Predicted burden of venous disease

Abstract

Chronic venous disease is a common condition with clinical signs and symptoms ranging from spider veins, to varicose veins, to active venous ulceration. Both superficial and deep venous dysfunction may be implicated in the development of this disease. Socio-economic factors are shaping our population, with increasing age and body mass index resulting in significant pressure on healthcare systems worldwide. These risk factors also lead to an increased risk of developing superficial and/or deep venous insufficiency, increasing disease prevalence and morbidity. In this chapter, the authors review the current and future burden of chronic venous disease from an epidemiological, quality of life and economic perspective.

Keywords

Deep vein thrombosis varicose veins quality of life assessment cost effectiveness epidemiology

Introduction

Chronic venous disease (CVD) describes a spectrum of signs and symptoms caused by inefficient venous drainage from the lower limbs secondary to dysfunction in the superficial and/or deep venous systems. The clinical presentation, described by the Clinical Etiological Anatomical Pathophysiological (CEAP) classification system,¹ ranges from asymptomatic disease to active skin ulceration, with varicose veins, limb swelling and skin changes all falling within this spectrum (Figure 1).

Figure 1.

Spectrum of CVD according to the CEAP classification system with relevant prevalence rates.

CVD, whether caused by superficial or deep venous insufficiency, is a highly prevalent condition, with serious clinical sequelae if allowed to progress. From a quality of life (QoL) perspective, CVD is a chronic condition with clear negative effects on mood and well-being.² As a function of its high prevalence, the management of CVD is also very expensive, particularly in venous ulceration, a condition that requires a significant amount of care, particularly in the community.

The risk factors for CVD are becoming an important socio-economic and public health burden. The increasing prevalence of obesity, in addition to the progressive ageing of our population, will result in an increasing prevalence of CVD over the next decade, putting significant strain on available resources for its management. In this article, we aim to review the burden of superficial and deep venous disease from an epidemiological, QoL and financial perspective, with predictions for the expected increase in the future years.

Superficial venous disease (SVD)

Epidemiological burden

The reported prevalence rates for SVD in the literature are very heterogeneous. Spider veins, the mildest manifestation of CVD, are extremely prevalent and reported to affect up to 80% of the population.³ They are 2–3 times more common than trunk varices and can represent a significant cosmetic concern for patients but do not warrant routine treatment on the National Health Service (NHS) in the UK.⁴

Varicose vein prevalence is estimated at approximately 30% of the population. However, epidemiological studies report variable figures, from 2 to 56% in men and <1 to 60% in women.⁵ This difference is partly explained by variability in study population and study modality, which may investigate prevalence in patients from different age and ethnic groups. Studies analysing primary and secondary care data may also be subject to selection bias. These only take into account patients that have visited a clinician for their condition, omitting a significant proportion of patients that may have CVD but simply do not see their doctor for it. These studies may therefore not provide a realistic estimate of disease prevalence. Population based questionnaires such as the English Longitudinal Study of Ageing (ELSA) may provide a more realistic estimate of background prevalence; questionnaire data, however, has its own limitations in terms of non-completion rates and subjectivity.

Venous ulcers affect 1–2% of the UK population and are a cause of significant morbidity, particularly in the elderly, where the prevalence can increase up to 5%.⁵ These are a significant concern as they may be very difficult to treat with recurrence rates as high as 50% at five years. Dressing changes, topical therapy, antibiotic courses for superimposed infection and, where necessary, hospitalisation, all contribute to the rising cost of venous ulceration.

There is evidence that CVD is a progressive disease. The Bonn Vein study found that over six years, the progression of C2 disease to higher CEAP classes was 32% in patients with saphenous reflux and 19.8% for those with non-saphenous reflux.⁶ This suggests that, if left untreated a significant proportion of patients will move along the spectrum of venous disease from varicose veins, to oedema, progressing to skin changes and, ultimately, ulceration. This has important implications in terms of health economic factors and healthcare planning and highlights the importance of early prevention of disease.

QoL burden

CVD, like all chronic diseases, impacts on QoL. This has been recognised by the increased use of QoL assessment tools as primary outcome measures in trials assessing treatment modalities, as well as in government initiatives to investigate the effect of intervention. An example is the Patient Reported Outcome Measures (PROMs) questionnaire now being implemented in the UK for patients undergoing varicose vein procedures, hernia repair and hip and knee replacements.

There is a significant body of literature regarding QoL in venous disease, assessed both by general and disease-specific tools, such as the Aberdeen Varicose Vein Score and the Chronic Venous Insufficiency Quality of Life Questionnaire. Studies have shown that QoL is significantly worse in patients with varicose veins² and correlates with CEAP class and clinician-completed assessment tools, such as the venous disability scoring system.⁷ This is supported by findings suggesting that QoL in individuals with venous ulceration is comparable to that of patient with congestive cardiac failure, suggesting that the more advanced the class of disease, the more burdensome CVD is to the patient.

Importantly, treating varicose veins has a positive effect on health-related QoL, reducing the burden of disease. This is clear from PROMs analyses, which by comparing QoL before and after surgery, show a statistically significant improvement in both general and disease-specific tools.⁸

In addition to QoL effects, the presence of CVD is associated with depression. The prevalence of self-reported depression in the general population is 10%; however, in CVD, depression is prevalent in up to 24% of patients, more than double the general population rate.² PROMs data also confirm a high prevalence of depression and anxiety in varicose vein patients, which improves following intervention (unpublished data).

Financial burden

In addition to representing a significant clinical and QoL burden, varicose veins and CVD present a significant expense to the national health budget. This is particularly true for the labour-intensive area of venous ulceration, which requires long-term medical and nursing care. Despite affecting 1% of the population, venous ulcers are responsible for 1–2% of NHS budget expenditure in Western European Countries and the USA.⁹ Varicose veins, on the other hand, were responsible for a £40 million expenditure in 2005–2006, also representing a significant cost.

