By Elna Masuda and Steve Elias

In September 2019, the Wall Street Journal published an article entitled “Overuse of stenting in arteries in the leg.”¹ As a result, a flurry of responses followed in the Society for Vascular Surgery online discussion, which expressed concerns of overutilization of venous procedures, similar to but possibly reaching a larger scale than the arterial counterpart.

Currently, venous technology such as endovenous vein ablation has been simplified and provides a minimally invasive method of effectively treating chronic venous disease ranging from varicose veins to venous ulcers. Since it does not require significant open operative skills or hospital settings traditionally held by vascular or general surgeons, many non-procedural specialties have adopted venous procedures as a practice.² The application of new technology has outpaced sufficient teaching and application of standards, which crosses all specialties caring for vein disease patients. These endovenous techniques have enabled more patients with venous disease to receive the attention they previously lacked. The widespread use of these latest venous technologies can be categorized into three types: appropriate use, unnecessary use, and harmful use to patients.

In response, the American Venous Forum (AVF) in conjunction with the Society for Vascular Surgery (SVS), American Venous and Lymphatic Society (AVLS) and Society of Interventional Radiology (SIR) participated and endorsed this multi-society project. The goals were to address the increasing inappropriate application of venous procedures. The project entitled, “The 2020 appropriate use criteria (AUC) for chronic lower extremity venous disease” is the first of its kind for venous disease. The manuscript has been accepted for publication and is available online, with printed version to follow in a few months.³ Among the participating societies, there were over 30 individuals who generously offered their expertise and time to the project. The participating societies in this project need to continue to collaborate with any other societies to create a unified “venous and lymphatic voice” in the U.S. in order to move the field forward towards appropriate patient care.

Listed in this AUC are some commonly performed clinical scenarios which are rated for appropriateness using a validated method.⁴ This AUC methodology has been used in other specialties including cardiology, vascular surgery, orthopedic surgery, bariatric surgery and others. This combines expert opinion from panelists representing multiple societies and multiple disciplines, who are presented with an extensive literature review and scenarios which are subject to ratings using a modified Delphi process. The project’s goal is to produce a guide that can help define levels of appropriateness including ratings of appropriate, may be appropriate, rarely appropriate, and a first for AUC “never appropriate.” In addition to providing reference for general use, the ratings serve to identify and draw attention to some of the reported ways venous procedures are being applied inappropriately to patient care.

As was pointed out by SVS Past President Peter Lawrence5 and AVF Past President Marc Passman,6 the scope of inappropriate utilization of venous treatment is difficult to quantify. Yet, many practitioners are aware of its prevalence. For us to address the problem, it would be beneficial to identify metrics that may provide insight into practice patterns. One example of a measure of appropriate use of venous procedures suggested is the number of veins ablated per person. There is no “correct” number of veins for each individual and each case needs to include a careful assessment to distinguish venous causes from other etiologies such as in the case of limb pain and/or swelling and to justify the use of procedures based on clinical severity and prognosis. Ultimately the decision for each individual needs to be made at the bedside after careful consideration of multiple patient-centered factors.

However, there are practice patterns that can be noticed as outliers with a high number of ablations. For example, ablation of a mean of 11 veins per patient annually in a Medicare population is undoubtedly abuse of the procedures.⁶ As recently published in the JVS VL, there are several reports^2,7,8 that indicate based on the Medicare claims database between 2013 and 2017, and a single-center experience9 found that the mean number of ablations per patient per year ranged from 1.3-1.9. This is just one metric of venous treatment that can assist in identifying where overuse may exist. Another metric that is being analyzed is data from the AVLS and SVS/AVF separate venous registries utilizing the concept of a coordinated research network (CRN).

