Summer Sanders Helps Raise Awareness of Varicose Vein Health Risks

NEW YORK – April 18, 2012 – Swimming legend and Olympic Gold Medalist Summer Sanders has joined with the American College of Phlebology (ACP),  Society for Vascular Surgery^® (SVS) and American Venous Forum (AVF) to launch Rethink Varicose Veins.

This important educational campaign encourages those suffering from varicose veins to learn more about their condition and speak to a vein specialist about treatment options. If left untreated, varicose veins can progress to a more serious form of vein (venous) disease called chronic venous insufficiency (CVI). Only 1.9 million of the more than 30 million Americans suffering from vein disease seek treatment annually; the vast majority of sufferers remain undiagnosed and untreated.^1,2,3

As part of the campaign, Sanders is sharing her experience with venous insufficiency, the underlying cause of varicose veins. She also describes how she improved following treatment.

“My legs were achy and heavy, especially after a long day. I thought these symptoms were just a natural part of living an active lifestyle, being on my feet a lot and getting older,” said Sanders. “I finally spoke with my vein specialist, who told me that these symptoms were due to venous insufficiency.  He explained that if I didn’t seek treatment and my condition progressed to CVI, I could end up with more serious symptoms like skin color and texture changes, severe pain and even leg ulcers.”

With CVI and varicose veins, the valves in the leg veins that direct blood from the legs back toward the heart no longer function properly, causing blood to pool in the legs. Although this can occur at any age, increased age is a risk factor.⁴ Varicose veins and CVI also tend to be more prevalent in women who have been pregnant,⁵ people who have a family history of CVI or those whose jobs require them to spend a great deal of time standing.⁴ Although many people who suffer from varicose veins feel uncomfortable with their condition, they often  think it is just a cosmetic problem or a natural part of the aging process, and do not seek treatment.

“Every day in our practice we see patients – both men and women – who don’t realize that CVI is a progressive disease that requires proper diagnosis and treatment,” said Mark A. Adelman, M.D., Chief of the Division of Vascular Surgery and Endovascular and Associate Professor of Surgery at NYU Langone’s Cardiac and Vascular Institute. “There are effective and minimally-invasive treatment options that are covered by many insurance plans, allowing sufferers to address the condition before it progresses further. With the Rethink Varicose Veins campaign, we hope to encourage those with varicose veins to seek treatment options that may be right for them.”

Visit www.RethinkVaricoseVeins.com to learn more about varicose veins, CVI and treatment options. Visitors to the website also can assess their risk with an online tool, find vein specialists trained in diagnosis and treatment, read more about Sanders’ experience with vein disease and treatment and share an e-card with friends or family members to encourage them to learn more about the condition.

This educational campaign is sponsored by Covidien. Summer Sanders, the spokesperson for the Rethink Varicose Veins campaign, has been compensated by Covidien.

About the Rethink Varicose Veins Partners

American College of Phlebology (ACP)

The American College of Phlebology (ACP) is the premier association for physicians and allied health professionals working in the field of phlebology (the study and treatment of venous disease). The ACP not only acts as a forum for physicians and other health professionals to exchange medical knowledge, it also offers education and training dedicated to improving the standards of medical practitioners and the quality of patient care. The ACP comprises more than 2,000 health professionals who are leaders in the field of phlebology. For more about the ACP, visit www.phlebology.org.

Society for Vascular Surgery^® (SVS)

The Society for Vascular Surgery^® (SVS) is a not-for-profit professional medical society, composed primarily of vascular surgeons, that seeks to advance excellence and innovation in vascular health through education, advocacy, research and public awareness. SVS is the national advocate for 3,500 specialty-trained vascular surgeons and other medical professionals who are dedicated to the prevention and cure of vascular disease. Visit its website at www.VascularWeb.org^® and follow SVS on Twitter by searching for Vascular Health or at http://twitter.com/VascularHealth.

