[Feasibility of a National Screening Program for Venous
Disease]{.underline}

[Robert B. McLafferty, M.D.]{.underline}

[Professor of Surgery]{.underline}

[Division of Vascular Surgery]{.underline}

[Department of Surgery]{.underline}

[Southern Illinois University]{.underline}

[Springfield, Illinois]{.underline}

[April 7, 2006]{.underline}

[Correspondence:]{.underline}

[P.O. Box 19638]{.underline}

[Springfield, IL 62794-9638]{.underline}

[Phone: 217-545-7983]{.underline}

[Fax: 217-545-2563]{.underline}

[Email: ]{.underline}

[The two most common manifestations of venous disease include venous
thromboembolism (VTE) and chronic venous insufficiency (CVI). In
laymen's terms, VTE means the development of blood clots within the
veins of the legs with potential migration of those blood clots to the
lungs (aka. pulmonary embolism - PE). CVI refers to the condition in
which the venous valves in the leg function poorly and as a result,
blood pooling from gravity leads to morbid changes in the ankle area.
]{.underline}

[Statistics are staggering when evaluating the consequences of VTE as 1
in 20 people will be diagnosed with VTE over a
lifetime.]{.underline}^[1-3]{.underline}^[ VTE is responsible for over
600,000 hospital admissions per year and PE is the third most common
cause of hospital death. Similarly, over 6 million individuals in the
United States have severe symptoms from CVI that range from inflammatory
skin changes to recalcitrant ulcers in the ankle area. Other less morbid
but clinically relevant manifestations of CVI include varicose veins
(VVs) and lower extremity edema. Over 24 million Americans are estimated
to have VVs.]{.underline}^[4,\ 5]{.underline}^[ Overall, venous disease
is ten times more common than arterial disease. ]{.underline}

[Considering the scope of venous disease, public awareness remains
paramount to the possibility of improving outcomes of prevention,
identification, and treatment. Additionally, all specialties of clinical
medicine may benefit from improvements in VTE and CVI education.
Previous reports have documented difficulties by physicians in providing
adequate VTE prophylaxis during high risk situations as well as early
diagnosis and proper treatment for CVI.]{.underline}^[6-8]{.underline}^

[There are many examples of public screening programs implemented with
the goal of early disease detection.]{.underline}^[9-11]{.underline}^[
Enhanced public awareness and education of physicians may be further
improved by these programs. Over the last eighteen months, the American
Venous Forum (AVF) has begun the mission of providing a free
comprehensive national screening program that: educates about VTE, VVs,
and CVI; identifies those at risk for VTE, examines for venous
obstruction and/or reflux, and inspects for the presence of CVI; and
empowers those screened to inform their physician of their risk and/or
presence of venous disease.]{.underline}

[ The decision to embark on a public screening program for venous
disease was made by the Executive Council of the AVF during a retreat in
Washington, D.C. in September 2004. An Ad hoc Venous Screening Committee
was formed to develop a preliminary screening instrument and begin
dialogue with the Arterial Screening Program of the American Vascular
Association (AVA). During the 17]{.underline}^[th]{.underline}^[ Annual
Meeting of the AVF in February 2005, representatives from the Ad hoc
Venous Screening Committee and the AVA refined the screening instrument
using the model of the AVA Arterial Screening
Program.]{.underline}^[12]{.underline}^[ The Executive Council of the
AVF voted unanimously to move forward with the screening program and
formed a National Venous Screening Committee. Funding for the program
would be overseen by the AVF while the development of the screening
program would be in partnership with the AVA. National Venous Screening
Week was designated to be from November 7 -- 12, 2005, approximately 6
months following the national AVA Arterial Screening Program. Prior to
the screening in November, tasks completed to develop the program
included: testing the preliminary screening instrument at three academic
institutions during the AVA arterial screening in May 2005; further
refinement and completion of the screening instrument; development of a
screening tool kit; writing educational brochures concerning VTE, VVs,
and CVI; identification of sites desiring to participate in the venous
screening; design, printing, collating, and distribution of venous
screening materials. ]{.underline}

[The process of the screening included self-completion of the
demographic questionnaire and VTE risk assessment, abbreviated venous
ultrasound examination for obstruction and valve reflux of the lower
extremities, inspection by an allied health professional or physician to
classify the lower extremities using the CEAP classification
system]{.underline}^[13]{.underline}^[ for severity of CVI, and exit
interview with venous report card given to the person being screened.
Participants were also asked to sign a patient release form and no
identifiers were used when compiling data for the screening.
]{.underline}

[ Seventeen institutions screened 476 people (mean: 28 per site, range 6
to 71 per site). Slide 5 lists basic demographic data and medical
information of the screened population. Forty -- five percent of
participants indicated their doctor was a family practitioner, 40%
indicated an internist, and 12% indicated another specialty. Reasons for
coming to be screened included: 43% - varicose veins; 36% - free
screening; 13% - swollen leg; 3% - "blood clot"; 2% - cosmetic problem;
1% - other.]{.underline}

[ When considering the DVT risk if placed in a high risk situation, 22
(5%) participants were low risk, 87 (18%) were moderate risk, 186 (39%)
were high risk and 179 (38%) were at very high risk. Slide 7 shows the
distribution of obstruction and reflux discovered in the common femoral
vein, saphenofemoral junction, and popliteal vein of each leg. Twenty --
six (6%) people had one or more segments of obstruction and 190 (40%)
people had one or more segments of reflux. Slide 8 shows the
distribution of clinical class for CVI for each extremity. VVs were
present in 32% of people, edema without skin changes in 11%, skin
changes attributable to venous disease in 8%, and healed or active
venous stasis ulcer in 1.3%. ]{.underline}

[The population participating in the national venous screening was not
random. Sites were advised to screen adults 40 years or older and those
who finally responded to advertising to participate were a select group
more apt to participate in a free health screening. Not surprisingly,
this screening process reveals a very high rate of positive findings for
venous disease. In contrast, although the public may be aware of venous
disease, they may not be generally privy to the devastating risks of VTE
and the potential morbidity of CVI. Thus, the screening further verifies
the commonality of DVT risk, VVs, and CVI. Critically needed in this
commonality is public awareness and fostering public responsibility in
prevention of these potentially serious problems. The exit interview
with a physician or allied health professional in combination with a
report card to share with the participants' primary care provider begin
the foundation for building a national paradigm of improved health
through public education and empowerment. ]{.underline}

[Herein, AVF reports on the mission of providing a free comprehensive
national screening program that: educates about VTE, VVs, and CVI;
identifies those at risk for VTE, examines for venous obstruction and/or
reflux, and inspects for the presence of CVI; and empowers those
screened to inform their physician of their risk and/or presence of
venous disease. More work is needed and the National Venous Screening
program hopes to expand to more centers in the future. Other goals
include providing participants with more educational materials, linking
screenings with awareness campaigns directed to physicians, and
continuing to build sponsorship. This first pilot program was feasible
due to a generous grant from the Juzo Company (Aichach, Germany), makers
of compression garments. Of note, all screening materials were void of
any link to industry sponsors. Physicians and allied health
professionals who are capable of meeting the requirements of performing
a venous screening are encouraged to participate and offer this public
health service to their community. A single day of free screening to the
public for venous disease seems little to ask when one considers the
scope of venous disease and the sorely needed beginning of preventative
medicine in the United States.]{.underline}

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12. [The American Vascular Association. VascularWeb, Provided by the
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