Just Because We Can, Should We?

As we start the New Year, I hope everyone will stop to reflect on the past year and see if there is anything we can do better or differently to improve the lives of our patients. For me, one thing that has been brought to my attention this past year is the large number of patients I am seeing that have been told they need venous ablation procedures. I know venous insufficiency is a major problem with many people. It has been estimated that about 50% of the population has chronic venous insufficiency (CVI).¹ Sometimes it seems as if all of them have been told they need their veins ablated! About 6% of these patients have a current or healed venous ulcer and 10% are asymptomatic.^2,3 That means about 34% of patients with CVI are “symptomatic” but have no ulcer disease. Do all of these patients need ablation? I recently treated an 89-year-old man who was hemiplegic from a recent stroke and confined to a wheelchair. He and his family were told he needed a venous ablation in his paralyzed leg to treat the swelling. I was dismayed that some vascular surgeon had recommended this procedure. To say the least, this patient is doing very well, with his swelling being completely controlled by using mild compression therapy. Unfortunately, if this is the “state of the art” of indications for treatment of venous insufficiency, I think a re-evaluation of the procedure is indicated.

Back in the “good old days,” venous disease was treated by ligation of the greater saphenous vein at the saphenofemoral junction with stripping of the greater and, possibly, lesser saphenous vein. The patient selected for this operative procedure had severe, symptomatic venous disease and/or ulcer disease. The outcomes of this treatment generally were good. I still see patients I treated for their venous disease more than 20 years ago who are still doing well and without further venous problems. However, it now seems as though technology has taken over! As minimally invasive procedures have been developed to treat venous insufficiency under local anesthesia in an outpatient setting, the number of procedures being done has exploded. From 2012 to 2015, the number of venous ablation procedures performed in the United States increased up to 62% in parts of the country.⁴ During that time, the Medicare Coverage Database shows 341 750 patients underwent 619 029 ablation procedures by 3244 providers.⁴ Did all of those patients really need the procedure?

As it became technically “easier” to perform the procedure, and it could be done in an office or outpatient setting, the types of providers doing the procedures increased. As expected, providers who treat venous disease, such as vascular surgeons, interventional cardiologists and radiologists, and general surgeons, performed two-thirds of the procedures. Astoundingly, one-third of the procedures were done by providers in 33 other specialties, including anesthesiologists, emergency medicine physicians, obstetricians and gynecologists, nephrologists, neurologists, orthopedic surgeons, pathologists, pediatricians, pulmonary disease physicians, urologists, nurse practitioners, and physician assistants.⁴ The data show the practitioners without vascular training did more procedures on each patient than those with formal vascular training.⁴ The implication is that many patients who may not have needed treatment are receiving it, and, possibly, many who did receive appropriate treatment received poor treatment requiring more repeat procedures.⁴ The ease of performing a procedure and the agreeability of the patient are not indications for doing it. Underlying this are the results of recent studies^4,5 that suggest there is no benefit in treating asymptomatic patients, even though they have the disease.

Unfortunately, the question of fraud has arisen. Are some of these procedures being recommended just so the provider can increase their charges? We hope this is not true, but unfortunately, it has already occurred. If there are suggestions of “stretching” a diagnosis to make the procedure qualify for reimbursement or any other suggestions of performing venous procedures that are not needed, bigger problems will result.⁶

No matter what the disease or how easy the treatment, judgment must be used before we subject our patients to any therapy. The benefits must outweigh the risks of any treatment. Always, we are obligated to act in ways that are best for our patients.⁷

Terry Treadwell, MD, FACS
woundseditor@hmpglobal.com 

This article was not subject to the WOUNDS peer-review process.