American Venous Forum (AVF)

The American Venous Forum (AVF), which is composed mostly of vascular surgeons, was born from the SVS and is the focal point for progress in venous science. Modern venous surgery, venous diagnostics and the classification of venous disease were formulated under its direction. The AVF continues to lead by improving public awareness of venous diseases, promoting research in venous and lymphatic disorders, publishing evidence-based practice guidelines and establishing cross-specialty collaborations. Visit its website at www.veinforum.org.

Covidien

Covidien is a leading global healthcare products company that creates innovative medical solutions for better patient outcomes and delivers value through clinical leadership and excellence. Covidien manufactures, distributes and services a diverse range of industry-leading product lines in three segments: Medical Devices, Pharmaceuticals and Medical Supplies. With 2011 revenue of $11.6 billion, Covidien has 41,000 employees worldwide in more than 65 countries, and its products are sold in over 140 countries. Please visit www.covidien.com to learn more about our business.

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1 Gloviczki, P., MD., Comerota, A., MD., Dalsing, M., MD., Eklof, B., MD., Gillespie, D., MD., Gloviczki, M., MD., Wakefield, T., MD. The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011 May; 53(5 Suppl): 2S-48S.

2 “Age and sex composition: 2010.” In 2010 United States of America Census (c2010br-03). Web. http://www.census.gov/prod/cen2010/briefs/c2010br-03.pdf.

3 US Markets for Varicose Vein Treatment Devices 2011, Millennium Research Group. 2011.

4 Chiesa R, Marone Em, Limoni C, Volonte M, Schaefer E, Petrini O. Chronic venous insufficiency in Italy: the 24-cities cohort study. Eur J Vasc Endovasc Surg. 2005;30:422-429.

5 Criqui MH et al. Epidemiology of chronic peripheral venous disease; JJ Bergan Editor, The Vein Book, Elsevier Academic Press (2007): 30.

To date, over $3.1 million has been raised from 17 corporate supporters and 41 individual ACP members.

Leaders of the VFT National Steering Committee will be contacting many ACP members personally in the next several months, however, click here to take a look at the website for information on successes of the ACPF since its founding in 2006, initiatives to be funded through VFT, and a list of VFT donors.

If you would like a VFT packet mailed to you, please contact the ACPF office at 510-346-6800 or email info@acpfmail.org.

“To the current donors, on behalf of the College’s and Foundation’s leaders, thank you for your support of phlebology through ACPF. To those who are not yet participating in VFT, the VFT National Steering Committee looks forward to seeing your name added to the ever growing list of committed donors.” – Ted King, MD – Vision for Tomorrow National Steering Committee Chair

Policy Approval Date: February 26, 2012

Introduction

The ACP Board of Directors recognizes the importance and value of the recognition and branding of the American College of Phlebology’s name, tag lines, and associated logo(s) and websites.  They also acknowledge that its members, corporate partners, and Foundation donors often request to reference the ACP in their various printed and electronic media materials by using its name, logo(s), taglines, and website address.

The ACP Board of Directors approved the following policy and procedures to enable its members, partners, and Foundation Donors to use its name, tag lines, and associated logo(s) and website links.

Policy

The name and logo of the American College of Phlebology are trademarked and the property of the ACP. However, the ACP grants permission to all of its members to use the ACP logo and the ACP Widget and name on their websites.  This improves the ACP’s presence on the Web by increasing search engine optimization.  Members who post the ACP Logo and/or Widget must be in good standing as described below^Ý.

Active, Fellow and Honorary members are allowed to use logo on promotional materials such as business cards, letterhead, flyers and other advertising materials.

The ACP Logo and name may not be used in any manner to imply that a member is in any way an agent of ACP or that the ACP in any way warrants, approves, or endorses any product or service provided by the member.

ACP must approve any other use of the ACP Logo and name not specifically enumerated. Individual members are prohibited from allowing their employer to use the ACP member logo on the employer’s letterhead or promotional materials. Any employer who does so will be subject to trademark infringement liability.

The right to use the ACP member logo shall terminate and be revoked upon the member’s failure to remain in good standing, in the event of misuse by the member as determined by ACP, or any other breach of this Policy for Use. Upon such termination and/or revocation, the member will eliminate the use of the ACP Logo and name from all materials, products, and services, regardless of whether such materials, products, and services are; preprinted or pre-existing at that time.

