Abstract
INTRODUCTION
Recent research confirms that uncomplicated varicose vein surgery provides significant benefits in terms of quality of life compared to conservative treatment at a relatively small cost. There appear to be major variations in indications for treating varicose veins across the UK and this seems to be based mainly on financial restraint imposed by local Primary Care Trusts (PCTs). This survey was aimed at quantifying this variation.
MATERIALS AND METHODS
An E-mail questionnaire was sent to 245 surgical members of the Vascular Society of Great Britain and Ireland across the UK. The main questions asked were aimed at finding out whether surgeons were having any restrictions imposed on them by their local PCTs with regard to treatment of varicose veins.
RESULTS
A total of 109 surgeons replied (44% response rate). Of these, 64% of surgeons had restrictions set upon them by their local PCTs; however, 62% of surgeons under restrictions still offered surgery for symptomatic uncomplicated varicose veins. Restrictions varied from 100% to 0% across different regions in the UK.
CONCLUSIONS
Many patients are denied surgical treatment for their symptomatic uncomplicated varicose veins according to where they live in the UK regardless of their symptoms.
Keywords: Varicose vein surgery - Audit, E-mail survey
A significant proportion of the adult population in industrialised countries is affected by varicose vein disease. The Edinburgh Vein Study, a cross-sectional survey of a random sample of the Edinburgh population, showed that 40% of men and 30% of women aged 18–64 years had varicose veins.1 In the UK, the treatment of varicose veins and their complications used to consume about 2% of the total NHS budget.2
Health rationing began in the mid-1990s with some common treatments being singled out for exclusion, including the treatment of varicose veins (10 out of 129 health authorities in England, Scotland and Wales).3 Exclusion criteria varied widely between areas.3 The presence of varicose veins rarely presents as a significant medical problem; despite this, their presence can have a significant impact on quality of life.4 Two recent trials showed that surgery for uncomplicated varicose veins provides significant benefit over conservative treatment in terms of health status, quality of life and patient satisfaction at a relatively small cost.5,6 Therefore, should surgical treatment be rationed and, if there is rationing, to what degree is this taking place across the UK? The aim of this study was to answer these questions.
Materials and Methods
An E-mail questionnaire was sent to 245 surgical members of the Vascular Society of Great Britain and Ireland. Members residing in the Republic of Ireland (because of differences in the provision of healthcare), retired surgeons and those with no traceable E-mail address (78 surgeons) were excluded. The E-mail addresses were obtained from the 2005 Year Book of the Society. Two E-mail reminders were sent to non-repliers.
The questionnaire was a simple ‘Yes’ or ‘No’ questionnaire designed to enquire about the surgeons' NHS practice in terms of treating uncomplicated symptomatic varicose veins (unsightly or aching) and veins with complications (ulcers/bleeding/recurrent phlebitis/skin changes). Surgeons were also asked if any restrictions were imposed by their local Primary Care Trusts (PCTs). If there were any restrictions, the surgeon was asked whether she or he agreed with these restrictions.
Results
A total of 109 surgeons replied (44% response rate). The surgeons represented 84 hospitals across the 11 UK health regions. All surgeons operated on complicated varicose veins with no restrictions. Seventy surgeons (64%) reported restrictions on interventional treatment (surgery or sclerotherapy) for uncomplicated varicose veins imposed by local PCTs. Of these surgeons, 24 (34%) thought that these restrictions were justified.
The presence of restrictions for the treatment of uncomplicated symptomatic varicose veins varied considerably across the UK ranging from no restrictions at all in the North West and Northern Ireland to 100% of surgeons reporting restrictions in the South West. Despite these restrictions, 62% of surgeons under restrictions would still consider operating on uncomplicated symptomatic varicose veins depending on the particular patient. Regional details are presented in Table 1.
Table 1.
Regional details
| Region | Hospitals | Surgeons | Surgeons reporting restrictions | Surgeons agreeing to restrictions | Surgeons performing sclerotherapy | Surgeons performing uncomplicated vein surgery |
|---|---|---|---|---|---|---|
| Eastern | 11 | 11 | 10 (91) | 6 | 0 | 3 (30) |
| London | 7 | 9 | 7 (78) | 2 | 2 | 6 (67) |
| North Ireland | 3 | 4 | 0 (0) | 0 | 0 | 4 (100) |
| North West | 7 | 9 | 0 (0) | 0 | 4 | 9 (100) |
| Northern and Yorkshire | 8 | 12 | 2 (18) | 1 | 7 | 10 (83) |
| Scotland | 5 | 7 | 4 (57) | 3 | 2 | 4 (57) |
| South East | 12 | 12 | 11 (91) | 2 | 1 | 5 (45) |
| South West | 12 | 16 | 16 (100) | 3 | 2 | 6 (33) |
| Trent | 8 | 11 | 7 (70) | 2 | 1 | 6 (45) |
| Wales | 5 | 9 | 5 (62) | 4 | 2 | 9 (100) |
| West Midlands | 6 | 9 | 8 (89) | 2 | 0 | 6 (67) |
| Total | 84 | 109 | 70 (64) | 24 (34) | 20 (18) | 68 (62) |
Figures in parentheses are percentages.
Discussion
There are no published E-mail surveys relating to vascular surgery. Previous research into the response rate of E-mail surveys of healthcare professionals range from 9% to 94%, reaching higher response rates with up to five follow-up reminders.7 A response rate of 44% in this study was considered reasonable since all the regions were evenly represented.
