1. Limiting Indications for Varicose Vein Surgery to Maximise Service Provision in an Era of Restricted Funding; An Audit of Compliance at the GCHHS
Manoharan B, Jackson M & Butcher W
Gold Coast university Hospital, Southport, Australia
Introduction
In 2011 Queensland Health implemented the Scope of Publically Funded Services Policy to improve effectiveness of health services through re- allocation of resources to priority areas. The treatment of uncomplicated varicose veins no longer attracted funding under the Activity Based Funding (ABF) model. The exceptions are varicose vein patients with significant dysfunction or disability, or venous ulcers. As the exact scope of the change was never formally defined, local policy was formulated at the Gold Coast Hospital (GCH). From January 2013 surgery was only offered for,
Patients with lipodermatosclerosis or with acute or recently healed venous ulcer
Patients with spontaneous bleeding from varicose veins
Patients with superficial thrombophlebitis
Patients with venous eczema
Australian data has previous shown that the cost of inpatient management of venous leg ulcers can amount to over $12,000 per admission, with variable results/improvement of the ulcers upon discharge. These patients usually require ongoing follow up in out patient settings and ongoing community based wound care (Gruen et al, 1996).
Add acknowledgements
Conclusions
Better case selection and also shifting appropriate cases to Outpatient management (i.e. Sclerotheraphy) has allowed us to ensure maximum benefit from limited funding and reduce inpatient days.
Complicated varicose veins will be treated with the imperative being to heal or prevent ulceration
Careful patient selection and increased provision of outpatient management has allowed us to continue varicose vein management provision in complex patients requiring treatment in an era of funding shortfall.
Figure 2. typical Setup of a Radiofrequency Ablation procedure done with ultrasound guidance. Photo Courtesy of the Miami Vein Center.
Discussion
We found that since the change in policy (end of 2012), except in cases where patients with indications such as pain/cosmesis were added to surgical waiting lists before the policy change, that the indications were being adhered to.
The length of stay in hospital and complication rate were excellent in comparison to external benchmarks. In 2013, 96% patients were discharged on the same day as their procedure, compared to benchmark of 85% at the NHS in the United Kingdom.
The incresing number of Bilateral surgeries reflects good use of resources (bilateral surgery is only marginally more expensive). In general only one leg will have a clear indication, however, with a two surgeon team bilateral surgery where indicated seldom adds more than a few minutes to operating time
It is important to know that although the majority of varicose veins are in some way symptomatic, it is unusual for varicose veins to cause symptoms that interfere substantially with the activities of daily living. Varicose veins also very rarely precipitate major health problems, and therefore, apart from pain there is no imperative to treat varicose veins.
Figure 1. Case Mix for time period between 2011 and 2013 looking at relative percentages of Classical Varicose vein Surgery (VV) compared to Radio Frequency Ablation. A number of Sclerotheraphy proceducres were performed in 2011 an 2012 in the setting of operative theatre however since 2013 onwards were wholly performed in an outpatient setting and thus excluded from this graph.
Methods and Results
METHODS: An audit of practice at the Gold Coast University Hospital (October December 2013) and the old Gold Coast Hospital (2011- October 2013) was conducted from to compare changes to service delivery and outcomes based on the new policy. As sclerotheraphy provision (for high risk surgical patients) is now performed in the outpatient setting it was excluded from this study.
Data was obtained from the National Australasian Vascular Audit (AVA) database and where possible supplemented with information from Hospital patient records, imaging reports and operative notes.
We also investigated the utilisation of Radio Frequency Ablation (RFA) at our Institution. RFA is an image-guided minimally invasive treatment alternative to surgical stripping of superficial venous reflux. RFA does not require an operating room or general anaesthesia and has been performed in an outpatient setting by a variety of medical specialties including surgeons and interventional radiologists. Rather than surgically removing the vein, RFA works by destroying or ablating the refluxing vein segment using thermal energy delivered through a radiofrequency catheter. At our institution, RFA is still performed in an operating theatre environment, but generally under Sedation and local anaesthesia and same day discharge.
RESULTS: 158 procedures were performed in 2011, 72 in 2012 and 59 in Between 75%-90% of cases wee conventional varicose vein surgery, compared to Radiofrequency Ablations (5-21%). In 2013, 51% of cases were bilateral compared to 33% (2012) and 44% (2011) % of all patients had day surgery with no overnight admission. Median Hospital Stay was 1 day in all year groups analysed.
In 2013, 3% of procedures were for recurrent varicose veins compared to 7% (2012) and 13 % (2011) highlighting the growth of Outpatient Sclerotheraphy in managing this patient group. ASA scores have increased across the years (6% ASA 3&4 in 2011, 12.5% in 2012 and 18.6% in 2013) highlighting more complex patients being selected for. There were no complications documented for any of the cases.
Figure 3: Relative % of cases in each year shown as main indication for surgery. As expected Pain as an indication decreased over the period of the study (49% to 4%) however Thrombophlebitis and Lipodermatosclerosis both incresed as a relative rpoportion.
References
Gruen R, Chang S & MacLellan D (1996). ‘Optimizing the hospital management of leg ulcers.’ Aust N Z J Surg. Mar;66(3):171-4.