Members in all categories must have maintained their paid membership in the College to use the ACP name and logo. Other copyrighted materials and/or trademarks that are the property of ACP and may be used with the permission of the College according to the ACP Copyrighted Material Policy approved by the ACP Board of Directors on January 22, 2010.

Along with an academically rigorous curriculum, special emphasis has been placed on innovation and interactivity this year by the two Program Co-Chairs, Diana Neuhardt, RVT, RPhS, and Julianne Stoughton, MD, FACS.

Program highlights include hands-on simulated workshops on ambulatory phlebectomy, duplex ultrasound, sclerotherapy, and compression bandaging.  In addition, there will be a dynamic international perspective on duplex hemodynamics with insights from various experts on vein mapping, diagnosis, and treatment planning.  The meeting will showcase numerous debates on controversial treatment paradigms, live duplex ultrasound demonstrations of chronic venous insufficiency and pelvic vein disease, high level scientific abstracts, and invited intersocietal symposia.

The co-chairs have also invited two keynote speakers to be featured.  One keynote address will be delivered by ultrasound innovator Steve Talbot, RVT.  Talbot is a pioneer in the field of ultrasound and renowned for being the first to utilize ultrasound in the diagnosis of venous diagnosis in the limbs.   His work over the last thirty years has revolutionized the ultrasound diagnosis of deep vein thrombosis and provides the basis for many of the techniques ultrasound technologists use today.

The second keynote address will be delivered by Michael Jaff, DO. A clinical consultant in all aspects of vascular medicine, Jaff is an associate Professor of Medicine at Harvard Medical School and Director of the Vascular Center at the Massachusetts General Hospital. Jaff will bring his unique perspective from vascular medicine to the topic of Deep Vein Thrombosis (DVT).

As plans are finalized, the ACP will provide program and registration information at the acpcongress.org website. Look for an announcement of the newly redesigned site in the next few weeks. For international attendees, the ACP also offers travel scholarships to the Annual Congress. for more information and to apply, please visit

http://www.phlebology.org/education/scholarships.html

Dr. Amar Amaresh

Dr. Gary Augter

Dr. David Bellamah

Ms. Laura Boettcher

Dr. Ramon Castro

Dr. Paul Cathcart

Mr. Thomas Church

Dr. Roger Coletti

Dr. Henry Docherty

Mrs. Tammy Doerhoff

Ms. Lisa Downey

Dr. Delton Farquharson

Ms. Cecelia Fehner

Dr. Enrique Fraga

Dr. Christian Galvez

Ms. Erin Gibbs

Dr. Nicolas Gomez Amalbert

Dr. Ali Harb

Dr. Jose Heisecke

Mrs. Kimberly Hentges

Dr. Sadiq Hussain

Dr. Daniel Isenbarger

Mr. Eric Johnson

Mrs. Lori Jones

Dr. Manohar Kachare

Dr. Waqar Khan

Mrs. Callan Kosnik

Dr. Sanjay Kulkarni

Dr. Lucy LaPerna

Mr. Khoa Le

Dr. Christopher LeCroy

Dr. Luis Martinez

Dr. J. Jack Messina

Dr. Peter Miles

Mitzi Mobley

Mr. Chris Morris

Dr. Alan Nadour

Dr. George Nicola

Mrs. Julie Ninow

Mrs. Karah Norton

Mrs. Aleata Parker

Ms. Amber Rittal

Dr. Jose Rosa

Dr. Rakesh Safaya

Dr. Shakti Sharma

Dr. Navi Shergill

Ms. Leslie Simms

Dr. Brent Steadman

Dr. Robert Stevens

Ms. Linda Sweeney

Dr. David Swierzewski

Ms. Felecia Townsley

Dr. Julio Vasquez

Dr. Ruben Vellettaz

Dr. David Verebelyi

Ms. Elham Zarnegar

By Kimberly Dickerson, CPC, CPCO, CBCS - OutCode, LLC

Many practices have trouble understanding when and how to properly bill follow-up ultrasound codes.  Here are a few tips to help you overcome some hurdles presented by the insurance carriers.

