"Do you feel your legs limit you?” Incorporating this simple-yet-open question in your practice can unveil valuable patient information. It can assess your patient's functional level, which is essential to know in a cardiology practice. Their perceived functional limitations can help you risk stratify them by potentially identifying “dormant” peripheral arterial disease (PAD) or chronic venous insufficiency (CVI) as the culprit of this limitation. However, is your practice prepared to address the answer to this question?

Vascular diseases of the lower extremities are a growing problem in our aging, overweight society. Both PAD and CVI can cause functional decline and can be associated with significant debility.1 Disability and/or a sedentary lifestyle brought on by both of these disease processes can worsen comorbid conditions, affecting overall health. Both of these disease states can carry cardiovascular implications, yet these conditions are not foremost in the minds of many cardiology practices.

Early identification and awareness of these diseases can provide patients better outcomes. Conservative management has long served as a “bandage” for both PAD and CVI, addressing symptoms rather than the underlying cause. Recent advances in research and technology are challenging and changing our treatment and practice patterns. Guidelines are being generated and updated to follow suit. Where there were once few options, there now exists an opportunity to give function, activity, and life back to our patients who have vascular disease. According to Delos M. Cosgrove, MD, CEO and President of the Cleveland Clinic, “The future belongs to those who seize the opportunities created by innovation.”2

At Eastlake Cardiovascular (St. Clair Shores, MI), we seized this opportunity to provide our patients with innovative vascular treatments. The desire to offer complete cardiovascular care was an enlightening and rewarding journey. It originally began with PAD and evolved with the incorporation of venous disease. Our experience may provide pearls in creating and refining your own complete vascular practice.

Physical limitations brought on by venous disease are not fully appreciated in the healthcare community and carry many preconceived notions.3,4 A majority of our society recommends being more active and follow a heart-healthy lifestyle. For some patients, this is simply not an option; they are “peripherally challenged.” As we ventured into the peripheral space addressing the circulatory limitations of our patients, we unexpectedly found our diagnosis had migrated more often than not from arterial to venous pathology. Lifestyle-limiting claudication and nighttime symptoms requiring analgesics were, and could be assumed to be, atypical PAD symptoms. This was the genesis of respect for venous disease within our practice.

By inquiring about our patients' overall leg health and function, we found that venous disease was abound and that several patients had both arterial and venous disease. We met the biases and myths of venous disease head on. It is not a benign cosmetic annoyance; it carries medical implications and can be debilitating. CVI was embraced as part of our vascular efforts to offer full circulatory care to our patients. We incorporated venous treatment and complementary services into our practice including the Venefit procedure (RF ablation) (Covidien, Mansfield, MA), superficial venous reflux studies, and compression stockings, which added another dimension and further differentiated us from other practices. We took our key learnings from incorporating PAD and applied them to CVI for our vascular transformation. Our peripheral culture, which had matured over the years, led to a level of comfort among the office staff when expanding this vascular focus. Speaking to patients about their complete leg health (now including venous disease) seemed only natural and was a nearly seamless transition. I attribute this progression to our physicians seeking and recognizing the disparity of patients who have functional limitation and physical lifestyle changes due to circulatory problems and their lack of awareness of options and treatments.

I also consult with other cardiology practices around the country, and I have begun to see a similar adoption curve. New technology is contributing to the emergence of a new specialist: a circulatory care physician, expanding on medical and endovascular intervention.

Each practice, patient, geographical location, and payer mix is different. These variables present their own unique challenges; however, to build a successful, sustainable vascular program, all practices require the same critical elements. These elements, although they may seem basic, are often taken for granted and overlooked. They include the creation of an internal culture adopted by the entire practice and office, capturing existing patients, educating your referral physicians, and finding new patients through community outreach.

No matter how good the intentions are, change in any form can be challenging. We found taking a stepped approach and building a strong internal foundation can help transform your vascular practice into a sustainable entity. These steps should be initiated internally first and then branch out to your referrals and the community.

