Servier – Phlebolymphology

The VEIN CONSULT Program, a joint initiative by the Union Internationale de Phlébologie and Servier, is the largest global effort to raise awareness of chronic venous disease among patients, health care professionals, and health authorities. It has been endorsed by the Union Internationale de Phlébologie (UIP) and supported by an unrestricted grant from Servier Research Group, and involves the collaboration of 4500 GPs and 500 venous disease specialists.

The aim of the program is to update information on the prevalence of primary chronic venous disease in different geographic areas, to compare the management of the disease between countries, and to improve our understanding of the relationship between general practitioners and venous specialists, in order to propose a straightforward approach to earlier diagnosis.

In this international, observational, prospective survey, the prevalence and impact of chronic venous disease were assessed in two steps. First, a screening program in primary care was used to describe the adult patient population with chronic venous disease. All consecutive adult outpatients over 18 years of age, male or female, who had signed an informed consent form and were not consulting for an emergency, were screened in a short period. Second, the follow-up program was carried out in secondary care to assess confirmation of diagnosis, patient description, venous risk factors, history of chronic venous disease, lower leg examination, investigations recommended, evaluation of costs, venous complications, and treatment. Patients were asked to fill in a self-administered quality-of-life questionnaire and to answer questions related to the cost of the disease.

The program ran throughout 2009 and 2010 in 20 countries worldwide. Thirteen countries have already completed the survey, in Eastern Europe (Georgia, Hungary, Romania, Russia, Serbia, and Slovakia), Western Europe (France, Spain), South America (Brazil, Mexico), and Asia-Africa (Pakistan, Singapore, UAE), totaling almost 70 000 patients. Meaningful data from these geographic areas will be presented during the special session devoted to the program in Prague. The findings clearly show that chronic venous disease is under-recognized and undertreated, and has a considerable impact on health care.

VEIN CONSULT Program is screening a very large number of patients from many countries using the same questionnaire and the same classification (CEAP), and is the first to consider symptomatic patients, even at a very early stage (C0s), and to assess patients who consult spontaneously for chronic venous disease.

A. Puskas (Romania)

The VEIN CONSULT Program is the largest international epidemiological survey ever undertaken in the field of phlebology. The program ran throughout 2009- 2011 in 20 countries worldwide. Thirteen countries have already completed the survey in Eastern Europe, Western Europe, Central and Latin America, and the Middle East/Far East, totaling almost 70000 patients. Subject screening was performed over a short period of time (1 week) in GPs’ offices in a framework of nonemergency ordinary consultation for every person more than 18 years old. Primary care patients were mostly women (except in Pakistan) and were older in Europe than in other geographical areas. A majority (>60%) said they had a maternal history of primary chronic venous disease and around 9% had a personal history of venous thrombosis. For the first time symptomatic patients at the early stages (C0s) have been considered: 20% of screened patients complained of venous symptoms without any visible CVD. Reported symptoms in order of importance were: heaviness, pain, sensation of swelling and night cramps and were found to intensify mainly at the end of the day or after prolonged standing. Symptoms significantly increased with age and with severity of disease. Most screened subjects believed they had leg problems at the time of consultation (52.8%), while only about 20% presented spontaneously for venous care. This shows that patients underestimate chronic venous disease. Chronic venous disease is also underestimated by GPs, who often need the presence of one sign to diagnose the disease. After examination of legs by physicians, it appeared that 62% of subjects had visible signs at least on one leg. So in the global population 81% of patients suffer from chronic venous disease of stages C0s to C6s.

A. Mansilha (Portugal)

The author presented the results of the VEIN CONSULT Program concerning the evaluation of the impact of chronic venous disease on patients’ professional activities and health, and its effects on their quality of life.

The subjects found to have chronic venous disease after examination by general practitioners were requested to fill in a self-administered questionnaire reporting features about their professional activities and quality of life. The CIVIQ-14 was used to assess quality of life (score 0 for bad to 100 for very good quality of life). Patient data were compared with the clinical outcomes reported by practitioners. Data from the countries that had completed the survey at the time of analysis were pooled.