1. Review insurance carrier medical policy for ultrasounds to determine if there are any limitations on billing. (ie: number of times allowed, certain diagnosis codes, etc)

1. Be aware of global time frames.  Many services have a global time frame where any additional services performed during this time are considered part of the initial service.    Examples:  Stab Phlebectomy’s has a 90 day global; Sclerotherapy has a 10 day global; Endovenous Laser (EVLA/EVLT) or Radiofrequency ablations (RFA) currently have 0 global days.

Procedures billed during the global period must have a modifier attached.  The most commonly used modifiers for procedures are 58 (staged or related procedure) or 79 (unrelated procedure within a global).

1. Many practices prefer to perform a follow-up ultrasound on their patients a week or so after an ablation to rule out the possibility of a DVT and to ensure closure.  The proper CPT code to use for this follow-up ultrasound is 76970(Ultrasound study follow-up).  With proper documentation of the visit it will provide evidence to the payer of the service performed and allow proper reimbursement for your time.  Remember the EVLA and RFA’s do not have a global period attached to them so no modifier is needed.

Reviewing the individual carrier medical policies and guidelines as well as knowing when it is appropriate to add a modifier will eliminate undue denials, delays by insurance carriers and increase revenues for your practice.

From the University of Michigan

HPI: A 51 year-old female presented complaining of 6-7 years of bilateral, painful, lower extremity varicose veins.  The patient reported aching, painful and cramping legs.  Her symptoms had increased over the last few years.  Sitting made her symptoms worse.  She was treated with injection sclerotherapy in the past and had been wearing 20-30 mmHg compression stockings for the last few years.  Her sisters also had varicose veins.  She denied any history of superficial or deep venous thrombosis, pulmonary emboli, hypercoagulable disorder, venous ulceration, variceal bleed, or claudication symptoms.

PMH: GERD, allergic rhinitis, and headaches

PSH: Rhinoplasty for deviated septum

MEDS: Motrin PRN, Allegra-D qam, Allegra 60 mg qpm, Prilosec OTC daily, Celexa 20 mg qhs and Nortrel (OCP) daily

ALLERGIES: Ceclor causes rash.

SH: married, medical biller, nonsmoker, 2-4 alcoholic beverages per week, G2P2

FH: Her father, age 72, has coronary artery disease.  Her mother died at 57 with uterine cancer.  Her sisters have varicose veins.  No history of VTE.

ROS: Unremarkable

PEXAM: Alert and oriented in no apparent distress.  Ht: 5’6” WT: 143 lbs  BMI = 23.1 BP: 122/64 left arm
HEENT: anicteric sclerae and clear conjunctivae, mmm  NECK: no JVD or carotid bruits.  HEART:  RRR, no m,r,g  LUNGS:  CTA B  ABDOMEN: soft, normal bowel sounds, no bruits.  PULSES: normal carotid, radial,
femoral, posterior tibialis, and dorsalis pedis pulses bilaterally.

VENOUS EXAMINATION: With the patient standing, reticular and spider varicosities are seen on both lower extremities, most notably along the bilateral anterior tibias and lateral right calf.

ULTRASOUND: Deep venous insufficiency affecting the common femoral veins bilaterally.  No evidence of DVT or SVT.

TREATMENT COURSE: The patient underwent visual injection sclerotherapy of varicose veins along the anterior tibias bilaterally.  2 days after treatment, she developed discomfort and erythema along the left medial knee.  The discomfort and associated erythema progressed proximally.  Due to the left medial leg pain and erythema, she presented for re-evaluation 5 days post sclerotherapy.

Upon examination, there was tenderness along the left medial leg in the course of the GSV from mid-thigh to just below the knee and the skin was mildly and intermittently erythematous.  Lungs were clear, heart was regular without murmur.  DP and PT pulses were equal and present bilaterally.  There was no calf pain, tenderness or swelling.

An ultrasound revealed thrombosed left GSV, extending 3 cm distal to the SFJ to the ankle.

Lovenox 100 mg SQ daily was started; 30-40 mmHg thigh-high compression hose were donned, and ambulation, NSAIDs, and warm compresses were recommended.  Nortrel (OCP) was discontinued.

