Choosing the Best Vein Center for Your Wound Care Patients

For chronic wound care providers, finding an appropriate, competent vein specialist to refer patients to for the treatment of venous ulcers and related complications can, sadly, feel quite similar to online dating. How can you confidently determine that what these self-proclaimed “expert” providers are promoting about themselves and their practices is valid and honest? How can you legitimately trust that sending patients to any one provider to collaborate in their care planning is truly the best option when there are so many other professionals out there who offer the same specialty care? The pool of available practitioners is deep, and the waters can be murky for those clinicians who do not thoroughly conduct their research.   

This article will provide guidance for those providers in outpatient wound clinics who are seeking referral options. Questions that will be addressed include: Who is the ideal patient to refer to a vein center? Does location of the ulcer matter? Are there patients who should not be referred? How does one assess the credentials of a venous specialist? What types of procedures (and why) should be expected for patients who undergo treatment at a vein center? Is there a simple explanation as to which type(s) of treatment(s) one should use for specific type(s) of disease states? 

VENOUS NEEDS: BY THE NUMBERS

First, let’s consider some facts:

• 21% of all wounds seen in wound care centers are venous.¹ 
• 1 million people in the United States are living with venous leg ulcers.² 
• 50-70% of lower extremity ulcers are venous.³
• $14.9 billion are spent annually on this area of care in the U.S.⁴

Given these facts, wound care centers and vein centers should form a natural, complementary partnership; however, finding a true match for your patients can be difficult. To best attempt to break down the proverbial walls that can be built between the silos within the healthcare landscape, let’s try to tackle a few of the most frequent questions that wound care clinicians have when it comes to collaborating with vein specialists. 

Question No. 1: Who is the ideal patient to refer? The ideal patient to refer is really anyone suspected to be living with any aspect of venous disease. Now, this may seemingly cast a large net; however, there will rarely be a patient seen in a vein clinic with only one condition contributing to the ulcer disease. Venous edema and lymphedema go hand in hand. Venous insufficiency, left untreated, will eventually lead to lymphedema.⁵ Conditions that predispose patients to lymphedema, such as obesity, immobility, and prior trauma, also predispose patients to venous insufficiency.^6,7 Those living with diabetes who develop diabetic ulcers are also prone to arterial disease and arterial ulcers. Those diabetic patients who become obese and/or have decreased calf muscle pump activity are also prone to venous disease and lymphedema.^8,9 Even though “classic” venous ulcers are located at the medial malleolus, they can be found anywhere in the lower leg, particularly in the gaiter region (lower medial one-third).¹⁰ As far as one’s age goes, yes, it can be “just a number,” however, patients older than age 90 have been known to be treated for venous ulcers. If the patient is truly mobile, he/she could be a candidate for treatment. Ultimately, that decision is best determined by the vein specialist. What follows might be the best way to summarize candidacy: if vein disease exists (or if the ulcer is of an arterial etiology – or any other), if an ulcer warrants treatment, and if the benefits of treatment outweigh the risks.

Question No. 2: How should the wound clinic provider recognize/select a quality vein center? Let’s start with the role and training of the physician in a vein center. A reputable vein center will revolve around a well-trained and affable physician who serves as the clinical decision-maker. The phlebologist can have a variety of specialty backgrounds ranging from vascular surgery to vascular medicine, emergency medicine, interventional radiology, and surgery, to name just a few. The level of educational commitment that the physician has made in the field of phlebology is the telling factor of one’s expertise. Is he/she board-certified by the American Board of Venous and Lymphatic Medicine? Does he/she belong to/attend/participate in any major national venous conferences? The quality of a phlebologist’s educational commitment to the field will likely be reflected in the quality of his/her care. 

Transitioning from one specialty to another represents a natural trajectory in the history of medicine. At one time, only family doctors and surgeons existed. As time has passed, surgeons and primary care physicians have sub-specialized. As technology advances, so do these subspecialties.  At one time, heart surgeons treated coronary artery disease and vascular surgeons treated peripheral vascular disease. With the advent of interventional procedures, cardiologists and interventional radiologists started treating these diseases. Infradiaphragmatic venous disease is so vast and so complex that it requires a knowledge base from almost every specialty, including dermatology (skin changes), emergency medicine (acute deep vein thrombosis and phlebitis), and gynecology (pelvic venous disease). The best practices may include a variety of specialists who regularly communicate and educate one another to understand and properly treat the entire spectrum of venous disorders. This is also the function of professional society meetings. 

A reputable phlebologist will prioritize treatment plans by first identifying and appropriately treating or ruling out any suspected arterial disease, as this has the most dire consequences if left untreated and is a contraindication to compression. The phlebologist should also be able to identify whether the patient’s venous hypertension arises from pelvic venous insufficiency and, subsequently, treat the pelvic veins appropriately (10-15% of all patients living with venous disease).¹¹ The common thread must be the physician showing the humility and commitment to learn a new field — phlebology. Once you have found a phlebologist/vein center, the next step is to figure out whether this person/group is willing to partner with you. Ask for an interview: If someone is too busy to discuss how they intend to collaborate on a care plan, just move on. During the interview process, get to know the clinicians’ experiences, and do not be shy: ask to see real data showing the number of procedures performed and outcomes. Published results give more credibility, if available. If not, ask for national database registry inputs. Following the interview, invite the vein specialists to attend the wound clinic and present to staff members. Host a question-and-answer session. Also, discuss and develop a plan that outlines the frequency and mode of communication between the vein center and the wound clinic early in the relationship. If the potential partner is not willing to provide these commitments, move on. Once a patient has been referred for treatment, the wound clinic staff should be sure to monitor the patient’s progress on subsequent visits and monitor how well the vein center staff provides follow-up information to the patient and wound care provider. Invite the phlebologists to attend any regularly occurring meetings/educational programs that the wound clinic’s administrators host for their staff members to help ensure that lines of communication remain open and that patient treatment plans are cohesive. The key to a successful long-term relationship between the wound clinic, vein center, and patient is ongoing to be regularly scheduled communication. Wound clinic staff members should also ask for periodic updates on patient progress in addition to any shared group meetings.

