The Royal College of Surgeons of England (RCS) published a Commissioning Guide for varicose veins in 2013. This guide is designed to assist clinical commissioning groups (CCGs) to make decisions about appropriate healthcare for specific clinical circumstances and fulfil their obligation to commission healthcare for their population that meets the five domains in the NHS Outcomes Framework.
The high value care pathway contained within this guide aims to provide patients, the public, health and social care professionals, commissioners and service providers with a clear description of what constitutes a high quality service for varicose veins.
High Value Care Pathway for Varicose Veins
1.1 Primary Care
Asymptomatic varicose veins Offer people information and explanation:
- This should include information on the likelihood of developing symptoms as well as complications such as skin changes, leg ulcers, bleeding, thrombophlebitis and deep vein thrombosis;
- Lifestyle advice should be offered that encourages people to maintain a healthy weight, undertake moderate physical exercise and avoid prolonged standing
Symptomatic varicose veins People with varicose veins (primary & recurrent) should be referred to a vascular service if they have
- Symptoms; for example pain, swelling itching and cramps; Lower limb skin damage thought to be due to venous insufficiency;
- Superficial thrombophlebitis (hard, painful, thrombosed superficial veins); Past history of leg ulceration;
- A leg ulcer thought possibly to be due to venous (with or without arterial) disease (an ulcer is defined as a break in the skin below the knee that has failed to heal within 2 weeks)
Patients should be referred immediately to vascular service if they have:
- Bleeding varicose veins
Varicose veins can develop during, or be exacerbated by, pregnancy. Interventional treatments are not indicated in pregnancy except in exceptional circumstances. Information should be supplied and compression hosiery offered for symptom relief.
1.2 Secondary Care
- Duplex Doppler ultrasound is recommended in all patients with lower limb symptoms thought possibly to be due to venous disease as it is necessary to confirm the diagnosis and plan treatment
- Compression hosiery should only be offered if interventional treatment is not suitable or declined by the patient
- Patients with symptomatic varicose veins and truncal reflux should be offered initially endothermal ablation (ETA); if not suitable for ETA then ultrasound-guided foam sclerotherapy (UGFS), or if not suitable for ETA, UGFS then conventional surgery.
- Patients’ suitability and preferences do need to be considered.
- Symptomatic tributaries and varices should be treated by phlebectomy or sclerotherapy. This should generally be performed at the same time as the truncal reflux treatment but may be deferred if thought appropriate.
- Compression hosiery or bandaging is usually only required for a maximum of 7 days after ETA and surgery but may be indicated for a longer period after UGFS.
- Day Case Rates: Providers should be able to demonstrate close to 100% day case rate. Non-day-case procedures should be justified on an individual case basis
- VTE within 90 days: Providers should be able to identify a 90 day symptomatic VTE rate of <1%
- Unplanned readmission within 30 days for any reason: Provider demonstrates a rate of 1%
You can read the full Royal College of Surgeons’ Commissioning Guide below:Varicose Veins Commissioning Guide (2)