Patient returned 5 days later for follow-up.  She denied CP, SOB or palpitations.  Her leg symptoms were stable.  Ultrasound revealed extension of the SVT to the SFJ.  The patient was admitted to vascular surgery and underwent GSV ligation the same day, without complication and without extension of the thrombus into the CFV.

The patient recovered well and ultimately underwent hypercoagulability work-up.  Lab results showed a Factor V Leiden gene mutation.  Upon probing her family for additional history, the patient discovered that both of her sisters and a niece had been previously diagnosed with Factor V Leiden gene mutation.

FACTOR V Leiden GENE MUTATION: A single point mutation in the gene coding for coagulation factor V results in a form of factor Va that is resistant to degradation by activated protein C.  This leads to a relative hypercoagulable state. The mutation, factor V Leiden, is found in 4% to 6% of the U.S. population. 

Factor V Leiden mutation is associated with three to sevenfold increases in risks for primary and recurrent venous thromboembolism, especially in patients without transient risk factors, such as surgery or trauma. Risks for venous thromboembolism in genetically affected persons are substantially higher among patients with coexistent predispositions for thrombosis, such as advanced age, use of oral contraceptives, hyperhomocystinemia, and deficiencies of protein C and protein S. Factor V Leiden mutation does not seem to increase risks for arterial thrombosis. (American College of Physicians, 2004)

Table V. Estimated relative risks for a first episode of venous thromboembolism (VTE)*

Thrombophilic defect                                                      Relative risk

Antithrombin deficiency                                                       8–10

Protein C deficiency                                                       7–10

Protein S deficiency                                                       8–10

Factor V Leiden/APC resistance                                     3–7

Prothrombin 20210A mutation                                     3

Factor V Leiden and prothrombin 20210A                    20

Elevated factor VIII:c (dose-dependent)                   2–11

Elevated factor IX:c                                                       2–3

Elevated factor XI:c (>90^th percentile)                  2

Mild hyperhomocysteinemia                                     2.5–2.6

Anticardiolipin antibodies

All                                                                         1.6

High titers                                                       3.2

Lupus anticoagulant                                     11

Adapted from Weitz JI, Middeldorp S, Geertz W, Heit JA. Thrombophilia

and anticoagulation drugs. American Society of Hematology education

book, 2004.

*Individuals with a thrombophilic defect compared with individuals without

a defect; derived from family and population-based case-control studies.

Meissner, M., Wakefield, TW., Ascher, E., et.al, Acute Venous Disease: Venous Thrombosis and Venous Trauma, Journal of Vascular Surgery, Vol. 46, Iss. 6, Supplement, Dec. 2007, pp. S25-S53.

By Jean-Jérôme GUEX, MD, FACPh
Cabinet de Phlébologie, Nice, France

What is meant by “Burden”?

The first definition is medical and obvious, i.e. the consequences of the disease on the individual who suffers from it. We already know symptoms, signs, disability and impairment of quality of life (QoL) related to the evolution and complications of chronic venous disorders (CVDs). The literature provides information on these effects, and their description is essentially clear and satisfactory. However, their point of prevalence remains fuzzy.

The second definition, which is less obvious, more specific and certainly unknown to most physicians, is the socio-economic appraisal of the consequences of a disease in a population.  We will call it the Burden of CVD (BoV).

The first Global Burden of Diseases campaign began in 1990 and was commissioned by the World Bank. Another campaign, sponsored by the World Health Organization (WHO) and several other institutions and universities, commenced in 2005.¹ The burden of many diseases, not all potentially lethal, has been evaluated from malaria to diabetes. The WHO has provided the following definition: ‘The WHO global burden of disease (GBD) measures burden of disease using the disability-adjusted life year (DALY). This time-based measure combines years of life lost due to premature mortality and years of life lost due to time lived in states of less than full health. The DALY metric was developed in the original GBD 1990 study to assess the burden of disease consistently across diseases, risk factors and regions’.² The formula DALY ¼ YLL +YLD (years of life lost + years of life lost due to disability) may look cryptic but deserves some attention.^3,4 Another measurement, Quality Adjusted Life Years (QALYs)^5,6 may also be used.

