HealthVaricose Veins: Socioeconomic Factors and Access to Care

Varicose Veins: Socioeconomic Factors and Access to Care

Socioeconomic Factors and Varicose Veins

Varicose vein disease is not equally distributed across all segments of the population. A number of studies have demonstrated that it is more commonly reported in those with blue-collar, working-class occupations. One survey of almost 6000 men and women in western San Francisco found that the disease was 2-3 times more prevalent in those working in service sector jobs or sales than in managers and professionals. This occupational difference in prevalence is likely to be due to the fact that those engaged in manual work are predisposed to increased ambulatory venous pressure and the associated increased risk of venous valve incompetence. This was evidenced in a study of 73 pairs of identical twins which found that subjects who had spent more years in occupations with prolonged standing had a higher risk of developing varicose veins.

Impact of Occupation and Lifestyle

Generalized as a disease of the elderly and those who have borne many children, varicose veins have been associated with increasing age, female sex, parity, obesity, leg injury, and a history of deep vein thrombosis. The idea of it being a disease of the elderly is not modal because it is estimated that 25% of the population has some form of varicose veins, and it is expected to increase as life expectancy and the elderly population increases. This means that it is important to identify how varicose veins affect the quality of life, which could result in decreased employment and productivity. This will identify if it is important to create prevention programs that would benefit the workforce in high-risk populations.

Studies have shown that people with varicose veins typically have a lower quality of life, with chronic pain, lower self-rated health, and limitations in physical functioning and activities compared to population-based controls. Other quality-of-life data indicate that patients with the advanced chronic venous insufficiency of CVI — a severe disorder related to varicose veins — have significantly lowered physical and mental health summary scores. This shows that it is important to identify how socioeconomic status affects the disease and how the patients perceive their lower limb venous condition. This will provide a better understanding of how to allocate resources used to diagnose and treat this disease and help to prevent it in high-risk populations.

Varicose veins are dilated, often palpable subcutaneous veins usually having a diameter of 3 mm or more. Usually, they have a tortuous course and appear swollen and bulging. They are developed when damage occurs to the valves in the veins. This can cause blood to accumulate or “pool” in the veins and cause them to abnormally enlarge. Varicose veins can occur in any vein, but are more common in the legs and thighs. It is estimated that 1 in 3 people in the United States will develop a varicose vein condition in their life. This means that the cost and resources used to diagnose and treat this disease are very big, and it affects a wide variety of patients.

Influence of Income and Education

Occupation and education are considered surrogate markers of SES, and both have been associated with the presence of varicose veins. Certain occupations such as sales work, teaching, nursing, hairdressing, and other service industries have been associated with a higher prevalence of varicose veins. Many of these jobs are more likely to be held by women, particularly as they pertain to the health services industry, thus occupation may also be confounded by gender. These studies are often limited by their dependence on subject recall of past job descriptions and on univariate analysis with inadequate adjustment for other known risk factors of varicose veins. Of the few jobs that have been identified as having a lower prevalence of varicose veins, the armed forces is one example. Inverse associations between various aspects of education and varicose veins are reported in many studies. A study in the United States found a negative association with the number of years of school completed and the prevalence of varicose veins among women ages 18–64. This relation seemed to be driven by private school education, as those with public school education did not have significantly lower odds of varicose vein presence compared with those with less than 8 years of education. Further studies have also demonstrated a lower likelihood of varicose veins among those with higher educational attainment.

