The European burden of primary varicose veins

Abstract

Background:

The treatment of varicose veins has been demonstrated to improve quality of life, alleviate symptoms of depression and treat the complications of venous disease. This study aims to show the studies which contain information regarding the prevalence and distribution of venous disease. Then using the population and prevalence data for venous disease, and considering the cost of treating varicose veins, this study aims to analyse the treatment of varicose veins and assess whether there is a disparity between European countries.

Methods:

Relevant papers regarding the prevalence or incidence of venous disease were identified through searches of PubMed (1966 to October 2010). The search terms ‘prevalence OR incidence’ AND ‘varicose veins or venous disease’ were used. Population data, prevalence data and the number of varicose vein procedures performed in each country was obtained for 2010.

Results:

Four studies were included. From calculated values comparing the predicted and actual number of patients requiring treatment for venous disease, the UK, Finland and Sweden are potentially not treating all patients with C2 disease. In contrast to this, all other European countries represented are treating more patients, suggesting that they may be treating additional patients. There was up to a four-fold difference in the numbers of procedures per million population that were performed for varicose veins in different European countries.

Conclusion:

There is a marked disparity across Europe between the predicted number of patients with varicose veins requiring treatment and the actual care given. The factors influencing this need more detailed investigation.

Keywords

varicose veins healthcare burden treatment

Introduction

Venous disease is common in the UK.¹ Although prevalence data are highly variable, other European cohorts report comparable prevalence data.^2–4 The majority of patients with venous disease have superficial venous reflux alone with clinical manifestations including telangiectasia, varicose veins, oedema and venous ulceration. Superficial venous disease does not pose an immediate threat to life; however, the treatment of varicose veins has been demonstrated to improve quality of life,⁵ alleviate symptoms of depression⁶ and treat the complications of venous disease.⁷ Patients with superficial venous reflux and varicose veins have benefitted from recent advances, particularly the use of endothermal technologies to ablate superficial veins.⁸ All treatment modalities have been shown to improve patients' quality of life in national non-selected patient-reported outcome measures⁹ and in the UK, all treatment modalities have been shown to be cost-effective in terms of quality-adjusted life-years gained relative to conservative treatment.¹⁰

In the UK, the National Institute for Clinical Excellence referral advice document, published in 2001, recommends referral by the general practitioner (GP) for specialist advice if patients have ‘troublesome symptoms attributable to their varicose veins, and/or they and their GP feel that the extent, site and size of the varicosities are having a severe impact on quality of life’ as well as patients who have healed or active ulceration or bleeding varicosities.¹¹ However, despite this, individual primary care trusts (National Health Service [NHS] funding bodies) are commonly recommending, and indeed will only reimburse treatment if patients have severe skin changes and have failed a six-month trial of compression, or if the patient has leg ulceration, chronic continuous pain or severe oedema.¹² If patients are treated in the earlier clinical stages of disease, then progression, estimated to be approximately 2% per year from C2 to C3–C6 disease,¹³ may be halted. In the long term, to prevent the more costly severe clinical stages of venous disease, it may prove to be more cost-effective to treat early symptomatic disease, although larger studies are needed.

Is this management strategy reflected across the rest of Europe? How many procedures for varicose veins are performed and is there a difference between countries? Which clinical stages of disease are being treated and is there consistency? Importantly, what are the potential treatment costs of performing these procedures and can they be justified?

This study aims to show the studies which contain information regarding the prevalence and distribution of venous disease. Then using the population and prevalence data for venous disease, and considering the cost of treating varicose veins, aims to analyse the treatment of varicose veins and assess whether there is a disparity between European countries.

Methods

Relevant papers regarding the prevalence or incidence of venous disease were identified through searches of PubMed (1966 to October 2010). The search terms ‘prevalence OR incidence’ AND ‘varicose veins or venous disease’ were used. Article titles and abstracts were screened for inclusion. A manual reference list search was also carried out for further appropriate studies to be considered for inclusion. Articles regarding cardiac or coronary disease, cancer and thromboembolism were excluded. Relevant full-text articles were scrutinized and all studies reporting the distribution of venous disease in a representative sample population, that is not those seeking specific treatment for venous disease, were included. The relevant data including the prevalence of venous disease in the population and the distribution of clinical disease severity within that population were included.