The WHO classification of diseases (ICD-10) mentions CVDs in chapters I83, I86.2, I86.3, I87.⁷

However, CVD has not been well described or appraised, although it is of utmost importance to us.

Why do we need to evaluate the BoV?

The BoV, especially if evaluated through DALYs and QALYs, allows descriptions and comparisons between populations, etiologies and groups. It also allows cost-effectiveness of health-care technologies assessment. To our knowledge, even if several teams have been working on CVDs with these kinds of tools as part of the GBD project, few presentations have appeared in our meetings and scant papers have been published in journals.^8,9

Why is it difficult to appraise the BoV?

Since CVDs are (fortunately) very seldom lethal, appraisal through YLL is impossible. Mutilations (leg ulcers) and amputations are more frequent,¹⁰ but are probably not always applicable in Western countries since the incidence of chronic venous insufficiency (CVI) ulcers is probably below 2% in general, and below 1% in some countries. The BoV also depends on signs, symptoms and consequences of everyday life. To some extent, generic (EuroQol EQ5D, SF 36 or SF 12, etc.) and specific (CIVIQ, AVVQ, SQOR-V, etc.)  QoL scales can be used, but they assess the QoL instead of the burden of the disease, and logically, a different approach must be taken when constructing an auto-questionnaire for assessing the specific personal burden of a chronic venous patient.¹¹ Finally, socioeconomic data must be taken into account such as the number of days off work, number of days in the hospital, cost of drugs and stockings, cost of surgical procedures, etc.

What do we need to know?

As explained in the GBD document (see ‘operations manual’),1 the main steps of evaluation of the specific BoV will require the following: disease and risk factor epidemiological review, mortality estimation (limited in the case of CVDs), cause of death estimation (same observation), disability weights measurement, comparative risk assessment, and years lived with disability (YLD) estimation. It will be necessary to compute DALYs and QALYs in the different groups of patients and to describe the natural history of treated and untreated CVDs.

What do we need to do?

The Alliance against the Burden of chronic Venous disorders (AVB) task force has recently met. Its goals are to publish a complete and comprehensive consensus document on this topic. This document should have enough relevance to be endorsed by the WHO, and serve as a basis for further discussion about CVDs with national and local authorities. It will demonstrate the severe consequences of these disorders, which have not been well appreciated outside our specialty.

References

1 See http://www.globalburden.org/ (last accessed 11 August 2010)

2 Seehttp://www.who.int/topics/global_burden_of_disease/en/ (last accessed 11August 2010)

3 See http://www.who.int/healthinfo/nationalburdenofdiseasemanual.pdf (last accessed 12 August 2010)

4 See http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/index.html (last accessed 11 August 2010)

5 See http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/QALY.pdf (last accessed 11 August 2010)

6 See http://www.nice.org.uk/newsroom/features/measuringeffectivenessandcosteffectivenesstheqaly.jsp (last accessed 12 August 2010)

7 See http://apps.who.int/classifications/apps/icd/icd10online/ (last accessed 11 August 2010)

8 Moore HM, Gohel MS, Davies AH. The forgotten burden of deep venous disease. Phlebology 2010;25:53

9 Heit JA. Venous thromboembolism: disease burden, outcomes and risk factors. J Thromb Haemost 2005;3:1611–17

10 Tsai S, Dubovoy A, Wainess R, Upchurch GR, Wakefield TW, Henke PK. Severe chronic venous insufficiency: magnitude of the problem and consequences. Ann Vasc Surg 2005;19:705–11

11 Guex JJ, Rahhali N, Taïeb C. The patient’s burden of chronic venous disorders: construction of a questionnaire. Phlebology 2010;25:280–5

The Alliance against the Burden of Venous disorders (AVB)

Jean-Jérôme GUEX, MD. FACPh. Founder & Chairman AVB

Background

The World Health Organization (WHO) recognizes the “burden” of various disease states such as cardiovascular disease, diabetes, breast cancer, and many others. With this recognition comes funding for disease intervention in the form of research and public awareness campaigns. In order to gain recognition of a specific health problem, it is necessary to provide the WHO with an inventory of the burden of the health problem, including signs and symptoms, associated disability, complications, etc. There needs to be a classification and evaluation method for the health problem, as well as the associated epidemiology within age groups and international regions. The true cost of the health problem must also be assessed according to standard measurement tools.

