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  • Title: The recommended goal in the United Kingdom's National Institute for Health and Care Excellence Clinical Guideline 168 for immediate referral of patients with bleeding varicose veins is not being achieved.
    Author: Cragg J, Nyamekye I.
    Journal: J Vasc Surg Venous Lymphat Disord; 2021 Mar; 9(2):377-382. PubMed ID: 32726670.
    Abstract:
    OBJECTIVE: Published in July 2013, National Institute for Health and Care Excellence Clinical Guideline 168 (CG168) recommended that people with bleeding varicose veins be referred immediately to a vascular service. We have examined the impact of CG168 on referral practice for patients with bleeding varicose veins from primary to secondary care in a local National Health Service setting. METHODS: Referrals to a local vascular service in the 6 years before (group 1) and 6 years after (group 2) publication of CG168 were analyzed to assess patients' management after a bleed, with particular reference to a patient's initial presentation and delays in referral to the vascular service. This was done by retrospective electronic database and case note interrogation of patients presenting with bleeding varicose veins. Relevant data were collected onto an Excel spread sheet (Microsoft, Redmond, Wash) in relation to demographic information, comorbidities, clinical presentation, and treatment pathway. RESULTS: During the period studied, 73 patients presented with bleeding varicose veins. Their mean age was 66 years, and 56% were men. Their mean body mass index was 28 kg/m2. Of note, 33 patients (45%) initially self-treated before going to see their general practitioner; another 18 (25%) went to the emergency department. In 51 patients (70%), the underlying superficial disease involved the great saphenous vein, and most patients (73%) were treated with foam sclerotherapy with or without truncal thermal ablation; 45 patients (group 1) were treated in the 6 years before publication of CG168, and 28 patients, allowing 6 months for dissemination, were treated in the 6 years after CG168 publication (group 2). Mean time from index bleed to referral to the vascular service was faster after publication of CG168 (84 days before and 20 days after publication of CG168; P = .00842). Publication of CG168 was also associated with reduced mean bleed to intervention times (194 vs 60 days; P = .00097). CONCLUSIONS: Publication of UK National Institute for Health and Care Excellence guideline CG168 has been associated with a significant reduction in the delay to referral of patients presenting with bleeding varicose veins; however, the goal of immediate referral to a vascular service is not being met. CG168 is likely to have been a significant component of the factors that have led to the improvements seen thus far.
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