Role of Healthcare Access and Insurance Coverage

The role of healthcare access and insurance coverage has not been specifically measured in association with the presence of varicose veins. However, the nature of the disease and the resources required to care for it would lead one to believe that it is associated with a lack of healthcare access. It can be inferred that those without the means to obtain proper medical care and follow-up are at a disadvantage in dealing with chronic disease states. Studies comparing varicose vein patients to those with a more serious chronic venous disease, such as venous ulcers, have shown that fewer varicose vein patients seek out medical treatment. This is likely due to the fact that venous ulcers are often covered under insurance plans because they are considered to be more medically necessary and can be associated to a greater extent with more serious underlying venous pathology. Varicose veins, on the other hand, are often viewed as a cosmetic issue or as a normal sign of aging, and the treatments are usually not covered by insurance plans. This puts those of lower economic status at an additional disadvantage because they may not be able to afford these treatments out of pocket. Due to unrealistic patient expectations as to the effectiveness of treatments and the lack of insurance coverage, the decision of whether or not to undertake varicose vein treatment is very complicated. This may lead to disparities in care by income level. In order to test this hypothesis, one must assess patient populations with differing socioeconomic statuses and evaluate their knowledge and attitudes regarding varicose vein treatment, as well as their actual behaviors in seeking out treatment. An observational study on patients with chronic venous disease showed that those of lower social classes had less knowledge about their disease state and treatment options. The majority of participants in this study were varicose vein patients; similar results in patients with varicose veins would indicate a lack of understanding about the disease and treatment options in lower socioeconomic groups. This lack of understanding may be a barrier to effective physician-patient communication and shared decision making. In another observational study, patients that were referred to a phlebology clinic for varicose veins were interviewed about what motivated them to seek treatment. The majority of these patients were women and their motivation was improvement of leg appearance. However, for those with a lower quality of life due to their vein symptoms, this is not the appropriate indication for treatment. This suggests that there are disparities in treatment decisions for varicose vein patients of differing socioeconomic status, based on the belief that certain treatments are purely cosmetic and the lack of understanding about the chronic nature of the disease. Overall, the evidence suggesting a link between varicose veins and socioeconomic status is limited. However, the nature of the studies conducted in conjunction with the known epidemiology of the disease would suggest that there are disparities in the prevalence of varicose veins and in the treatment received by different socioeconomic groups. This is an area where more research is needed, especially studies assessing specific varicose vein populations and their behaviors, attitudes, and treatment decisions in association with their socioeconomic status.

Barriers to Accessing Care for Varicose Veins

Due to an outdated treatment paradigm and lack of disease understanding among patients and primary care physicians, many have never considered treatment from a vein specialist.

In many cases, a job that requires prolonged periods of sitting or standing can make vein symptoms worse and have led to occupational disability in extreme cases. Such patients are often unaware that their vein disease is a medically treatable condition that, if addressed, would improve their symptoms and allow them to keep working.

Those patients who have been educated about their venous disease progression by a vein specialist are much more likely to seek treatment compared to those who have not. A primary care physician is much less likely to recommend a particular advanced treatment, being that they are often unaware of the new technologies available in today’s vein care. This lack of understanding leads those who are affected to believe that treatment would require a hospital stay, time off of work, and have a painful recovery. As a result, they often avoid seeking treatment.

Many people with varicose veins may never seek treatment from a medical professional and thus live with symptoms such as daily leg pain and discomfort, swelling, and restless legs. This can lead to a decreased quality of life. We believe that this is due to a fundamental lack of understanding about the disease, not only from a patient perspective but also from a primary care physician standpoint.

Geographical Challenges

Residence in rural areas is associated with worse health outcomes and poorer access to medical care. This is related to the fewer number of healthcare providers and facilities in rural areas, especially specialists. Owing to the irreversible nature of endovenous treatments for varicose veins, there is a trend away from the old standard of dermatologist-performed procedures in private clinics, and instead general physicians are referring directly to vascular surgeons for more lasting and definitive treatment. This, in turn, means that patients with vein disease are being sent away from their local communities to larger treatment centers, increasing the travel burden for these specific patients. Widespread closure of smaller hospitals in recent years has meant that rural patients are often required to travel long distances for any potentially elective procedure. A direct comparison showing the effect on rural populations is the case of Scotland where varicose vein or venous leg ulcer patients from remote areas with no local vascular services were found to be 10 times less likely to receive a surgical opinion than those residing in urban areas.