Chronic Venous Disorders (CVD) are largely unrecognized by major health authorities. When they are recognized, minimal financial support is given. Further, the actual “burden of venous disorders” is largely unknown since adequate research and utilization of modern tools and methodology of health economics have not been brought to bear on this disease process. The purpose of the Alliance against the Venous disorders Burden (AVB), established as a non-profit organization registered in Monaco, is to identify and develop the statistically important data critical for the education and ultimately the recognition of the true extent of the burden of venous disorders by national and international health organizations such as the WHO. The initial volunteer physician and industry AVB members are listed below.

Methods and Process

The AVB will be responsible for selecting the measurement tools necessary to define the burden of venous disorders, producing, gathering and analyzing the available data, computing results, assessing the effects of therapeutic intervention, and developing a consensus document (“white book”) to be published in peer-reviewed medical journals. This will also be presented to the World Health Organization (WHO) in order to gain international recognition of this burden, and to facilitate obtaining funding for research and public awareness. This comprehensive consensus document will also be provided to phlebological societies for internal use and for communication with their national health authorities.

In order to calculate the burden of a particular health problem, it is necessary to describe the epidemiology, natural history, effects on the quality of life as regards disability for patients with the health problem, and the economic burden of the health problem for the patient and society as a whole. Going further, it is then necessary to assess the effects of health interventions, including prevention, patient awareness, early detection, and treatment. All these socio economic aspects are mathematically defined and use technical measures known as DALYs and QALYs.

At a meeting in Monaco in October, 2010, the initial volunteer members of the AVB Task Force, which included physicians and members from industry, opened this discussion and designated working groups with specific functions. With the expertise of the initial volunteer group, and with the intent to add more AVB members as desired and needed, much of the “heavy lifting” in this project is expected to be borne by individual members. The need for some external assistance in the development of a consensus document, such as a specialized subcontractor, became apparent during this meeting. The need for funding will be restricted to such things as data acquisition, analysis (computing DALYs and QALYs), modeling, and some face-to-face meetings of AVB members. It is estimated that funding requirements will be 60 000 €. We anticipate the final document will be ready for dispersal in 18-24 months. Meanwhile, the opportunity of a new task force meeting and its timing must be discussed. In addition to the project, the organization by the AVB of a one day open meeting joint to the task force meeting can be planned. The topics of this open meeting could be: socio-economics, epidemiology, cost effectiveness assessment, outcome measurements, etc … in phlebology. No such meeting exists to date and related papers are scattered in non-specific congresses.

AVB Members (as of October 2010)

PHYSICIANS

Jean-Jérôme GUEX  (F) Chair

Eberhard RABE (D) Co-Chair

Patrick CARPENTIER (F)

Alun DAVIES (UK)

Mark MEISSNER (USA)

Dragan MILIC (Сpбија, Serbia)

Nick MORRISON (USA)  Co-Chair

Amanda SHEPHERD (UK) Recorder

Steve ZIMMET (USA)

Mark MALOUF (AUS)

EXECUTIVE SECRETARIAT

PUBLICREATIONS Monaco

INDUSTRIAL MEMBERS

Hans Juergen THOMAE (D) – BAUERFEIND

Stephan TRAVERS  (D) – KREUSSLER PHARMA

Serge MAKO  (F) – KREUSSLER PHARMA

Nora RAHHALI  (F) – PIERRE FABRE

Xavier SAUDEZ  (F) – PIERRE FABRE

Françoise PITSCH  (F) – SERVIER

Helmut SCHEPERS  (CH) – SIGVARIS

Mike WATKINS  (UK) – STD PHARMACEUTICALS

By Helane Fronek, MD, FACP, FACPh

There is a lot to discuss when a patient has a new diagnosis of DVT.  However, once his overwhelm or fear sets in, only a small fraction of what we say really sinks in.  So how can we best inform our patient when we know how crucial it is for him to understand this new condition in his life?

