Abstract
Chronic venous disease is a common condition, bearing significant morbidity to patients. It is predicted that the population suffering from this disease will significantly increase in the coming years, with a growing demand for specialists in the field of phlebology.
Training and delivery of services are highly heterogeneous in the European Union. The establishment of the European College of Phlebology marks the opportunity to address these differences from a European perspective, with the aim of providing all patients with standardised, high-quality, accessible medical care.
In this paper, we review the current status of phlebology from a European and an international perspective, as well as highlighting the current and future roles of the European College of Phlebology.
Introduction
Chronic venous disease is a common condition in the Western world 1 with recognised risk factors including obesity and increasing age.1,2 Both the superficial and deep venous systems are implicated in its development.
Superficial venous disease is very common, with up to 80% of the population being affected by reticular veins 3 and approximately 30–40% displaying varicose veins. 3 Deep venous disease is also common, with an incidence of venous thromboembolism (VTE) of approximately 1 in 1000 people.2,4
The sequelae of both conditions cause significant morbidity and mortality 5 to affected patients. Superficial venous disease can result in trophic skin changes leading to ulceration, while up to 50% of individuals affected by VTE go on to develop post thrombotic syndrome. 5 Both conditions represent a significant health burden, not only with respect to patients’ well-being and quality of life6–8 but also from a socioeconomic perspective. 9
Significant improvements have been made in the management of venous disease over the last decade. High tie and stripping and open surgical thrombectomy have been replaced by minimally invasive techniques such as endovenous ablation 10 and catheter-directed thrombolysis. 11 Patients are increasingly being treated as day cases under local anaesthesia.
The demand for venous intervention is expected to continue rising in the coming years. With our rapidly ageing population and the unfolding obesity epidemic, 12 it is predicted that by 2050, superficial venous disease will markedly increase in Europe, 13 whilst the number of US adults with VTE is projected to more than double 2 ; this prediction is applicable to the European population.
The field of phlebology is expanding, with rapidly developing new technologies and a predicted increase in patient population. The balance lies in matching this demand with the delivery of safe, high-quality, evidence-based management and intervention. Phlebology training and delivery of services are highly heterogeneous in the European Union (EU). It is important to address this matter from a European perspective, aiming to provide all patients with high-quality, accessible medical care conforming to designated standards across all European states.
In this paper, we review the current status of phlebology training and service delivery in Europe, as well as highlighting the current and future roles of the European College of Phlebology (ECoP).
Phlebology training
European Phlebology training is highly heterogeneous. Different member states have individual training pathways for the trainee venous specialist, ranging from sub-specialisation within one’s own field of expertise (e.g. subspecialty of internal medicine, surgery or dermatology), to university-based masters courses in phlebo-lymphology. 13 This implies that the treating physician may have a different skill and knowledge set depending on their specialist background. Importantly, this may also result in different thresholds for treatment depending on what the physician is accustomed to, as opposed to what is advised by evidence-based medicine.
No unique European certification exists for phlebology. The European Union of Medical Specialties (UEMS) currently recognises vascular surgery as a distinct division. Physicians can apply to the UEMS Section and Board of Vascular Surgery to be eligible for examination to become Fellows of the European Board of Vascular Surgery (FEBVS). 14 Requirements include completion of training certificate and a mandatory number of logbook procedures. However, this logbook is a poor representative of phlebology, with only a brief mention of venous reconstruction and deep venous endovascular procedures. Furthermore, this certification is only accessible to vascular specialists, excluding physicians from different clinical backgrounds.
Phlebology is undoubtedly a multidisciplinary specialty, and has been the remit of general practice, internal medicine, surgery, dermatology, angiology, radiology and cardiology. 15 It is therefore crucial that training and accreditation of physicians delivering care to the patient with venous disease are standardised across all EU countries, enabling delivery of high-quality, evidence-based care to the European population.
