Varicose Veins in the legs: NICE podcast transcript
Hello and welcome to this podcast on the NICE clinical guideline on
varicose veins in the legs. This podcast is aimed at commissioners and
summarises the main changes in practice outlined in the guideline and
the cost benefits of implementing these changes. I’m at Charing Cross
Hospital with Professor Alun Davies, Professor of Vascular Surgery at
Imperial College London and Honorary Consultant Surgeon at Imperial
College NHS Trust, Charing Cross and St Mary’s Hospitals. Professor
Davies was also chair of the group that helped develop the guideline.
Q1: “Professor Davies, among the guideline’s recommendations are
the circumstances when patients should be referred to a vascular
service. What does NICE recommend and what change in practice will
this lead to?”
AD: “NICE recommends that all patients with symptomatic varicose
veins, be they primary or secondary, should be referred to a vascular
service. The classic symptoms are of aching, itching, swelling in the legs.
The guideline also recommend that those patients suffering from
complications, be that bleeding, thrombophlebitis and venous leg
ulceration should be referred for a vascular service for evaluation and
then advice with respect to subsequent treatment. A group of patients
who have skin changes ought to be referred also to a vascular service.”
Q2: “And what are the clinical benefits of this recommendation?”
AD: “Clinical benefits are that a large number of patients at present are
not being offered intervention for their symptoms of varicose veins.
Patients with the varicose veins, as I’ve highlighted, have symptoms of
aching, itching, pain, discomfort and swelling. It is also known that
patients have a significantly worse quality of life compared to their age
related rest of the population. And it has been shown that various
interventions on patients’ varicose veins will enable their quality of life
to return to normal.”
Q3: “And what are the likely cost benefits of implementing this
recommendation?”
AD: “Compared to the amount spent on varicose veins in 2013 the
estimate is that there will have to be an increase in expenditure of
approximately 25 per cent of budget. However, it should be noted that
in the preceding four years, secondary to a postcode lottery and
restrictions, we have seen a reduction in the number of patients having
intervention by at least 30 per cent. So that compared to figures in
2004/2005 we will be returning to that level of offering intervention. The
overall cost impact is thought to be around about £9,000 per 100,000 of
the population.”
Q4: “The guideline recommends a sequence of interventional
procedures for people with confirmed cases of varicose veins. What is
the sequence and why is it ordered as such?”
AD: “The sequence for the interventional treatment for varicose veins
has been predicated on the cost effectiveness of the intervention and
has been based on a cost effective model. There is a large heterogeneity
in patients who present with varicose veins but for a ”standard patient”
who has great saphenous vein incompetence with tributaries the
hierarchy for intervention is endothermal ablation. If this is not suitable
or declined then it is foam sclerotherapy with surgery being the third
option. There is the other recommendation that compression hosiery
should only be offered to patients in whom the other interventional
treatments are not suitable or are actually declined by the patient.”
Q5: “And are there any particular clinical benefits of endothermal
ablation?”
AD: “The overall clinical benefit is that the patient in this instance does
not need to have a general anaesthetic and can usually return to work
within a day or two.”
Q6: “And what does NICE say the cost benefits are of this sequence?”
AD: “Well, undoubtedly if you look at the economic modelling there is
significant benefit in offering endothermal ablation before foam and
foam before surgery. Overall it is cheaper to offer endothermal ablation
than surgery. And with the change in the availability of endothermal
ablation around the country this should actually result in an overall
reduction in the overall cost. And with an increase of endothermal
ablation up to about 70 per cent there will be probably an overall £8,400
saving per annum per 100,000 of the population. Therefore looking at
the previous figure it would suggest that overall this would only be a
cost pressure of £600 per 100,000 of the population per year.
Q7: “Compression hosiery is widely used as a first line treatment for
varicose veins yet the guideline says that this should only be offered if
interventional treatment is suitable. Why does NICE say this?”
AD: “NICE has come up with this recommendation as many patients
were being denied interventional therapy because it was thought that
compression hosiery was sufficient to treat their symptoms and this was
being delivered in primary care. The NICE guideline have shown very
clearly that the interventional treatments, such as endothermal ablation,
foam sclerotherapy and surgery, actually improve patients’ quality of life
significantly more than offering the compression hosiery. And the
recommendation is such to ensure that all patients are assessed
properly and are evaluated for what is the best and most cost effective
intervention. It should be noted that if you are recommending
somebody wears compression hosiery you are giving them that as a
recommendation for the rest of their life and that has an annual cost of
at least £182 per annum. So overall you can see that there is
undoubtedly a cost benefit and also there is a much more effective
treatment by offering them more interventional therapies.”
Q8: “What would you say is the current level of care of varicose veins
in this country?”
AD: “There is undoubtedly a postcode lottery. And in 2012 this was
identified using HES data to be at least a tenfold difference depending
on your location. Furthermore, there was also a significant difference in
the treatment options made available in the NHS. In some areas only
surgery was available or foam sclerotherapy. And it is hoped that this
guideline will ensure that all patients are offered the most suitable
modality for treatment of their varicose veins, and, as you have heard
previously, most people should be offered endothermal ablation. It is
also hoped that having worked with the commissioning groups at the
Royal College of Surgeons that the commissioners will be informed by
the NICE guideline so that they will purchase care at an appropriate level
to ensure that all patients in this country get an equal chance of having
the appropriate treatment for their varicose veins.
Professor Davies, thank you very much.
20 February 2014