There has been no survey, to date, investigating the presence of rationing as pertains to varicose veins or, indeed, if rationing is present, except for a postal survey for the indications of sclerotherapy,8 and whether rationing has changed surgeons' practice when it comes to uncomplicated symptomatic varicose veins.
It is obvious from this survey that rationing of treatment of uncomplicated varicose veins is wide-spread across the UK. The National Institute for Health and Clinical Excellence (NICE) guidelines for varicose vein referral are flexible enough for general practitioners (GPs) to exert some clinical judgement as to when to refer patients for surgery,9 but this is determined more by the local PCTs protocols. GPs may, however, actively promote symptoms such as phlebitis in order to get the patient seen in secondary care due to patient pressure. It is then down to the surgeons themselves to enforce the restrictive practice laid down by the PCT protocols. It is also obvious from this survey that some surgeons try to work around these restrictions according to the clinical need of the patient, as evident from the percentage of surgeons still performing surgery for uncomplicated varicose veins in regions where rationing has occurred.
There has been continuing research into the relevance of symptoms attributed to uncomplicated varicose veins and the benefits attained by surgery over conservative measures in their treatment. A number of studies, including two recent well-constructed randomised trials, provide some re-assurance that standard surgery for uncomplicated varicose veins provides significant benefit in terms of quality of life at a relatively small cost.3,4,10–15
Conclusions
On the basis of this E-mail study, rationing of treatment for uncomplicated symptomatic varicose veins is wide-spread, and is regionally dependent. It seems inappropriate that this diversity of treatment depends on which area of the country one lives. Surely, it is time for a nationally agreed policy on NHS treatment of symptomatic varicose veins, and that this should be accepted by the PCTs and not altered for local financial reasons.
References
- 1.Evans CJ, Fowkes FG, Ruckley CV, Lee AJ. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. J Epidemiol Community Health. 1999;53:149–53. doi: 10.1136/jech.53.3.149. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Laing W. Chronic venous disease of the leg. london: Office of Health Economics; 1992. [Google Scholar]
- 3.Court C. Survey shows widespread rationing in NHS. BMJ. 1995;311:1453–4. doi: 10.1136/bmj.311.7018.1453a. [DOI] [PubMed] [Google Scholar]
- 4.Sam RC, Bradbury AW. Varicose Veins: Vascular and Endovascular Surgery. 3rd edn. Amsterdam: Elsevier Saunders; 2006. [Google Scholar]
- 5.Michaels JA, Brazier JE, Campbell WB, MacIntyre JB, Palfreyman SJ, Ratcliffe J. Randomized clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins. Br J Surg. 2006;93:175–81. doi: 10.1002/bjs.5264. [DOI] [PubMed] [Google Scholar]
- 6.Ratcliffe J, Brazier JE, Campbell WB, Palfreyman S, MacIntyre JB, Michaels JA. Cost-effectiveness analysis of surgery versus conservative treatment for uncomplicated varicose veins in a randomized clinical trial. Br J Surg. 2006;93:182–6. doi: 10.1002/bjs.5263. [DOI] [PubMed] [Google Scholar]
- 7.Braithwaite D, Emery J, De Lusignan S, Sutton S. Using the Internet to conduct surveys of health professionals: a valid alternative? Fam Pract. 2003;20:545–51. doi: 10.1093/fampra/cmg509. [DOI] [PubMed] [Google Scholar]
- 8.Galland RB, Magee TR, Lewis MH. A survey of current attitudes of British and Irish vascular surgeons to venous sclerotherapy. Eur J Vasc Endovasc Surg. 1998;16:43–6. doi: 10.1016/s1078-5884(98)80090-7. [DOI] [PubMed] [Google Scholar]
- 9.National Institute for Health and Clinical Excellence. Referral Practice: a Guide to Appropriate Referral from General or Specialist Services. < http://www.nice.org.uk/article.asp?a=1178>.
- 10.Bradbury A, Evans CJ, Allan P, Lee AJ, Ruckley CV, Fowkes FG. The relationship between lower limb symptoms and superficial and deep venous reflux on duplex ultrasonography: The Edinburgh Vein Study. J Vasc Surg. 2000;32:921–31. doi: 10.1067/mva.2000.110509. [DOI] [PubMed] [Google Scholar]
- 11.Bradbury AW, Evans CJ, Allan PL, Lee AJ, Ruckley CV, Fowkes FG. Vascular Surgical Society of Great Britain and Ireland: symptoms of varicose veins. Br J Surg. 1999;86:700. doi: 10.1046/j.1365-2168.1999.0700b.x. [DOI] [PubMed] [Google Scholar]
- 12.Campbell WB, Vijay KA, Collin TW, Allington KL, Michaels JA. The outcome of varicose vein surgery at 10 years: clinical findings, symptoms and patient satisfaction. Ann R Coll Surg Engl. 2003;85:52–7. doi: 10.1308/003588403321001462. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Palfreyman SJ, Drewery-Carter K, Rigby K, Michaels JA, Tod AM. Varicose veins: a qualitative study to explore expectations and reasons for seeking treatment. J Clin Nurs. 2004;13:332–40. doi: 10.1046/j.1365-2702.2003.00840.x. [DOI] [PubMed] [Google Scholar]
- 14.van Korlaar I, Vossen C, Rosendaal F, Cameron L, Bovill E, Kaptein A. Quality of life in venous disease. Thromb Haemost. 2003;90:27–35. [PubMed] [Google Scholar]
- 15.van Rij AM. Varicose veins. Br J Surg. 2006;93:131–2. doi: 10.1002/bjs.5319. [DOI] [PubMed] [Google Scholar]