Abstract
For decades, the absence of adequate assessment tools, surrogate markers and/or solid outcomes has impaired evaluation of the severity of, and validation of, therapeutic results in chronic venous disorders (CVD).
The success and widespread adoption of the clinical, aetiological, anatomical and pathological classification has enabled the phlebological community to use a common language. This served as a first step towards an objective appraisal of CVD. However, improvement was needed as assessment of disease severity was not perfectly or easily obtained with the available instruments. The Venous Clinical Severity Score is one example of the improved tools that have been recently developed. Michael Vasquez's article in this issue 1 presents an extensive and comprehensive critical review of CVD assessment. He also presents an overview of the use of quality-of-life scales in CVD, which deserves some commentary.
For us, one of the most important recent advances in medical thought has been to consider the patient's opinion and to measure it. This can be done with patient-reported outcomes (PRO), the most common of which are Visual Analog Scales and auto-questionnaires. The topic is in constant evolution and tools are improving. Revicki says, ‘the history of health outcomes research contains varied definition and conceptual issues, and we have seen the evolution of terms from health status to quality of life to Health Related Quality of Life (HRQL) to now the commonly used rubric of patient-reported outcomes (PRO),’ and later in the same address, ‘(…) the patient's perspective and patient-reported HRQL is the ultimate outcome for health care interventions’. 2
Even if we, doctors, need to observe and judge the diseases of our patients, without our intervention or after care, our appraisal is biased. The ‘experimenter-expectancy effect’ modifies our results, which is critical when a comparative study cannot be double-blinded or when a clinical study is not comparative. In CVD, where a choice of very different therapeutic modalities is offered for very similar conditions (e.g. ultrasound-guided foam sclerotherapy versus phlebotropic drugs to relieve heavy legs), patients can be randomized but not blinded.
Modern PRO constructs can measure the disease-specific health-related quality-of-life of the patient but they can also tell us what the patient's main concern is. Whatever our instrumental or clinical findings, whatever our pathophysiological theories and therapeutic reasoning, the bad or good results are the patient's own. The final outcome, which can be measured year after year during the evolution of the disease, must be a composite criterion taking into account the various features of this complicated disease. But most of all, it must be reported by the patient. We have designed such a tool, the SQOR-V. 3,4 A recent presentation by another team encourages our research. 5
Our credo in this field is that even if the physician-reported outcomes improve, the patient-reported outcomes are here to stay; they not only improve the level of confidence of studies, but they can tell us if, from the patients' point of view, we are on the right or wrong track.