See the Table above for an example of a treatment plan that the authors provide for ongoing communication and collaboration on the patient’s care. This report is typically sent via fax, electronic health portal, and/or is delivered by the rendering provider and/or physician liaison who visits the wound clinic (depending on the wound clinic’s preference). See Figures 1 and 2 above for examples of follow-up pictures that the authors send to the referring wound center routinely via secure email. 

Additionally, many vein centers today employ physician liaisons who visit referring offices. These liaisons can be another good way to openly communicate with the vein specialists. Take the time to engage these folks in conversation and listen to their suggestions if they appear to be engaged in the patient’s care.  Ken Chisholm, RN, MBA, BS, medical director of Mercy Wound Care Center, Toledo, OH, recently described the approach that he took to select vein specialists for his facility’s wound care patients: “As our center’s director, my first order of business was to research neighboring geographic areas for the existence of these ‘vein clinics,’” he said. “Further research would include identifying the relevant expertise of the providers, attempting to glean the quality centers from the typical ‘storefront’ clinics, of which many offer ancillary services not directly related to quality vein care but more to provide additional revenue streams, thus diminishing their credibility.”

Question No. 3: Which types of comprehensive services should the vascular experts conduct for wound care patients? Once the appropriate clinical partner has been identified and the patient referral process is completed, wound clinic staff should expect the vein center to conduct all proper ultrasound testing with a full slate of results (ie, results that go beyond communication that “there is a clot” or that “there is no clot.”) Just as there is no “magic” wound care dressing for all ulcers, treatment modalities for venous disease depend on a multitude of factors, including which vein branch is the cause, the morphology of that branch, the patient’s insurance for coverage, prior treatment successes and/or failures, and the presence/absence of concomitant lymphedema. 

The vein center specialist should advise and select the appropriate treatment modality for the appropriate patient. For example, treatment of lymphedema is just as important as treatment of venous disease. Remember that venous insufficiency is a chronic disease with a spectrum of severity. A successful treatment is one that leads to increased number of ulcer-free years. Because chronic diseases can and often do return, patient education by both the vein center and the wound clinic is of high importance for this patient population. (A related patient handout is offered in this edition of Today’s Wound Clinic on page 21.)

Question No. 4: Is the vein center a partner in the overall vein health of the community? Any vein center that collaborates with the wound clinic should also offer ongoing educational opportunities and/or literature, such as scientific articles and/or continuing education events. When the wound clinic’s staff members have questions for the liaison(s), they should either know the answers or offer to get them from the physician. It’s time to move on if there’s a breakdown in this type of communication and/or if the vein specialists are not taking appropriate measures to help keep wound care clinicians educated. Additionally, remember that the patients should also have a voice in the matter. Are the referred patients actually improving? Do the patients offer positive feedback on their experiences with the vein center and staff? These are questions that should always be addressed. n

Zoe Deol is regional medical director, Sanjiv Lakhanpal is president and chief executive officer, Maxwell Tran is a medical student and an intern in the medical entrepreneurship program, and Jessica Freeze is director of sales at the Center for Vein Restoration, Greenbelt MD. 

References

1. The Outpatient Wound Clinic Market Performance Report. Net Health Analytics. 2013. Accessed online: www.nethealth.com/wp-content/uploads/2013/09/ToC-2013-Net-Health-Outpatient-Wound-Care-Market-Performance-Report.pdf

2. Hodde JP, Allam R. Small intestinal submucosa wound matrix for chronic would healing. Wounds. 2007;19(6):157-62.

3. O’Donnell TF Jr., Passman MA, Marston WA, et al. Management of venous leg ulcers: clinical practice guidelines of the society for vascular surgery and the american venous forum. J Vasc. Surg. 2014;60(2 Suppl):3S-59S.

4. Rice JB, Desai U, Cummings AK, Birnbaum HG, Skornicki M, Parsons N. Burden of venous leg ulcers in the united states. J Med Econ. 2014:17(5); 347-56.

5. Raju S, Furrh JB, Neglen P. Diagnosis and treatment of venous lymphedema. J Vasc Surg. 2012;55(1):141-9.

6. Willenberg T, Schumacher A, Amann-Vesti B, et al. Impact of obesity on venous hemodynamics of the lower limbs. J Vasc Surg. 2010;52(3):664-8.

7. Fife CE, Carter MJ. Lymphedema in the morbidly obese patient: unique challenges in a unique population. OWM. 2008;54(1):44-56.

8. White-Chu EF, Conner-Kerr TA. Overview of guidelines for the prevention and treatment of venous leg ulcers: a US perspective. J Multidiscip Healthc. 2014;7:111-7. 

9. Simon DA, Dix FP, McCollum CN. Management of venous leg ulcers. BMJ. 2004;328(7452);1358-62. 

10. Nelzen O, Bergqvist D, Lindhagen A. Venous and non-venous leg ulcers: clinical history and appearance in a population study. Br J Surg. 1994;81(2):182–7.

11. Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol. 1996;87(3);321-7.