Varicose Veins: Community Outreach and Education Initiatives

The traditional approach to such a strategy would involve ‘search and destroy’ sclerosis or surgery for an outpatient with troublesome physical findings. The development of new guidelines for referral to and practice by specialists makes a broader evaluation of treatment options for a wide range of patients with superficial venous disease. Randomized clinical trials comparing an assigned strategy with the available therapy in a specific clinical situation will provide outcome data for decisions on the relative contributions of invasive and noninvasive methods in superficial venous disease.

A community program involving management by compression and nursing support could serve as a preamble to definitive intervention in cases where cost, morbidity, and efficacy of treatment compare favorably with the noninvasive strategy. Monitoring would be expected to be safe and result in prevention of progression of the current disease state. This approach also has the potential to contribute to preventing recurrence of venous ulcers, minimize development of a new thrombotic event in the same or other site, and prevent the development of chronic venous insufficiency with its associated costs and morbidities.

Traditional management of varicose veins involves referral to secondary care. Secondary care tends to manage the most severe cases in terms of obstruction or skin changes. The referral system and the lack of familiarity of generalists with venous disease means that only a minority of patients with varicose veins are managed by specialists. The most common group of patients with varicose vein is middle-aged women in the lower social class and with multiple co-morbidities, a group who may have specific difficulties attending the hospital for a day case procedure. This group may not wish to change their legs, may not understand the risks and benefits of treatment, or may simply have more important health issues that require attention. This group needs a program of active follow-up to determine when venous disease becomes a priority in their overall health strategy. This implies monitoring in its broadest sense over long periods with the possibility of selecting other treatment options if and when the clinical status changes.

Varicose veins may be a common problem, but they have the potential to become a serious one at the individual and community level. People seek care for varicose veins for cosmetic reasons, but a percentage of those with varicose veins will develop symptoms. Monitoring would be expected to be safe and result in prevention of progression of the current disease state. This approach also has the potential to contribute to preventing recurrence of venous ulcers, minimize development of a new thrombotic event in the same or other site, and prevent the development of chronic venous insufficiency with its associated costs and morbidities.

Understanding Varicose Veins

Varicose veins are caused by weak or damaged valves in the veins. The heart pumps blood filled with oxygen and nutrients to the whole body. Arteries carry blood from the heart towards the body. Veins then carry blood from the body back to the heart. The veins in the legs must work against gravity to carry the blood back to the heart. Muscle contractions in the lower legs act as pumps, and the elastic vein walls help blood return to the heart. Tiny one-way valves in the veins prevent the blood from flowing backwards. If the veins are weak or damaged, blood can back up and pool in the veins. This causes the veins to become abnormally twisted or enlarged.

Varicose veins are enlarged veins commonly found along the insides of legs and ankles. These veins are twisted and are easily noticeable due to their dark purple or blue color. In addition to being a cosmetic concern, varicose veins can also cause discomfort and pain. They are more common among women than men and after the age of 50, the incidence of varicose veins rises.

Causes of Varicose Veins

Varicose veins develop when the small valves inside the veins stop working properly, that is to say they no longer block the flow of blood in the wrong direction. The blood then begins to flow in a reverse direction and causes increased pressure in the veins. The increased pressure causes the veins to get weaker, which eventually leads to varicose veins. Veins that are further up the leg become affected in the same way, however they can cause skin changes called venous eczema. This can cause the skin to become discolored near the varicose veins and it usually becomes very dry and itchy. If the eczema is left untreated, it can sometimes lead to more severe damage to the skin known as lipodermatosclerosis, where the skin around the calf becomes shiny and tight. Both venous eczema and lipodermatosclerosis are serious conditions and they will usually disappear if the varicose veins are treated effectively.

Symptoms and Complications

Complications from varicose veins are relatively uncommon. However, they can be severe. The most dangerous complication is the development of a blood clot in the distal part of the veins, known as deep vein thrombosis. Because superficial varicose veins are connected to the deep veins, there is a higher likelihood of a blood clot forming in the deep veins. If this happens, there is a risk for pulmonary embolism, a potentially fatal condition. Other complications include superficial thrombophlebitis, bleeding from the varicose veins, and chronic venous insufficiency with skin changes and ulcers.