Poor access to medical care is the most systemic and obvious of the socioeconomic factors influencing the treatment of chronic disorders. Its well-established impact on disease outcomes is most directly related to the lack of specific therapy in proportion to the severity of the disease. Geographical distance from the provider of medical care has been known to be a significant factor in predicting the use of medical services, such that those living further than 10 miles from their providers are less likely to use services than those living closer. The effect of travel on whether or not a patient seeks medical care is difficult to separate from the effect of travel on treatment compliance once an episode of care has begun. Specifically for chronic venous diseases, it is known that compliance for compression therapy is entirely dependent on patient satisfaction with treatment, and given that compression is the only treatment directly aimed at correcting the underlying pathophysiology of the disease, it stands to reason that those patients needing to travel long distances in order to receive medical care are at a disadvantage. Finally, travel burden includes not only transport costs but also wasted time which could otherwise be spent at paid employment. Given the very broad age distribution of chronic venous diseases, it is likely that the opportunity cost of time is increased for these patients compared with the general population.

Financial Constraints

Given that varicose veins afflict a large number of individuals who are older and are at a stage in life where income may be reduced, the cost of treatment becomes a significant issue. As has been shown above, with the projected increase in healthcare needs due to varicose veins, it is likely that there will be some form of rationing for treatment. This means that those with more severe disease are likely to be treated ahead of others, and those with minor disease may not be treated at all. The measures used for severity of disease are usually symptom-based, and it is quite common for those with minor visible signs of varicose veins to have quite significant symptoms, though severity of symptoms is not always correlated with visible signs. This can lead to frustration for many patients who may feel that their symptoms are not being taken seriously and increases the likelihood of self-treatment.

A common theme in the literature is that those who are being treated for varicose veins are ‘not sick enough’ to qualify for medical treatment. This alludes to the cosmetic nature of varicose vein treatment and the perception that only those with more advanced or severe disease should seek help. For many patients, this will mean that they will have to endure significant symptoms and lifestyle limitations before being considered for treatment.

Lack of Awareness and Education

Having a lack of awareness and education about any medical condition diminishes the chance of an individual seeking medical treatment until symptoms have worsened. found that only 2% out of their 1848 patients sought advice concerning their varicose veins from a general practitioner or vascular specialist. Another UK study found that 25% of patients sought advice and treatment, many considered that varicose veins were just a cosmetic problem. This resulted in such patients receiving no treatment especially if they also felt that symptoms were not severe enough to merit medical attention. The cosmetic implications of varicose veins can affect quality of life, particularly in women. The patients who had several and/or severe symptoms and those who had symptoms for more than 15 days in the preceding month were significantly more likely to seek medical treatment. also found that SVS scores were not only significantly lower in healthy control groups but also in patients when compared with age and sex-matched diabetes mellitus, hypertension, asthma, and chronic bronchitis patients. This indicates a poor general health status in patients suffering from varicose veins and an association between severe varicose veins and other chronic diseases. All of these factors make it imperative to increase awareness of the chronic and progressive nature of varicose veins and educate the general public on the potential severity of the disease.

Strategies to Improve Access to Care

Community outreach programs can also come in many forms, and their goal is to facilitate better care for specific populations. A free screening could be performed at a local senior center, for example, in an attempt to reach out to elderly patients who have limited resources and a limited understanding of their medical conditions. A more long-term outreach program might aim to educate specific populations, such as low-income families, about prevention and access to treatment for chronic venous disease. This could be done in conjunction with policy changes to reduce disparities in healthcare for specific populations.

Telemedicine is the use of electronic audio and visual means to communicate between a patient and a provider in separate locations. The idea is to allow patients access to consultation without incurring the time and expense of travel, as well as to facilitate regular follow-ups between patients and their providers. This can allow for better tracking of patients’ conditions as well as potential problems with access to care. Remote consultations could pose as a supplement to this, as they involve consultation via telephone. There are both pros and cons in regard to these methods. While it is clear that they would allow for better access to care for patients with limited mobility, implementation could be difficult and costly.