CREATION OF AN INTERNAL CULTURE: ENGAGE AND EDUCATE INTERNALLY

To truly brand your practice as a vascular center of excellence, you must first establish the culture in your office. Everyone in the office, from receptionists to medical assistants to your partners, must know the mission, understand the passion in this direction, and believe in it. Success is synergistic There is power in numbers. Incorporating arterial and venous disease treatment into a practice is not an easy process. It takes time, education, and dedication to achieve a mission of providing complete cardiovascular care. We had to change our physicians' existing practice paradigm by having them engage and inquire about their patients' vascular symptoms. This new process needs to be seamless and mindful of time. Trial and error with proactive revisions were paramount to our success.

We engaged our office through education. Several meetings with the partners were held to address recent technological advances and patient success stories. We went back to the basics and discussed risk factors, symptoms, and treatment algorithms. It is a misconception to assume that this information is known and mastered by those who do not practice it or see it daily. We devised a mission and a goal in implementing guidelines. This initiative was then carried to our staff, and a vascular champion was sought out to help manage the program. This “champion” can be anyone in the office that is driven and motivated by the vascular mission. It can be a nurse practitioner, nurse, MA, office manager, or a vascular tech, but is typically not a physician as they are usually too busy with the day-to-day logistics of the practice. This champion owns the program and seeks ways to implement and sustain it and is always open to improvements to the program. The champion is the liaison between the staff, physicians and the patient, and represents each perspective.

When your staff is knowledgeable about the goals and reasons behind the vascular endeavor in your office, they are empowered. They will feel ownership and are apt to play an integral role in establishing the culture. Several meetings outlined our mission with staff, and we welcomed their input. To identify these patients, complete vascular awareness must be part of the entire practice's mindset every day. The staff needs to be educated about venous disease and its signs and symptoms, as well as the solutions we can offer to lessen their burden. We created a culture in our office: “Be the expert, be proud, motivate, support, and create a complete cardiovascular experience for the patient.”

CAPTURING EXISTING PATIENTS

Your waiting room may have patients who already have venous disease. Many have lifestyles and occupations that contribute to this condition. Reach out to these established and engaged patients and educate them.

Given the role heredity plays in one's risk of developing CVI, a patient may have watched a parent or relative deal with the disease and assume they are destined the same fate. Patients tend to self-diagnose, or make assumptions about their symptoms and treatment options. They may believe their achy legs are a benign condition and a result of being on their feet all day or aging. Increasing patient awareness and education about CVI with in-office materials, such as posters and brochures in the waiting or examination rooms, can prompt patients to discuss their symptoms or concerns with their doctor. Educational materials are an effective way to convey important messages to patients about their risk factors, signs, symptoms, and treatment options. Patients might recognize themselves or family members through the use of photos displaying CVI progression with chronic skin changes. Our experience is that patients are more likely to make a connection to their leg symptoms after seeing educational posters in the waiting room.

DEAR PATIENT…

We found the most effective and efficient way to assess our patients, without disrupting the primary visit concern (for example, heart failure) was to institute a “Dear Patient” letter (see page 15). Whatever assessment method is chosen, it cannot interfere with existing office workflow. If it does, adoption, success, and sustainability will be more difficult to achieve.

The “Dear Patient” letter is given to patients annually and has been a key step in our vascular program. It is intended to briefly educate the patient with an opening paragraph explaining arterial and venous vascular disease, its implications, and prevalence. It also contains six simple questions focusing on different aspects of potential leg symptoms and functional limitations. The questions are pertinent in differentiating PAD and CVI and address risk factors and medical history.

Upon entering the examination room, patients are asked to remove their socks and shoes making their lower extremities more easily accessible for examination. The physician couples this with the responses given on their “Dear Patient” letter, and a treatment plan is formulated, if need be. At the very least, we are creating awareness of vascular disease among the community.

Do not underestimate the influence each patient can have in the success of your practice. Providing patients with a pleasant, inviting, and well-organized experience can speak volumes in terms of referrals. Each patient can become ambassadors for your practice.