When delivering bad news of any sort, it’s wise to understand that we are about to rock our patient’s world.  By first firing a “warning shot,” we allow him to prepare for a serious discussion. “ I’m sorry that I have some difficult news to share with you,” is both empathic and gives him a warning that he will appreciate.  Wait a moment and then tell him what the diagnosis or finding is.  Then wait again.  Make space for any emotion that might arise.  We never know how distraught a patient may be, so it’s useful to have tissues available. We can also ask if he would like a family member present for the rest of the discussion.

Many patients have preconceived ideas – some accurate and some not – about their condition.  Starting with their ideas allows us to assess their level of understanding, correct any misconceptions, and avoid telling the patient what he or she already knows.  So after informing the patient that he has a DVT, we can ask, “what do you already know about DVT?”  After he explains, we can then ask, “what more would you like to know about this?”  And we can continue with a combination of what our patient wants to know and what we feel is important for him to have a full understanding of his condition.

A good framework for breaking bad news is found in the SPIKES protocol, originally described by Dr. Robert Buckman, which identifies 6 steps to follow.  (The Oncologist 2000;5:302-211)

Set up the interview. It’s often helpful to mentally rehearse what we want to say, arrange for privacy, involve significant others, sit down, and manage potential interruptions.

Assess the Patient’s Perception. Questions such as, “what have you been told about your medical condition so far?” or “What is your understanding of the reason we did the ultrasound?” let us know what our patient already understands.

Obtain the patient’s Invitation. Ask our patient how she would like to have the information given to her and what she especially wants to focus on.

Give Knowledge and information to the patient.  Using words that are understandable and not inflammatory, use the “chunk and check” technique.  Provide part of the explanation and then check with your patient to make sure she understood that part before proceeding.

Address the patient’s emotions with empathic responses.  Name the emotion that we see the patient experiencing.  Let our patient know that we wish the news were different.

Strategize and Summarize. When patients know that we have a plan, they are less likely to feel overwhelmed and frightened.

Although we each have our unique way of interacting with patients, by following these suggestions, breaking bad news does not have to be such an unpleasant experience.  We can instead turn it into a process that allows us to build relationship with and partner with our patient as we embark on the management of this serious condition.

By Lisa Pavone, MD, RVT

DVT affects an estimated 2 million Americans each year.  Up to 600,000 people are hospitalized with the problem and approximately 300,000 people die each year from DVT-related PE in the U.S. alone.  As phlebologists, we are familiar with these statistics.  We are also keenly aware of the importance of increasing awareness, not just about DVT, but about our specialty, as well.  Given that, our spring issue of Veinline has been created with these themes in mind.

Some of the most exciting news is that the ACP sponsored documentary entitled “Vein Health: Discoveries, New Technologies and Breakthroughs” is scheduled to air on March 13, 2012 at 7pm on KAET-TV in Phoenix and via the website healthyveins.org.  Please be sure to read our lead article to get all of the information you need to view the special and see what incredible work the Public Awareness Task Force is doing.

In addition, Stephanie Dentoni, MD, FSVM, discusses the work-up of hypercoagulability.  JJ Guex, MD, FACPh, provides us with world phlebology insights, specifically discussing the importance understanding the burden of chronic venous disorders as well as the activities and goals of the Alliance against the Burden of chronic Venous disorders (AVB).  Helane Fronek, MD, resumes her series, Communication Matters, and discusses how to share bad news with patients.  A thrombosis case from the University of Michigan is also shared.

Don’t forget to register for the upcoming Ultrasound Advanced Skills, Ultrasound Registry Review and Nursing Sclerotherapy Courses to be held March 23rd and 24th in San Francisco, CA. – there is still time and space to do so, don’t miss out!

Please enjoy!  AND don’t forget to share your cases, opinions and ideas with us!  We welcome and encourage member-generated content and look forward to hearing from you!

Look for our next issue in June 2012!

Lisa