Common symptoms of varicose veins include leg pain or aching, feeling of heaviness or fatigue in the legs, throbbing or muscle cramping, itching around the veins, skin ulcers, inflamed veins, and a brownish-blue shiny skin discoloration. Symptoms like leg pain and aching can worsen after sitting or standing for long periods of time. Self-care measures such as exercise, elevation of legs, or use of compression stockings are known to improve these symptoms. Symptoms are also known to be worse during warm weather, or if the patient has been standing for long periods of time. Many patients are concerned about the cosmetic appearance of varicose veins and seek treatment for that reason alone. However, others with varicose veins seek treatment for relief of aching pain and discomfort.

Community Outreach Programs

Educational workshops can be held in community settings such as town halls, community centres, or even schools. These are especially useful for addressing groups with a higher prevalence of varicose veins and chronic venous insufficiency (CVI) such as the elderly or those with obesity. Educational workshops provide an opportunity to directly communicate with the public and appropriately address any of their concerns. As there are many myths and misunderstandings concerning varicose veins, providing an explanation of the underlying disease process is crucial in clearing up any misconceptions. Workshops can also serve to promote vein screening programs and encourage public awareness of the available treatment options.

There are several strategies to build upon general community awareness and understanding of varicose veins, with the ultimate objective of encouraging those who suffer from the condition to seek medical help. Campaigns using the mass media (television, radio, and newspapers) can reach large numbers of people. The key messages are that varicose veins are a common health condition, that they can often indicate more serious forms of disease, and that effective treatment is available. Printed educational materials should be made widely available to supplement these messages. They should be simple, easy to read and understand, and preferably have illustrations.

Public Awareness Campaigns

The development of a community-based educational campaign on the implications, prevention, and treatment of varicose veins and other venous conditions is one of the principal goals of this proposal. The need for such programming is clear. Data from the Framingham Study has shown that while there is widespread knowledge and concern about the medical and surgical treatment of arterial disease, the same is not true for venous disease. In the United States, while it consumes a great deal of healthcare resources, it is the opinion of many experts that it is inadequately taught at both the undergraduate and graduate levels and that it is underrepresented in primary care medical education. This has led to a lack of understanding about the condition among laypeople and primary care health practitioners. It is also believed that there is a significant amount of misinformation and an exaggerated belief in the seriousness and consequence of purely cosmetic venous disorders. An educated population and physicians are the key to improving access to effective treatment for venous disorders. A published critique of the National Institute of Health’s investment in venous research stated that “the public health burden for venous disease is substantial and likely to grow, and yet there is a substantial disconnect between the community, public health care providers, and even the primary care medical community and those who specialize in vein care. A broad-based educational campaign to inform citizens and healthcare providers about the true nature of venous disorders and to advocate for venous disease as a public health problem needing public health solutions may be the most viable route to improving care for venous disorders in the USA”. Well-informed patients will seek appropriate treatment and act as advocates to improve the quality of care.

Educational Workshops

A brief quiz, which was developed by a panel of venous experts and entitled the ‘Vein Disease Forum Quiz’, was administered to individuals before and after the workshop to assess their knowledge on several aspects of vein disease. During the workshop, two educational PowerPoint presentations were given by a vascular surgeon and two vascular ultrasonographers. A critical thinking worksheet, which was designed to assess the patients’ thoughts about their venous disease and its potential effect on their health-related quality of life, was also distributed at the workshop. This worksheet included a paragraph on ‘Ten Reasons to Think about your Vein Health’, which was developed by a venous disease educational company. The questions asked participants to circle answers ranging from strongly agree to disagree on some of the ten reasons mentioned to think about their vein health.

The effectiveness of educational workshops in the promotion of prevention and early detection of lower extremity venous disease (LEVD) using visual screening by experts in a community setting is unknown. Therefore, the purpose of this study was to assess the impact of educational workshops on the community’s knowledge of LEVD and attitudes to venous disease and its treatment. Two two-hour educational workshops in a community hall were promoted by local advertising, cost free to participants and included interactive informational booths on LEVD. A total of 148 people attended the workshop with a mean age of 64.2 ± 11.6 years and 91 (61.5%) were female.

Collaboration with Local Health Organizations

Finally, Dr. Rose has initiated discussion focusing on a collaborative study to compare community varicose vein screenings to more traditional conservative care, and subsequent quality of life and healthcare expenditures. This insightful approach will better define varicose vein treatment in regards to cost and care.