The treatment, or prevention, of venous disease and its complications is not only a clinical, but also a cost-effective exercise. Minimally invasive techniques, now considered first-line treatment options in the recently published UK National Institute for Health and Care Excellence (NICE) guidelines,⁴ have been described as cost-effective treatments for patients with CVD and may therefore contribute to reducing treatment expense per person.

Projected data

The approach to the referral and management of CVD has changed in recent years, moving from surgical treatment of complicated venous disease to earlier referral, assessment and, where required, initial treatment via endothermal techniques.⁴

The treatment of varicose vein disease is heterogeneous in Europe, with marked disparity in the number of procedures performed. Moore et al. compared the predicted number of patients requiring treatment for venous disease in European countries to the actual number derived from the literature. The authors reported that the UK, Finland and Sweden were potentially undertreating their population with venous disease, while Germany and the Netherlands were overtreating them.¹⁰

A reflection on the patterns of treatment of CVD is necessary when estimating the predicted burden of disease in the next decade. Populations in developed countries are increasing their life expectancy, whilst battling the obesity pandemic. Age is a recognised risk factor for CVD, whilst obesity is positively associated with this condition.³ The world population is projected to grow to 8.9 billion in 2050, resulting in an increasing proportion of patients who are elderly and have a high body mass index. It is clear to see that the population with CVD is set to rise in the coming years. US projected data have shown that varicose vein procedures have been increasing by 8% per annum.¹¹ With a similar demographic profile, estimated European data suggest a similar increase of 60% in the next eight years, with important implications in terms of service provision and training (Figure 2).

Figure 2.

Projected number of varicose vein procedures by 2021 according to:

Deep venous disease

Deep venous insufficiency manifests itself in the form of an acute thrombotic event (deep venous thrombosis (DVT)) or as a long-standing sequela in the form of post-thrombotic syndrome (PTS). Numerous risk factors for DVT and venous thromboembolism (VTE) exist, including age, inflammatory conditions, malignant neoplasms, obesity, pregnancy and oral contraceptives. VTE is the single most common preventable cause of hospital-acquired death.

Epidemiological burden

VTE, encompassing both DVT and pulmonary embolism (PE), is the third most common cardiovascular condition, contributing to the global burden of disease. Importantly, it is also the most common cause of preventable hospital-related death. The average annual incidence of DVT in the Western world is approximately 0.1%; 35% of these patients develop a potentially fatal PE. Age is an important risk factor for the development of DVT in both men and women. A comprehensive systematic review reported the incidence of DVT as 2–3 per 10,000 person years at age 30–49, increasing markedly to 20 per 10,000 person years at age 70–79.¹² Incidence rates are higher for women during the childbearing years, while after 45 years of age the incidence is higher for men.¹³ Interestingly, a recent study analysing recurrent VTE risk taking into account female reproductive factors found that men experienced recurrent venous thrombosis twice as often as women, suggesting that the male sex has a higher intrinsic risk of VTE.¹⁴

PTS is a major complication of DVT, occurring in 20–80% of patients.¹⁵ Those with a proximal thrombus in their deep vein are particularly at risk of developing PTS. Prevention of DVT recurrence and PTS development is very important and includes early assessment, pharmacological thromboprophylaxis and provision of graduated compression elastic stockings.

QoL burden

Kahn et al. assessed 359 patients with DVT with generic and disease-specific QoL tools. The authors found that, although 60% of patients had an improvement in QoL, at four months scores were still lower than average population norms.¹⁶ This suggests that although DVT is considered an acute event, its effects on QoL have a chronic nature that presents a significant burden to patients.

PTS also yields a negative impact on QoL, both on general and on disease-specific tools. QoL has been reported to significantly worsen with increasing clinical severity of PTS; the development of PTS is a significant determinant of QoL outcomes up to two years after a DVT.¹⁷ PTS severity is scored according to the Villalta scale, which assesses symptoms and signs of venous disease on a 4-point scale (none, mild, moderate, severe).

These studies demonstrate the significant burden DVT and PTS present to patients.

Financial burden

The effects of DVT and PTS do not limit themselves to QoL but also concern economic aspects. Low-molecular-weight heparins have been shown to be highly cost effective when compared to unfractionated heparin, due to reduced complications. Importantly, DVT thromboprophylaxis is cost effective in terms of avoidable deaths, reduced length of stay in hospital and prevention of PTS. New oral anticoagulants have also been shown as cost-effective alternative thromboprophylactic agents.

Once VTE develops, it is expensive. The average cost of treating primary DVT alone has been reported at $6000 per DVT. PTS complications were found to add a further 75% to the cost of primary DVT, estimated at $4300.¹⁸ The estimated annual direct cost of PTS symptoms is $200 million; indirect costs are even more staggering, with two million workdays lost annually because of leg ulceration.¹⁹

Predicted burden

Similarly to SVD, CVD caused by deep venous insufficiency presents a significant healthcare burden. This is set to increase, primarily as a function of increasing age, one of the main risk factors for VTE development.²⁰ Deitelzweig et al. performed an analysis of US VTE prevalence rates. The authors identified an increase of 33% in the number of cases over the five-year study period. They identified age and malignancy as significant risk factors and estimated that the number of adults with VTE will rise to 1.82 million by 2050²⁰ (Figure 3).

Figure 3.

Projected increase in VTE cases in the US.²⁰

The obesity pandemic will also contribute to this increase in prevalence. Prevention is key to avoid the development of VTE and PTS to ensure preventable deaths are avoided.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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