A total of 25 819 questionnaires from 10 countries (Russia, Romania, Slovakia, Georgia, Serbia, Hungary, Mexico, Emirates, Singapore, France) were analyzed. Eighty one percent of questionnaires were completed. Six percent of patients had been hospitalized and 3.7% had changed their professional activities because of venous leg problems. Loss of work days was reported in 15% of chronic venous disease patients. Number of lost work days did not exceed 1 week for most (45.2%), while 30% of them lost more (18% >1 week and 12% >1 month). Quality of life scores decreased with higher frequency of lost work days (from 68.40±19.50 for 1 time to 43.04±22.32 for >3 times) and with duration of the absence from work (from 77.25±18.84 for <1 week to 56.97±22.19 for >1 month). And so with increasing severity of chronic venous disease, ranging from 80.71±16.15 in patients with telangiectasias to 44.17±23.51 in those with an ulcer, and with the presence of a symptom (84.77±15.96 in patients without pain versus 66.86±19.80 in those with pain).

The author concluded that chronic venous disease worldwide is responsible for large productivity losses, as well as the physical and psychological suffering of patients which is reflected in worsened quality of life.

F. Fernandez (Spain)

The second step of the VEIN CONSULT Program, carried out by venous specialists, aims to characterize the typical chronic venous disease patient, and studies the characteristic of those who are referred for further studies and treatment.

Patients previously diagnosed by general practitioners as suffering from chronic venous disease (Step 1) usually went to specialized centers for confirmation of diagnosis and more in-depth investigations (Step 2). In countries which performed both Steps 1 and 2, patient data from specialists were pooled and compared with the corresponding data recorded by general practitioners.

A total of 4502 subjects diagnosed with venous disease in Step 1 of the survey had a secondary diagnosis and investigation in specialized centers, of which 20% were from Mexico and 80% from Russia. This shows a different behavior between countries regarding the need to refer diseased patients to specialists.

Patients referred to a specialist were older (54.8 vs 50.3 years), more often women (78.8% vs 73.5%), had higher body mass index (28.3 vs 27.5 Kg/m²), had more family history of chronic venous disease (52.8% vs 47.2%) and more personal history of thrombosis (18.6% vs 13.4%), and were at more advanced stages (51.6% vs 37.2% in C3-C6) than subjects screened in Step 1. The pathophysiology was reflux in 70.6% and obstruction in 15% of patients. When reflux was present, it was mostly in superficial veins (68.3%), then in perforators (17.2%) and the deep venous system (14.5%). Superficial reflux was mostly seen in patients with varicose veins, edema, and skin changes. Obstruction was found in deep (53.7%) and superficial veins (46.3%). Of the invasive treatments that were set up, open surgery ranked top (25.8%) ahead of liquid sclerotherapy (17.8%), foam sclerotherapy (9.1%), and endovenous ablation (4.7%).

There were no between-sex differences in the initial stages of the disease (CEAP C0-C2), but C3 was more frequently found in females (35.8 vs 28.6%, P<0.01) and skin changes (C4-C6) in males (15.6 vs 23.9%, P<0.001). These results mainly mirror Russian and Mexico habits regarding patient referral, diagnosis, and treatment, but less than 40% of patients who were referred to a specialist were visited by the latter, and only 41% of those referred to a specialist underwent instrumental exploration. Further results involving more countries are desirable.

JJ. Guex (France)

The proportion of patients presenting with CVD signs (C1 to C6) fluctuates between 61% and 72%, except in the Middle and Far East where numbers are lower (38.4%), but the population there is younger. These figures show that CVD is present throughout the world. Early stages of CVD predominated (C0s-C2=58%), but patients only consulted spontaneously at more severe stages, pointing to the need for earlier diagnosis. In addition, GPs did not refer patients to a venous specialist before they present with varicose veins. This shows the crucial role GPs may have in the early detection of the disease. It was also noticed that CVD was underestimated by GPs and by patients themselves, with more than 5 in 10 subjects diagnosed as CVD patients thanks to the VCP, while 2 in 10, mostly at severe stages, consulted spontaneously. Public awareness campaigns are needed to encourage patients to contact their physicians for care. Educational programs are also needed so that primary care physicians recognize cases of early CVD. This is one of the main goals of the UIP.