Venous disease care has a problem with optics in the context of growth in the number of venous procedures and the spectre of inappropriate care, the 2023 Charing Cross (CX) International Symposium (25–27 April, London, UK) heard.
The conversation thread emerged in a question from Stephen Black (Guy’s and St Thomas’ Hospital, London, UK), posed to presenter Erin Murphy (Sanger Heart and Vascular Institute, Atrium Health, Charlotte, USA), who had just presented possible solutions that can be targeted at not only discouraging inappropriate venous care but also encouraging appropriately administered procedures.
Having trained and carved out a career as a venous specialist, said Black, if he were to suddenly decide “to now go and do a coronary angiogram and stent, I would get absolutely obliterated”. So, he asked Murphy: “Why is it that it is so easy for people who have never trained in veins just to crack on and treat veins without any consequences?”
Murphy pointed to a problem with misperception—”that this is an easy patient subset to treat, and I think those of us who are in this room treating these patients know that there is actually very complex decision-making [involved] in order to get the right outcomes for our patients,” she said. “We need to change that perception.”
Murphy had outlined several ways she sees of helping to curb the problem, building on a talk Manj Gohel (Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK) gave last year. They included defining appropriate care through research initiatives, consensus statements and guideline data; educating and disseminating such data; holding practices accountable for decisions to carry out inappropriate care; and establishing correct financial incentives.
The biggest of these challenges currently involves educating a sprawling array of providers who treat venous disease patients, Murphy said. Are the right doctors treating the venous disease population? Vascular surgeons, for instance, “have no requirement in their board certification to be treating venous patients,” Murphy said, asking whether they are well-enough trained in the venous area. “Coming out of training, they have done about 40 venous cases overall.” Similarly, for interventional radiology, the situation is not any better, she reasoned. “Cardiology has no required training. So, what we do?”
The answer might be dedicated providers who undertake training and fellowship requirements specific to venous disease, as well as specific board certification, and accreditation. “This is in progress,” Murphy pointed out to the CX 2023 audience. “This is probably a direction that we need to go.”
In terms of accountability, she queried whether the venous space should be auditing for decision-making when people are trained appropriately. “We have seen when we identify practices that are doing things outside the norm,” Murphy explained, drawing attention to example of practices carrying out more ablations per patient compared to the average practitioner treating venous disease, “when we notified the practice of their outside-the-box numbers, they actually self-corrected to an extent.” The implication here is that they had been educated, she added.
Underdiagnosis and undertreatment probably affect more patients than overtreatment, particularly over time,” Murphy said. “So, we do not want to disincentivise. But a multimodal effort to address inappropriate care is needed, and, probably, educating providers is our number one thing.”