The problem can only be resolved by a multipronged approach. Several initiatives are currently underway toward providing optimal care for our patients. Under the leadership of AVF President BK Lal, and SVS President Kim Hodgson, both societies are partnering together and supporting the Vascular Quality Initiative of varicose vein module chaired by Jose Almeida. The Intersocietal Accreditation Commission for Vein Centers (IAC-Vein Center) provides the means for vein centers to achieve standards of accreditation and was established in 2015. The American Board of Venous and Lymphatic Medicine (ABVLM) provides an educational pathway for medical practitioners. State medical boards are responsible for physician licensure and respond to direct patient complaints or documented fraudulent activities that directly deal with licensure. All of these initiatives help to alleviate the gap between appropriately trained individuals and delivering proper care but fall short of reaching the vast majority of cases.¹⁰ Improving Wisely and Choosing Wisely are initiatives that are patient-centered and can increase public awareness as to the areas of concern. Finally, the JVS-VL Editor in Chief Peter Gloviczki and Editor Peter Lawrence have made it a priority to bring awareness of appropriateness to its readers by continuing to have articles addressing this.

Like that of arterial leg stenting overuse noted by the Wall Street Journal, our profession, which consists of a number of specialties including vein specialists, vascular surgeons, cardiologist, interventional radiologists, vascular medicine and vascular ultrasound technologists, needs to address the problem of overutilization of venous treatment options or the economic impact could be untenable. One out of every three or four adults has some form of venous disease. If the profession does not address how the technology should be used, this could create more unnecessary stress on an already financially overburdened medical system where 20 percent of our gross national product is spent for health care and it is anticipated that this may reach over 30 percent in the next two decades. The problem creates a nationwide concern that the technology needs to be applied for the right reasons and for the right patient by the right doctor. Physicians need to participate in clarifying how this technology should be applied and work with professional societies, payers, industry, sonographers, hospitals, and other stakeholders to better define how the technology should be used to benefit our patients.

Although practitioners can be identified as part of the problem, payers need to understand that there is also appropriateness to reimbursing procedures, specifically those deemed medically legitimate. When payers work with physicians or professional societies on standards of care, patients will receive the necessary procedures for the proper indications.

References:

1. Reddy, Sumathi. (Sept 10, 2019) “Doctors Sound an Alarm Over Leg-Stent Surgery,” The Wall Street Journal.
2. Baber, J. T., Mao, J., Sedrakyan, A., Connolly, P. H. & Meltzer, A. J. (2019) Impact of provider characteristics on use of endovenous ablation procedures in Medicare beneficiaries. J. Vasc. Surg. Venous Lymphat. Disord. 7, 203-209.e1.
3. Masuda E, Ozsvath K, Vossler J, Woo K, Kistner R, Lurie F, Monahan D, Brown W, Labropoulos N, Dalsing M, Khilnani N, Wakefield T, Gloviczki P. (March 4, 2020) “ The 2020 appropriate use criteria for chronic lower extremity venous disease of the American Venous Forum, the Society for Vascular Surgery, the American Vein and Lymphatic Society, and the Society of Interventional Radiology. J Vasc Surg. Venous Lymphat Disord. 2020. Available at: https://www.jvsvenous.org/#/article/S2213-333X(20)30094-9/fulltext.
4. Fitch, K. et al. (2001) The RAND/UCLA Appropriateness Method User’s Manual.
5. Lawrence, P. F. (2016) “Better” (sometimes) in vascular disease management. J. Vasc. Surg. 63, 260–269.
6. Passman, M. A. (2019) Where evidence, ethics, and professionalism converge. J. Vasc. Surgery. Venous Lymphat. Disord. 7, 8–16.
7. Mann, M. et al. (2019) Significant physician practice variability in the utilization of endovenous thermal ablation in the 2017 Medicare population. J. Vasc. Surg. Venous Lymphat. Disord. 7, 808-816.e1.
8. Crawford, J. M. et al. (2019) A review of United States endovenous ablation practice trends from the Medicare Data Utilization and Payment Database. J. Vasc. Surg. Venous Lymphat. Disord. 7, 471–479 (2019).
9. Crawford, J. M., Gasparis, A., Amery, S. & Labropoulos, N. (2019) Treatment pattern of consecutive patients with chronic venous disease. J. Vasc. Surg. Venous Lymphat. Disord. 7, 344–348.
10. Passman M. (2018) The Problem of Endovenous overalation and insufficiently trained operators. Endovascular Today;7: 88-90.