Venous disease will become an increasingly prevalent problem as the U.S. population ages. Changes in healthcare access throughout many regions of the country will likely exacerbate delays in care for patients with advanced venous disease.

A lack of a recognized Venous and Lymphatic Medicine (VLM) specialty by the American Board of Medical Specialties (ABMS) will continue to negatively impact the ability of patients to find medical practitioners with an adequate understanding of venous and lymphatic disorders and knowledge of appropriate treatment.

Furthermore, the lack of a specialty impedes the development of financial support for appropriately training physicians. The absence of a specialty designation also robs venous practitioners of a unified voice to advocate for the care of venous patients with government and private payors.

In the United States, an estimated 23% to 33% of adults between 18 and 64 years of age have chronic venous insufficiency. Nearly one-fourth of those affected patients have advanced disease, including skin changes and active or healed venous ulcers.^1,2 The problem of venous disease has an estimated financial burden in the United States of $14.9 billion each year.³ The severity of the disease may be mild enough for many patients to modify their lifestyle or manage symptoms conservatively.

For others, however, their condition may become progressively disabling, significantly impacting their quality of life. In addition to the impact of chronic venous disease, millions of patients face daily challenges from lymphedema, a debilitating chronic condition with no definitive curative treatment. Lymphedema is estimated to affect 140-250 million people worldwide and approximately 1 out of 1,000 people in the United States.^4,5 Lymphedema, a chronic lymphatic malfunction, can be either congenital or acquired and leads to excess interstitial fluid in the affected tissues.

The American Vein & Lymphatic Society believes a concerted effort to develop a designated, recognized medical specialty that professionally defines venous and lymphatic medicine is key to addressing the significant barriers to access to care for patients suffering from such diseases.

The impact can range from a mild annoyance to a profound disabling condition that is under-recognized and poorly treated in many healthcare systems. While many of the public health messages surrounding life-threatening conditions focus on heart disease and cancer, the Centers for Disease Control (CDC) reported that some 900,000 patients experience venous thromboembolic events (VTE) such as deep vein thrombosis (DVT) or pulmonary embolism (P.E.), resulting in 60,000-100,000 deaths per annum. Following the COVID-19 pandemic, we are still trying to understand the significant increase in VTE risk for up to 49 weeks post-infection and how to mitigate risks best and provide appropriate treatment.⁶

New advances in treating VTE are encouraging but must be thoroughly evaluated in a rigorous scientific fashion before being adopted as standards of care. Many challenges lie ahead in treating patients with venous and lymphatic diseases, and physicians who are well-trained in caring for these patients are vitally important. Current training pathways are insufficient to meet the complex needs of venous and lymphatic disease patients.

There are compelling arguments to develop a standalone subspecialty that focuses on developing and educating a physician base in the U.S. adequate in size and scope to care for this large population of patients appropriately. Over 20 years ago, the American AVLS recognized the need to pursue ABMS recognition for the VLM medical specialty and began investing in the requirements to achieve this milestone. Since then, the Society created the American Board of Venous and Lymphatic Medicine (ABVLM), established seven VLM fellowship programs around the country, and developed the largest data registry in the world for superficial venous disease.

The AVLS believes a concerted effort to develop a designated, recognized medical specialty that professionally defines venous and lymphatic medicine is key to addressing the significant barriers to access to care for patients suffering from such diseases.

In the Great Expectations Strategic Campaign, the Society has set forth goals to achieve this pursuit. Dr. Zoe Deol and Dr. Jeffery Schoonover are leading the Society’s efforts to enact the strategic plan. Dr. Erin Murphy is heading the Foundation for Venous & Lymphatic Disease’s fundraising efforts to support Great Expectations.

Advocacy

Over the past several years, the AVLS Health Policy Committee has led the Society to take a leadership position in advocating for venous and lymphatic-related matters in healthcare policy and payment. The committee is proud to have expanded our representation on the American Medical Association (AMA) RUC and CPT committees. Our volunteers and staff work daily to attend to various national and local issues by addressing clinical, regulatory, and financial policies.