For the subsequent calculations, prevalence data were obtained from the Bonn Vein Study (BVS).¹⁴ In this study 3072 people were selected at random from a population register and screened for venous disease. This included a full history, clinical assessment, completion of a quality-of-life questionnaire and venous duplex ultrasound examination. The severity of venous disease for each subject was given by the CEAP (clinical, aetiological, anatomical and pathological elements) classification.

Population data were obtained from the UK Office for National Statistics UKONS and Eurostat, the statistical office of the European Union, Luxembourg. The number of inhabitants aged between 15 and 79 years of age was obtained. This age range was selected as some of the data grouped patients from age 15 to 79 and also this represents the age range in which the majority of patients with venous disease would be offered a procedure in all countries. These datasets were used to calculate the numbers within the population and the actual numbers that would fall into each of the clinical stages of disease.

The number of varicose vein procedures performed in each country was obtained from the Hospital Episode Statistics (HES) for the UK and from the Millennium Research Group for continental European countries for 2010. These data were compared with the predicted number of patients that were previously calculated that would require an intervention for varicose veins, that is, the predicted numbers of patients with C2–C6 disease.

Data regarding the cost of treating varicose veins were obtained from HES online in the UK and for continental European countries from health economic analyses.^15,16 These datasets were used to estimate the cost of treating these patients with superficial venous disease. Venous experts in each of the European countries were contacted if information regarding the cost of varicose vein interventions could not be found in the literature. In these cases the reimbursement fees for each of the procedures were used for each country if available.

Results

Epidemiology of venous disease

The initial search strategy yielded 4896 results. After title and abstract screening, 11 full-text articles were examined. Seven were excluded as either the sampled populations consisted of patients presenting with venous disease so were not considered to be representative of the general population, or the population selected could not be classified by disease class as insufficient information was available, or if the selected population was restricted. The results from the four included studies regarding the prevalence and distribution of clinical disease class severity are shown in Table 1. Each study determined the prevalence of venous disease by a different consideration. Bihari et al.¹⁷ considered the presence of venous disease in any patient with a visible varicosity including reticular or spider veins. Evans et al.⁴ did not use the CEAP classification and considered patients with C1 disease in the ‘no disease’ category. Rabe et al.¹⁸ selected a large population; however, the results regarding clinical severity have not yet been correlated with the presence of reflux, so the number of patients with treatable disease is not known. Chiesa et al.¹⁹ and Evans et al.⁴ both assessed for the presence of reflux in the general population; however, there was selection bias in the study by Chiesa et al.¹⁹ as patients were selected by advertising, so it was not a representative of the general population. Rabe et al.¹⁴ however, although they note a high prevalence of C1 disease and above, over 90%, they also correlate this with reflux measurements, and therefore potentially treatable disease can be calculated. The prevalence data from all of these studies are shown in Table 1.

Table 1

The prevalence and distribution of varicose veins from epidemiological studies

Study	Country	Number of patients	Prevalence of venous disease (%)	Clinical disease class severity distribution (%)
Rabe et al. (2003)¹⁴	Germany		90.4	9.6	59	14.3	13.5	2.9	0.6	0.1
Chiesa et al. (2005)¹⁹	Italy	5187	62.9	22.7	64.8	29.4	13.6	13.6	3.4	8.6
Bihari et al. (2011)¹⁷	Hungary	566	57.1	42.0	31.1	10.1	7.1	6.9	1.8	1.0
Rabe et al. (2012)¹⁸	Worldwide	77,716	83.6	36.1	21.7	17.9	14.7	7.5	1.4	0.7

Prevalence of venous disease across Europe

Population data were obtained from the UK Office for National Statistics UKONS and Eurostat, the statistical office of the European Union, Luxembourg. The number of inhabitants aged between 15 and 79 years of age was obtained for each country. According to the BVS, the prevalence of venous disease in the population was 20%; therefore, the number of patients with potentially treatable venous disease between these age ranges was calculated. Subsequently, using data from the BVS regarding the percentage distribution of patients for each stage of clinical severity by CEAP classification, the estimated number of population with C0, C1, C2, C3, C4, C5 and C6 diseases were calculated. This is shown in Table 2.