In the context of varicose vein disease, access to care can be difficult for those in lower socioeconomic classes as well as those in rural locations. Even when symptoms are more severe, varicose veins are still most often considered a cosmetic issue and are, therefore, treated as such by insurance companies. Consequently, many patients are left having to pay for their own consultations and treatments. In addition, the elderly population, which comprises a large sector of those affected by varicose veins, may have limited mobility and difficulty with transportation. The following are various strategies aimed at improving access to care for those affected by venous disease.

Telemedicine and Remote Consultations

Telemedicine is a term that refers to when doctors interact with each other, patients, and others outside the standard medical environment, usually through the use of video-conferencing. Telemedicine has numerous potential benefits to patients, doctors, and healthcare systems. It offers a way to provide healthcare for individuals who live in rural areas. Now, it is possible to consult a vein specialist from another city or state without leaving your town. Patients will not need to travel long distances to see a vein specialist. Those with difficulty in mobility would benefit greatly from telemedicine, and early prevention of chronic venous insufficiency in this group would result in reduced spending in the future for managing venous ulcers and other complications. Another advantage of telemedicine is the reduced waiting time for appointments, specialist visits, and treatments since patients can speak to a doctor from home. Reduced healthcare system costs and visitation to the ER are side effects of less waiting and improved access to primary and specialty care.

Community Outreach Programs

These patients are particularly difficult to convince, as they may still have limited or temporary relief in symptoms from their past surgery or may have progressed to deeper reflux that was not previously diagnosed and can cause post-procedure recurrence. In each of these cases, a well-informed patient will be more likely to make the treatment decision and compliance will be increased.

This is due to the fact that the natural progression of varicose veins can lead to skin damage and ulcers, and patients are not aware of the severity of their condition and that it is an indication for treating the reflux, or they are unaware of the potential preventative effect of treatment on these severe forms of venous disease. Finally, patients commonly express regret at having previously undergone stripping surgery or other forms of avulsion, which they perceive to have been disfiguring and/or have had little effect on their symptoms.

At present, this is often not the case. This suggests that the decision-to-treat is often made reluctantly, with patients having previously exhausted other options. They may have previously been treated or have self-treated for chronic venous insufficiency, a condition which is not an indication to treat the reflux itself. So they consult a vascular surgeon but may remain undecided and lacking confidence in their decision.

A multicultural group of researchers contend that initiative to increase patient and practitioner knowledge has the highest potential impact of all possible strategies to improve care. This is due to the prediction that two or three simple but key changes in lifestyle, such as prolonged sitting and prolonged standing, may be more acceptable to the patient than prolonged use of compression hosiery or undergoing thermal ablation. But patients are unlikely to make these changes unless they perceive a strong relationship between their symptoms and venous reflux, and a strong belief that the proposed lifestyle change will make a difference.

Policy Changes and Healthcare Reforms

Policy changes have been enacted to improve data availability, medical surveillance, and to standardize diagnosis and treatment of diseases. These typically take the form of specific programs, at national, provincial, and state levels, addressing particular issues and diseases. An example would be the establishment of the US National Institutes of Health (NIH), which have variously funded research projects on vein disorders, leading to training grants for future researchers and specialists in the field. This is an effort to increase human resources for adequate treatment of various diseases. It is widely recognized that data for varicose veins and chronic venous diseases as a whole is lacking and funding would likely improve both physician and public knowledge of the diseases. This may indirectly encourage patients to seek treatment, knowing the efficacy and necessity of treating a particular disease.

Urbanization and the progressive shift to a more industrialized lifestyle resulted in a shift in the causes of human morbidity and mortality. Infectious diseases and acute illness were the most common health concerns. The past century has brought a dramatic reversal, such that chronic diseases, and more recently varicose veins, are the leading causes of poor health. Health services and public health systems have had to continuously adapt to meet the needs of society. Appropriate responses are necessary at various levels in the health care system, including the use of modern technology, community outreach programs targeting specific populations, and more recently efforts to affect policy changes to improve health care delivery.

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