Rewriting the Guidelines for the Care of Patients with Varicose Veins

Steve Elias: Welcome everybody once again to the Vein Magazine Podcast, or better known as vein specialists sitting around and talking, having drinks. Today we're at the American Venous Forum annual meeting, and with us is Peter Lawrence from UCLA, Peter Gloviczki from the Mayo Clinic and Mark Meissner, from the entire world because he is the world's best-known vein specialist. Is this true Mark Meissner?

Mark Meissner: I have no response to that Steve, because that clearly is not true.

Steve Elias: It takes three vein specialists to do a good job writing new guidelines on the care of varicose veins. And that's why we're here today. We have three people that are on the SVS AVF committee to rewrite the guidelines for the care of patients with varicose veins. Why do we need new guidelines? Don't we already know what we need to do to take care of varicose veins, Peter?

Peter Gloviczki: We have an idea of how to take care of varicose veins, but it's time to write new guidelines. The last guidelines we wrote were published in 2011, so that covered the literature until about the end of 2009. A lot has happened since that time. New evidence emerged, new treatment modalities were introduced and independent of the progress, every clinical practice guideline has to be rewritten every five years.

Steve Elias: What are some of the new things we need to address in the guidelines?

Peter Lawrence: We need to both respond to the MEDCAC report, which was done by CMS and has a big impact on reimbursement. There were several issues there that many of us disagreed with. There were the conclusion, the MEDCAC, one of them being the optimal way of imaging, and the conclusion that duplex ultrasound was not established as the best way to image veins. And you know, all of us, I think, believe that that's the case. So there needs to be, the guidelines need to really address that issue and look at the literature.

The second is since 2011 there's been the introduction of non-thermal as well as thermal techniques to close veins.
The third thing new guidelines need to address is that we see many physicians who are considered vein specialists ablate the perforator vein without any other vein being ablated in the extremity. So the role of certain locations, particularly perforators need to be addressed in the guidelines.

Steve Elias: There is actually a process by which people need to evaluate the literature and the data that's available when you're writing guidelines. I had a little bit of trouble getting my arms around what we need to know when we write guidelines. What are the guidelines for writing guidelines?

Mark Meissner: The guidelines to writing guidelines were part of the Medicare Improvement for Patients and Physicians Act in 2008 that authorize the Institute of Medicine to develop guidelines for writing guidelines. That is a document that's out there. It's a very good document. It's very long, but the executive summary is fairly short, and you can read that and come away with what you need. Peter already mentioned one of them, which is those trustworthy guidelines need to be updated every five years because new information, new data, new evidence comes along, practice patterns change, so they need to be updated.

But there's actually eight elements of it that need to be included in trustworthy guidelines, and essentially that establishes the process and the process is, first of all, coming up with the panel that's going to do the guidelines and there are criteria for that. Any guidelines should include all stakeholders in the guideline, whether you're a vascular surgeon, radiologist, phlebologist in the community. It should include all stakeholders. It should include a methodologist, always, to help you evaluate the data. Optimally it would include patients as well, although that's a bigger hurdle.

Mark Meissner: The second is that every guideline should be based on a systematic review of the literature. It may not be strong enough to do a meta-analysis on, but the literature should be systematically reviewed, and my takeaway from that, which may or may not be true, is that if you can't generate a data table from it showing the outcome and the results, it probably shouldn't be in a guideline. You ought to be able to do that.

The third essential component is grading the evidence, the Society of Vascular Surgery as well as most organizations throughout the year, throughout the world, have chosen the grade approach to do it. So you grade the evidence. The fourth component is writing it and then having an external review of it and I missed the second component which is developing the questions, which is probably the most important thing is developing a reasonable question for...

Stev