Table 2

The calculated number population in each European country with each stage of severity of venous disease

	Number of population × 1000
C0	930	83	1279	708	947	929	81	140	250	129
C1	5713	508	7859	4352	5819	5709	497	861	1536	794
C2	1385	123	1905	1055	1410	1384	121	209	372	192
C3	1307	116	1798	996	1332	1306	114	197	351	182
C4	281	25	386	214	286	281	24	42	75	39
C5–C6	68	6	93	52	69	67	6	10	18	9

A comparison of the calculated and actual number of varicose vein procedures performed

In order to calculate the estimated number of varicose vein procedures per year that would be required to treat all patients at each stage of clinical severity, the absolute numbers (Table 1), were divided by 64 (the number of years in the age range 15–79 years). The estimated number of treatments that would be performed per year in each European country if all patients with C2–C6, C3–C6 and C4–C6 diseases were treated was calculated. These are shown in Table 3.

Table 3

Estimated annual number of procedures required to treat different CEAP ranges

CEAP range	UK	Denmark	Germany	Spain	France	Italy	Finland	Sweden	Netherlands	Austria
C2–C6	47,509	4225	65,350	36,188	48,393	47,477	4137	7160	12,770	6604
C3–C6	25,873	2301	35,589	19,708	26,354	25,856	2253	3899	6954	3597
C4–C6	5447	484	7492	4149	5548	5443	474	821	1464	757

CEAP, clinical, aetiological, anatomical and pathological elements

Patients with C2 and more severe venous disease are likely to be the population who would seek treatment as visible varicosities and other symptoms may have an impact on their quality of life. Patients with C1 disease generally do not require treatment, apart from cosmesis. Therefore, a treatment threshold of C2 disease and above was assumed. The actual number of treatments carried out in each country was compared with the calculated figure of all patients with C2–C6 disease were offered treatment. This is represented graphically in Figure 1. The line running through ‘0’ represents the level at which the calculated number of required treatments is equal to the actual number of procedures carried out, that is if all patients with C2–C6 disease were treated. Above the line is additional actual number of procedures performed, and below the line is the shortfall, representing the predicted number of patients with C2 disease and above who are not receiving treatment. This is represented as a percentage relative to the predicted number of patients with C2 disease.

Figure 1

A comparison of the actual number of procedures performed with the calculated number that should be carried out if all patients with C2–C6 disease were treated

As shown on the graph, the UK, Finland and Sweden, according to the calculated values are not treating all patients predicted to have C2–C6 disease. In contrast to this, all other European countries represented are treating more patients, suggesting that they may be treating additional patients, which may represent the treatment of recurrent disease, multiple procedures on individual patients or that the calculated predicated numbers of patients with C2–6 disease were underestimated.

The cost of performing varicose vein procedures

The number of additional procedures or the number of patients with C2 disease not treated was compared with the actual number of procedures carried out in each country. The costs of performing varicose vein procedures in each of the European countries were obtained from recent health-economic analyses, insurance reimbursement costs and from European venous experts. The potential additional costs for the countries performing more varicose vein procedures than patients with C2–C6 disease were calculated and are shown in Table 4. The potential cost-savings by the countries not treating all patients with C2–C6 disease are shown in Table 5.

Table 4

Potential additional costs of treating more patients than those with C2–C6 disease

Country	Cost of all C2–C6 (€millions)	Additional procedures carried out	Potential costs (€millions)
Denmark	8	1775	4
Germany	105	124,650	199
Spain	58	30,812	49
France	77	31,607	50
Italy	76	22,523	36
The Netherlands	20	22,230	36
Austria	11	11,187	18

Table 5

Potential cost-saving of not treating all patients with C2–C6 disease

Country	Cost of all C2–C6 (millions)	Potential patients with C2 not treated	Potential costs saving (€millions)
UK	67	14,327	23
Finland	6	1152	2
Sweden	10	697	1

The term ‘potential’ is emphasized as these calculations are based on the predicted numbers of patients with C2–C6 disease and they do not take into account the long-term costs of disease progression, compression hosiery and societal costs of not treating this group of patients.

Comparison of the actual number of varicose vein procedures performed in different European countries

The number of varicose vein procedures carried out in each country in 2010 was compared with the number of population, and the number of procedures per million population was calculated to see if there was a disparity across Europe. The numbers of procedures per million ranged from a low of 685 in the UK to a high of 2853 in Germany. The values for each of the other European countries is shown in Figure 2.