Delivery of phlebology services
The treatment of a medical condition is dependent on national budgets, reimbursement pathways and procedural cost-effectiveness. Each country has individual guidelines and assessment systems for this purpose, resulting in variation in the provision of services within the EU.
In the United Kingdom, over the last two decades, the overall number of varicose vein procedures has been steadily decreasing. 16 The National Health Service (NHS) traditionally reimbursed procedures in patients with advanced signs of venous disease, including trophic changes and ulceration, or in those who had failed a six-month trial of compression stockings. 16 This limited patients with uncomplicated varicose veins to conservative measures only, with surgical intervention being reserved for patients with advanced disease. However, there is evidence that progression of venous disease may be halted by treatment in the earlier stages, 17 which may prove to be the more cost-effective strategy in the long term.
Recent new guidance from the National Institute for Health and Care Excellence recommends that all patients in the UK with symptomatic varicose veins be referred to a vascular specialist for assessment and, where appropriate, treatment via minimally invasive methods. 10 It will be interesting to see how this recommendation translates into patient referral pathways, and shapes the future delivery of varicose veins treatment in the UK.
A study comparing actual versus predicted intervention rates in EU countries revealed a significant disparity in the delivery of care to the patient with varicose veins. By using available population and prevalence data for European countries, the study revealed that the UK, Finland and Sweden were undertreating patients with uncomplicated varicose veins, compared to countries such as Germany, the Netherlands and Austria, characterised by a more aggressive approach. 16 The differences in the delivery of care between these countries may be secondary to reasons relating to the availability of services, national guidance, reimbursement pathways and physician or patient perceptions of disease severity. It does, however, highlight significant differences in the provision of venous services in the EU.
The American and Australasian models
The United States has had a unified approach to phlebology for a number of years. The American College of Phlebology (ACP) was funded in 1985 with the purpose of unifying physicians and surgeons from diverse specialties with a shared interest in the diagnosis and treatment of venous disease. It is a multidisciplinary body, including physicians from various specialty backgrounds, nurses and vascular scientists. With phlebology being a recognised, self-designated specialty approved by the American Medical Association, practitioners from a range of specialties can officially designate phlebology as their primary or secondary specialty. The ACP provides its members with ongoing education, supports training fellowships, promotes research and provides a community for individuals dedicated to vein care.
The American Board of Venous and Lymphatic Medicine (ABVLM), formerly the American Board of Phlebology, was established in 2007. It is a multidisciplinary body with the aim of improving the quality of medical practitioners and the care of patients with venous disorders. It is a nonprofit organisation for scientific and educational purposes and is not yet a Member Board of the American Board of Medical Specialties (ABMS). In 2008, the first American Board of Phlebology Certification Exam was delivered to candidates. 18 This certification, based on ABMS standards, now counts nearly 700 diplomats and verifies that physicians have met rigorous standards of education and evaluation, demonstrating relevant expertise and commitment to their specialty.
Training in venous disease can be highly heterogeneous due to the diverse backgrounds of practitioners. The ABVLM developed a core content for training in venous and lymphatic medicine 19 with the aim of formalising training standards in venous disease. This multispecialty effort defines the areas of knowledge essential for a practitioner in the field of phlebology, and is endorsed by both the American Venous Forum and the ACP.
The ABVLM is currently developing program requirements for graduate medical education in venous and lymphatic medicine. This document, developed by a multidisciplinary task force, aims to provide a consensus-based guide for a one year fellowship, setting standards for physicians wishing to specialise in phlebology.
The Australasian College of Phlebology was funded in 1993 and represents the largest phlebology society in Australia and New Zealand, with the aim of improving the standard of care related to venous disease. Similar to its American counterpart, a comprehensive training programme is available to physicians from diverse backgrounds wishing to specialise in the field of phlebology, including dermatology, vascular surgery, general surgery, interventional radiology, haematology and internal medicine. Scholarships and fellowships are available to researchers and trainees. However, unlike the US system, a formal certification is not yet available. The aim of the Australasian College is to establish and maintain high standards of learning skill and patient care in phlebology, as well as supporting academic and scientific symposia in the specialty. Similarly to Europe, phlebology is currently not a specialty recognised by the Australian Medical Council. The Australasian College of Phlebology is playing an important part in establishing phlebology as a distinct medical specialty.