Currently, we are attempting to have this type of care dedicated to Medicare patients. In doing so, we are helping the government to receive what it desires most: wisely spent healthcare dollars.

Dr. Rose has recently expressed enthusiasm toward doing even more, suggesting that we add varicose vein treatment to our list of activities. We are currently working to establish treatment guidelines in order to provide direction for diagnosis and care of disease at community health events. This could quite possibly be a revolutionary step in community medicine, and it is the dream of AVF to serve as a model for other organizations across this country.

In 2003, the Chairman of the Vascular Surgery Section at Dartmouth Hitchcock Medical Center, Dr. Steven Rose, developed a whole new level for our screenings by adding a lecture on venous disease and various types of arterial aneurysms and occlusive disease. This would be followed by a two-site screening for both 50+ and 65+ year old people. At each level, abnormal findings would be reported to the individual and their primary care physician by letter.

We have been very successful in collaborating with local health organizations. They have become highly supportive of our vein screening events, providing professional staff, advertising our events in the local media, and providing logistical support.

Impact and Benefits

Improved knowledge and awareness about varicose veins will have a cascading effect, potentially increasing the number of patients seeking treatment for their symptoms, as well as potentially encouraging compliance with preventative measures to alleviate early stage symptoms and impede progression to more severe vascular disease. Information has the potential to remove many of the myths and concerns held by patients about varicose vein treatment, as well as lessening the aspersions cast by some health professionals about its efficacy and safety. This reinforces the need for ongoing education of the general public and primary care practitioners, stressing the chronic and progressive nature of venous disease, and the importance of modern vein treatments in halting its progression, avoiding development of leg ulceration and in severe cases, irreversible damage to the deep venous system. Such knowledge may also increase the number of people taking up study of venous disease, bolstering the workforce in the area and leading to better outcomes for future patients.

Improved Knowledge and Awareness

There are very limited data regarding knowledge or awareness of varicose veins in the affected community. There are no validated disease-specific measures of knowledge or health beliefs that can be used to survey awareness, knowledge, or beliefs about varicose veins. A study of prevalence and practitioner management showed that only half of respondents understood that varicose veins could progress to become a more serious health condition. Ignorance of potential serious consequences noted here, and better understanding is likely to increase rates of seeking venous intervention earlier. It is possible to assess the impact and knowledge of our initiatives in the future by comparing trends in rates of seeking vein procedures and staging of clinical venous disease with a control disease, comparing rates of referral to specialist vein services with non-venous secondary care, and validating a general measure of belief about the consequences of varicose veins and chronic venous disease.

Early Detection and Prevention

Early detection of varicose veins is extremely important and is one of the core requirements of the effective prevention strategy. It is well known that the simplest tool for detection of superficial venous reflux, the underlying cause of varicose veins, is the combination of clinical examination and duplex ultrasound. The diagnosis of varicose veins relies largely on the physical appearance. Having detected the varicose veins early on in its pathogenesis will provide an increased range of treatment options. With early diagnosis, it is possible to prevent the condition from progressing to the more severe stages such as the development of leg ulceration. This is important as it has been stated that the cost to care for patients with severe chronic venous disease and associated leg ulcers is huge. By identifying these patients and employing effective treatment strategies earlier in the course of their disease, it may be possible to prevent progression to the severe stages and greatly reduce the health care costs spent on venous ulcer care. This in itself will have a very positive impact from the varicose veins community outreach and education initiatives.

Access to Treatment Options

In an effort to moderate the patient referrals, the physicians will have increased knowledge about venous disease and its various presentations. They will try to treat these patients within their own practices. Those that have gained increased knowledge and skill in the area of venous disease will begin to recognize that the more severe cases need to be referred to a specialist in the area. This is a big step for increased patient access to qualified vein specialists. Given that the current state of most referrals is based on severe symptoms and/or failure of conservative management, this is a significant improvement in disease management.

Before initiating the program, the knowledge and awareness about venous diseases and its treatment options will be nil. As the program progresses, the target population will begin to be knowledgeable about the treatment options that are available to them. The Mini-Fellowship and Grand Rounds lecture series will be an activity for the physicians in the community. Topics will include Venous Disease Overview, Diagnosis, and various treatment options. The activity will increase physician knowledge that can be directly applied to their patients’ care.

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