Developing a clearly defined and recognized medical specialty would establish standards of care in the field and strongly position the AVLS to leverage our advocacy experience resources to address payment and policy issues. In addition to a lack of care providers, venous and lymphatic patients have faced undeniable barriers to access care through payor denials for appropriate treatment. Advocates for their care in the spheres of “decision-makers” is of vital importance.

To achieve our advocacy goals, the AVLS will expand its Health Care Policy and Advocacy department by adding a full-time staff member to support individual members in dealing with specific policy and payment issues that affect them locally.

Research

A medical specialty must invest in research to advance knowledge and expertise in managing and treating its patient population. The AVLS supports research in venous and lymphatic medicine through the Patient Reported Outcome (PRO) Venous Registry 2.0, support for guidelines projects, and investing in research efforts. Producing publishable content, including supporting guidelines for the practice of venous and lymphatic medicine, will greatly assist in underpinning the value of defining and defending patients through a unified medical specialty designation.

The Great Expectations Strategic Plan includes four research goals to advance this vision.

1. The AVLS will increase the available grant funding to support research teams to produce 8-10 publications annually.
2. We are excited to assist in coordinating the EMBOLIZE clinical trial in pelvic venous disease management.
3. We will support developing patient-reported outcome tools for everyday use in clinical practice.
4. Finally, the Society will continue the development of novel research data collection tools to advance specific research interests.

Education

AVLS is a globally recognized medical education innovator and provider of continuing medical education in venous & lymphatic disease, as demonstrated through our Annual Congress, regional courses, online courses, webinars, and investments in virtual reality learning.

Continuing medical education is critical to ensuring appropriate patient care and advancing our knowledge and understanding of new and innovative approaches to medical care. It is also vital for a medical specialty to address the training of new and future physicians that enter the field.

AVLS is actively taking steps to expand the VLM Fellowship program across the U.S. to establish a minimum of 15 programs over the next five years. Additionally, as part of our commitment to education, the Society plans to hire a full-time Fellowship Program Director to support program development and recruitment efforts and the oversight and accreditation programs.

By developing more academic fellowship programs, AVLS will address the remaining obstacle to securing recognition from the ABMS and the Accreditation Council for Graduate Medical Education (ACGME) for ABVLM Diplomates.

We are steadfast in our support of the growing field of venous and lymphatic medicine. The AVLS will continue to invest in our internal infrastructure to support our growing membership. Our vision is to create a society that sustains the new VLM specialty. The AVLS initiatives in the Great Expectations build toward an inclusive future for medical professionals committing to this field of practice through academic training and maintaining experiential avenues to board certification in venous and lymphatic medicine for existing physicians and advancing credentialing for technologists, therapists, and nurses working in this field. Together we look toward a future with improved patient access to well-trained and compassionate caregivers for venous and lymphatic diseases.

To read the full strategic plan and learn more, go to www.myavls.org/great-expectations.


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.
2. Kaplan RM, Criqui MH, Denenberg JO, Bergan J, Fronek A. Quality of life in patients with chronic venous disease: San Diego population study. J Vasc Surg 2003;37:1047-53.
3. Rice JB, Desai U, Cummings AK, Birnbaum HG, Skornicki M, Parsons, N. Burden of venous leg ulcers in the United States. J Med Econ 2014;17:347-56.
4. Marcos Lopez a, Mya L. Roberson b, Paula D. Strassle c, Adeyemi Ogunleye. Epidemiology of Lymphedema-related admissions in the United States: 2012–2017. Surgical Oncology 35 (2020) 249–253
5. A.K. Greene, S.A. Slavin, H. Brorson, Lymphedema: Presentation, Diagnosis, and Treatment, 2015.
6. CVD-COVID-UK/COVID-IMPACT Consortium and the Longitudinal Health and Wellbeing COVID-19 National Core Study. Association of COVID-19 With Major Arterial and Venous Thrombotic Diseases: A Population- Wide Cohort Study of 48 million Adults in England and Wales. Circulation. 2022;146:892–906. DOI: 10.1161/ CIRCULATIONAHA.122.060785