Kingdom
Article Outline
Introduction
This study aimed to document the extent of rationing of treatment for varicose veins in the United Kingdom (UK) national health services and the extent to which new treatments are being used.
Report
Completed questionnaires were received from 75% (307/411) vascular surgeons from all areas of the UK. 46% restricted access to treatment – 13% in the absence of local referral guidance. 76% would treat patients privately who did not fulfil their health service criteria. In the health service vs private practice, foam sclerotherapy was used by 28 vs 42; radiofrequency ablation by 8 vs 30; and laser ablation by 16 vs 22.
Discussion
Rationing of health service treatment for varicose veins is common in the UK. More explicit selection criteria are required for introduction of new treatments and reconfigured services.
Keywords: Varicose veins, Hospital referrals, Health services, Health policy
Introduction
Varicose veins are common and many people want treatment for a range of symptoms, including discomfort and cosmetic embarrassment. When they cause complications, such as lipodermatosclerosis, ulcers or bleeding there is a clear medical indication for advising treatment. However, patients with uncomplicated but “symptomatic” varicose veins pose a potentially huge financial burden to health services throughout Europe. In the United Kingdom they are widely perceived as deserving low priority despite national guidance on referrals which advises referral to a specialist if patients “have troublesome symptoms attributable to their varicose veins, and/or they or their GP [primary care physician] feel that the extent, site or size of the varicosities are having a severe impact on quality of life”.1 Access to treatment is “rationed” by many hospitals, but the nature and extent of this rationing is unknown.2
In the United Kingdom surgery has traditionally been the predominant treatment. New methods such as foam sclerotherapy3 may reduce costs and offer the possibility of treatment to more patients within cash limited health services. Their introduction will require transparent criteria for referral and selection for treatment. This study aimed to document current restrictions in varicose vein treatment in the United Kingdom and also to discover how widely new treatment methods are being used.
Report
Questionnaires were sent to 411 members of the Vascular Society of Great Britain and Ireland during the latter part of 2005. Responses were received from 307 surgeons (75%) representing all 28 Strategic Health Authorities in England, and most other areas throughout the United Kingdom. The Republic of Ireland was not included. Among those who responded to each question, 160 (54%) had local referral guidance for primary care, and 141 (46%) restricted access to outpatient consultation – 19 (13%) in the absence of referral guidance. One hundred and thirty consultants did not see patients with only cosmetic concerns (129) or with discomfort/swelling (32). Surgical treatment was not offered by 120 consultants to all patients who wanted it; but 76% (143/188) of consultants said they were prepared to treat patients privately who did not fulfil their criteria for National Health Service (NHS) care.
Newer treatments were used (NHS vs private practice respectively) by the following numbers of consultants: foam sclerotherapy 28 vs 42; radiofrequency ablation 8 vs 30 and laser ablation 16 vs 22.
Discussion
This study shows that 54% of vascular surgeons restrict access to outpatient consultation for people with varicose veins, most as a result of published local guidance: even for patients attending hospital many surgeons are not prepared to offer health service treatment to all those who want it. These practices seem out of tune with recent evidence supporting the clinical and cost effectiveness of varicose vein surgery and sclerotherapy,4 and also with national guidance which supports referral as described in the Introduction.1
The high prevalence of varicose veins is a driving force in rationing of treatment. Other influences are the beliefs of many clinicians and healthcare providers that varicose veins are medically unimportant and that some patients exaggerate symptoms to obtain treatment for cosmetic motives; and scepticism about the significance of leg symptoms, which are often not due to concomitant varicose veins.5 A few people have gross interference with their lives because of cosmetic concerns, but value judgements about offering treatment are difficult.
The precise place of new treatments such as foam sclerotherapy and ablation by laser or radiofrequency is not yet clear: this survey supports the belief that their use is more common in private practice than in the state funded health service. Foam sclerotherapy in particular is becoming popular, but its widespread introduction would require reconfiguration of facilities – transferring from operating theatres, and provision of ultrasound scanners. These important changes would be better planned in the context of explicit and consistent agreements about criteria for treatment of varicose veins. Data on the services and treatment methods used for varicose veins in other parts of Europe would offer interesting comparison.
Acknowledgement
We thank all the surgeons who completed questionnaires for this study.
Ethics Approval. Approval for this study was sought and granted through the Research Governance processes of the Royal Devon and Exeter Healthcare Trust (study number 509110: reference number 2004/12/146).
Funding. None.
Contributions of authors. Bruce Campbell conceived and supervised the study and was principal author. Ben Lindsey assisted in design of the study, conducted the survey and collated the figures.
References
- National Institute for Clinical Excellence NICE 2001/043. Referral advice. Issued: 20 December 2001.
- . Surgical treatment of varicose veins: the effect of rationing. Ann R Coll Surg Engl. 2006;88:37–39
- . New treatments for varicose veins. BMJ. 2002;324:689–690
- . Cost effectiveness analysis of surgery versus conservative treatment for uncomplicated varicose veins in a randomized clinical trial. Br J Surg. 2006;93:182–186
- . What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. BMJ. 1999;318:353–356
PII: S1533-3167(06)00060-4
doi:10.1016/j.ejvsextra.2006.05.002
© 2006 Elsevier Ltd. All rights reserved.
