Venous Disorders Poised For National Spotlight

BY CHRISTINE KILGORE
Writer Karen Dente contributed to this story

At a strategic planning retreat 2 years ago, leaders of the American Venous Forum agreed that they needed to raise awareness of venous disease, a malady that has been underfunded, undertreated, and underappreciated.

Today, with completion of the AVF's first national venous screening program, increased attention from national quality-of-care organizations, and the May 2006 Surgeon General's workshop on deep venous thrombosis, they are hopeful that deep venous thrombosis and other venous disorders will get their due share of attention.

"To hear that the Surgeon General thinks venous disease is important enough to look at is extremely exciting," said Dr. Thomas W. Wakefield, a professor of surgery at the University of Michigan, Ann Arbor, and immediate past president of the American Venous Forum (AVF), which is an 18-year-old international coalition.

"Studies have shown that the incidence of deep venous thrombosis and pulmonary embolism hasn't changed much in the last 30 years, despite the fact that we have new [treatments] and some more awareness than in the past," he said. "It's gratifying to see the government interested."

Dr. Wakefield is scheduled to represent the AVF at the Surgeon General's workshop early this May, along with Dr. Joseph A. Caprini of Northwestern University in Chicago, and Dr. Robert B. McLafferty of Southern Illinois Medical School, Springfield.

If the Surgeon General, Dr. Richard H. Carmona, decides after hearing from experts at the workshop to issue a "call to action" on deep venous thrombosis (DVT), venous disease would become a national public health priority. In the absence of such a mandate, the workshop could still result in other actions and recommendations.

Most physicians generally know about DVT, which kills 200,000 people a year, said Dr. Wakefield and other AVF leaders interviewed for this article. Many, however, do not appreciate the swelling, ulceration, and other long-term consequences of the disease when it is not properly treated.

Many physicians also are unaware of newer therapies, such as outpatient treatment of uncomplicated DVT with low-molecular-weight heparin, and more aggressive treatments that are available for severe forms of thrombosis such as iliofemoral clots, they said.

Dr. Bo Eklof, a former AVF president and retired professor of surgery, said that education is now the buzzword in the field. "In the U.S. [venous disease] has been some kind of stepchild," he noted. "Everything has been concentrated on arterial disease, which is unfortunate, since venous disease hits us much younger."

Dr. Michael C. Dalsing, current AVF president, said one of his main goals for this year is to create a multidisciplinary venous council--bringing together primary care physicians, pulmonologists, and others who care for patients with acute and chronic venous disease.

The more attention venous disease receives, the more likely it is to "find its proper place in the hierarchy of public health funding, research funding, and clinical support through avenues like Medicare and Medicaid," he said.

The results of the first national survey for venous disease indicate that 77% of the 476 men and women who participated were at high or very high risk for venous thromboembolism if they were in a high-risk situation such as undergoing major surgery or subjected to prolonged bedrest.

A total of 40% had evidence of valvular reflux, roughly a third were reported to have varicose veins, and about 5% were found to have venous obstruction, based on data from the screening, which was conducted in November 2005 and the findings presented at the annual meeting of the American Venous Forum.

About 20% had a clinical, etiologic, anatomic, and pathophysiologic (CEAP) classification system score of three or greater. The scores reflected problems ranging from leg swelling to active ulceration.

The free screening consisted of a demographic questionnaire, use of a modified version of the AVF's DVT risk assessment tool, inspection of the legs to derive a CEAP score, and an abbreviated duplex ultrasound scan to assess reflux and obstruction. A downloadable template of the AVF's risk assessment tool is available on the AVF Web site, www.venous-info.com.

The screening program, headed by Dr. McLafferty, was conducted in partnership with the American Vascular Association and was funded through industry grants. The screening took place at 17 sites, all of which had established arterial screening programs.

Those considered at risk were predominantly female (78%) and white (84%). Only about a third had a body mass index (BMI) of less than 25 kg/m2 (18.5-24.9 kg/m2 is considered normal). One in every 20 people screened was morbidly obese

"Ten times more people have venous disease than common arterial diseases," explained Dr. McLafferty, who spearheaded the program that was first conceived at the American Venous Forum retreat in September 2004.

Both Dr. McLafferty and Dr. Dalsing said they hope to establish a screening site in every state this year. They envision a patient-driven scenario in which people who have been screened take a "report card" back to their physicians, along with a ThumbDrive (portable storage drive) for their physicians that briefly explains prevention and treatment options.

In the meantime, DVT risk assessment is advancing in the hospital setting. One of the 30 "safe practices" established by the National Quality Forum--a private organization of hospitals, provider systems, and various professional and consumer groups--states that all patients should have a risk assessment for thrombosis on admission to the hospital and that appropriate prophylaxis methods should be used.

The Joint Commission on Accreditation of Healthcare Organizations is field-testing 10 performance measures that it believes could be used to monitor hospitals' compliance with safe practices, starting in 2008, said Dr. Caprini.

To advance knowledge of venous disease, the AVF is prioritizing more than 20 potential research areas. Among those at the top of the list, according to Dr. Wakefield, are the use of heparin versus more aggressive therapies such as thrombectomy for proximal clots, the use of duplex ultrasound and other imaging modalities to prognosticate what may happen to a clot, and the development of a test to better diagnose venous obstructions.

Venous disease has received growing recognition from the National Institutes of Health, Dr. Wakefield said. Over the past few years, for example, the NIH has sought and funded projects on inflammation, thrombosis, and critical issues in postphlebitic syndrome.

"Ten years ago, if you had told me that the government was interested in venous disease and would actually be funding projects in venous disease, I would have said, 'No, that's unlikely,' " Dr. Wakefield said.