ECoP
Individual phlebology societies exist in most of the EU member states. These are united by the International Union of Phlebology (UIP) as member societies, but are otherwise independent of each other.
The increasing prevalence of venous disease and the heterogeneity of clinical care delivery and guidance amongst European countries has led to the need for a European body representing the specialty. The ECoP was established in 2012,
13
with the following aims:
To stimulate optimal, standardised care for European patients suffering from venous disease To unify phlebologists from European member states To promote the multidisciplinary nature of phlebology as a specialty.
The ECoP has been pivotal in the recognition of phlebology as a multidisciplinary Joint Committee member by the UEMS in 2014. In addition to this, it plays an important role in shaping the future of phlebology in Europe.
Treatment of venous disease
The treatment of venous disease is highly heterogeneous in Europe. One of the aims of the ECoP is to bridge these differences by establishing a European guideline delineating the best, evidence-based care for the patient with venous disease. 15 The guideline will provide European phlebologists with up-to-date treatment options that can be tailored to their patients. Local funding schemes will still be applicable, but the evidence base for treatment will be available so that both clinician and patient can make an informed decision on the preferred treatment modality. Furthermore, an accredited European body, setting standards for the treatment of venous disease, will be in a position of authority to arbitrate provision of state-funded care with governments and health insurance companies regarding the necessity and cost-effectiveness of venous interventions. Over time, this may reduce the heterogeneity between member states.
Training and accreditation
Currently the UEMS recognises vascular surgery as a distinct division, offering the FEBVS examination. However, this is not sufficiently representative of venous disease and is clearly not adequate as a stand-alone phlebology certification, highlighting the need for a separate logbook and assessment system. The aim of the ECoP is to create a formalised assessment to certify physicians from any clinical specialty who want to be accredited phlebologists: the European Certificate in Phlebology. Achievement of this accreditation will ensure that practicing phlebologists in the EU are trained and assessed in a standardised fashion, leading to a more uniform delivery of care for the patient with venous disease. This will not only set standards and hopefully stimulate improvement in patient care, but will also support the free movement throughout Europe of Certified Phlebologists, promoting collaboration and links between European practitioners.
A European curriculum for phlebology will form the foundations for certification. Based on the current UIP curriculum, 20 it will cover both theoretical and clinical aspects of venous disease in a modular system with certified training modules. European courses, workshops and e-modules will supplement this curriculum, enabling members of the ECoP to be eligible for examination and certification.
Research
The ECoP will have a significant role in promoting high-quality research in Europe, in the same way that the American and Australasian Colleges do for their respective regions.
The establishment of European Guidelines and a new Curriculum will help identify areas where further investigation is needed; collaborative efforts amongst the ECoP member centres will make planning and implementation of future large-scale trials easier to organise. ECoP could act as a central registry, allowing member centres to combine data on, for example, the local epidemiology of venous disease, as well as treatment and outcome measures for their populations. This will help identify areas for future research, as well as being an audit tool for treatment provision, aiming to avoid disparity between member states.
Conclusion
Phlebology will become increasingly prominent in the coming years, due to the ongoing changing population. It is a truly multidisciplinary specialty that can benefit from the experience and skill set of physicians from numerous clinical backgrounds. The establishment of the ECoP as a multidisciplinary, European body for phlebologists, is a golden opportunity to shape the future of European phlebology, training clinicians to the highest possible standards, promoting academia and research in current and new interventions, as well as treating patients according to guidelines relying on the best evidence-based medicine available. The recognition of phlebology as a multidisciplinary Joint Committee member by UEMS is the first step in the establishment of a body promoting excellence for the care of the European patient with venous disease.
Footnotes
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest
None declared.