Figure 2

The number of varicose vein procedures carried out per million population in each European country

Discussion

From this study there is currently a marked disparity in the way in which varicose veins are treated throughout Europe. This is shown by both the wide variation in the numbers of procedures per million persons as well as the calculated values of the different numbers of patients with different disease severity being treated. The UK is performing the lowest number of varicose vein procedures per million persons and from the calculated data if it is assumed that all patients with higher disease class severities are being treated, the majority of patients with uncomplicated varicose veins are not undergoing intervention. Current trends indicate that the number of varicose vein procedures performed each year in the UK is decreasing (Figure 3). This may increase costs overall, and leave patients with worsening but potentially treatable venous disease.

Figure 3

The number of varicose vein procedures performed in the UK

In the UK, patients with C2 disease, are often not offered treatment on the NHS. Conversely in other European countries, notably Germany the Netherlands and Austria, many more procedures are being carried out per million population, up to four times more than that in the UK, and from the calculated data, patients with disease class severity of less than C2 disease are even being treated. The differences between countries may occur for many reasons, including primary health-care service availability, patient and physician perceptions of the importance of venous disease and the demand for cosmetic treatment. Different procedures for reimbursement may contribute, as in some countries procedures are carried out in stages as each modality of treatment is separately reimbursed.

There is currently a paucity of accurate longitudinal evidence to support this supposition, as there are currently no studies that exist assessing whether endovenous or open varicose vein procedures performed early in clinical disease have an impact on progression. However, there is evidence to suggest that the number of patients with venous ulcers can be reduced by half if patients with mild-to-moderate venous disease are offered surgery.²⁰ In the long-term, this may prove to be more cost-effective, although larger studies are needed. The calculated potential additional shown in Tables 3 and 4 are only for the treatment of one leg and not for recurrent varicose veins, so these may be underestimated. In the UK, the procedures performed in private practice are not included in these calculations. However, estimates from independent private health-care providers in the UK suggest that these figures are not increasing as the number of procedures performed within the NHS are decreasing.

This study has limitations. The data from the BVS on the distribution of clinical venous disease severity by CEAP classification was applied to the 20% of patients with reflux in at least one superficial vein, which represents those that would be suitable for treatment, rather than the whole population. This is likely to have resulted in an underestimation of the number of patients that may be eligible for treatment, as patients with radiological reflux are probably more likely to have signs of venous disease than a selection of the population as a whole. The costs of ongoing treatments including compression stockings, treating higher classes of disease severity and recurrence were not included. It was assumed that each treatment was carried out on one limb of one patient and costs of treating recurrence were not included. This resulted in an underestimation of the cost of treating venous disease. The costs used were taken as either the reimbursement tariffs for a procedure or the average costs of the different procedures from the literature, but as some procedures, for example sclerotherapy, are less expensive than open surgery, this will alter the results. Data regarding whether the procedures were carried out under local or general anaesthetic were not available and so could not be taken into consideration.

In the current time of economic austerity, where public spending is under considerable inspection, treatment provision is an area of growing interest. Across Europe, there is a wide disparity in the number of procedures for varicose veins between countries. Different clinical stages of disease are being treated and there is little consistency. Importantly, the potential treatment costs of performing these procedures need to be considered and the question asked: can they be justified? If the costs of treating higher classes of disease severity and the impact on patients' quality of life are taken into consideration, it may be that treating more patients with varicose veins is more cost-effective in the long term.

Conclusions

There is a marked disparity across Europe between the predicted number of patients with varicose veins requiring treatment and the actual care given, with the UK, Finland and Sweden possibly under-treating varicose veins. However, it may prove more cost-effective in the long term to treat all patients with varicose veins to prevent disease progression which may prove more expensive to treat. The factors influencing this need more detailed investigation.

Footnotes

Acknowledgements and Funding

The research was supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Imperial College Healthcare NHS Trust and Imperial College London. The views expressed are those of the authors and not necessarily those of the NHS, NIHR or the Department of Health. The research was funded by the European Venous Forum, Royal Society of Medicine, Graham-Dixon Charitable Trust, the Royal College of Surgeons of England and the Circulation Foundation.

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