YOUR REFERRAL BASE: EDUCATION AND EXTERNAL EXPANSION

Once your internal platform is established, a more formal focus can be placed outside your office to drive in new patients and increase awareness. Begin with established referral streams and build upon these existing relationships. This is best done with small personal meetings, dinners, lunches, or “curbside consults.” Educate them on evolving technologies, prevalence, symptoms, and etiology. Most importantly, abolish the ingrained cosmetic misconceptions revolving around venous disease. Help them understand that disability caused by venous hypertension and reflux is a progressive disease that can be effectively treated. As health care professionals, we share the responsibility to increase the awareness and identification of CVI as part of the vascular disease continuum. Commit to the circulatory health of mutual patients by being on the forefront of technology.

Remember, you are presenting yourself as the expert in this space. Anticipate the questions your referral base will have and provide them with the information they will need to refer patients. This includes questions the patient may ask regarding RF ablation, conservative therapy, what to expect before and after RF ablation, what is normal, and when patients should be referred back. Extend an invitation to these referring clinicians to visit your lab and observe cases. You also need to convey that appropriate and timely care of patients is a priority. Communication with your referring community with prompt feedback is key. Know the best way to keep them abreast of their patients' treatment plan. Again, as with your staff, involvement and engagement ignites empowerment and builds trust and loyalty. Apply the 80/20 rule of business: 80% of your success comes from 20% of your efforts. The key however, is learning where to focus those efforts.

Once you feel you have successfully built a support system internally and among your referral base, it is appropriate to branch out and develop new, targeted referral streams. Seek out those health care providers who may have patients who could benefit from your relationship. To find these resources and relationships, revisit the risk factors and complaints of CVI patients (the key patient attributes being female sex, history of pregnancy or obesity, standing or sitting occupation, and wounds and skin alterations). Primary care physicians are obviously important for referrals; however, we have found that we also need to target the specialists who are most likely to see these at-risk patients, such as podiatrists, obstetricians, and gynecologists.

We are also active with local medical group chapters and we make presentations at their meetings. Some of our partners include SALSAL (Save a Leg, Save a Life Foundation), Michigan Podiatric Society, and the Second Chance Heart Club. Grand rounds at your local hospital and speaking at seminars for residents all support your reputation and dedication, as well as foster awareness.

COMMUNITY OUTREACH: BRANDING AND EXPANDING

Community outreach serves two purposes. It establishes your practice with patients in your community as a vascular or circulatory center of excellence, and it also breeds awareness. Considering the scope of CVI, awareness and education are paramount in the improvement of outcomes, prevention, identification, and treatment. In the United States, more than 30 million people have varicose veins or CVI, yet only 1.9 million seek treatment.5,6 This underdiagnosis and undertreatment of CVI is not all related to the health care community's biases and lack of awareness. Patients may be unaware of their options with recent technological advancements and research. Varicose veins are, erroneously, often not viewed as a true medical condition that interventions (1) could successfully treat, and (2) would be covered by insurance.

Outreach can take many forms, including educational seminars or screening events. We have held evening lectures in our office focusing on leg symptoms and have an open forum addressing concerns and options. In these forums, patients see they are not alone and can take hope from this event that they could potentially regain a more active, pain-free lifestyle. Regardless of the platform, advertising and promotion of these events are essential. Also, keeping in mind the target audience of this disease, you should make these events convenient and accessible for your target patient to attend. This may require evenings or weekends to reach a working population. Keep in mind the risk factors and demographics of this population. Then, “go to the disease.” By this, I mean go to the environment where patients with the risk factors for CVI can be found—mothers, nurses, teachers, assembly line workers, etc. Given the prevalence and target audience of patients with varicose veins or CVI (women/mothers between the ages of 35–60 years who have a standing occupation), a great place to conduct your initial educational event might be at the hospital itself. This can be promoted to the nursing staff and other employees. New patients can be generated and should be sought in your marketing efforts as well. Contact the local media to run a news story. They can be a catalyst to driving conversation and questions.

The nurses and physicians in our practice also speak at various locations covering CVI and other topics to educate and make a presence in the community. Some of these venues we put together and run, others we piggyback onto. These sessions may be at senior centers, health expos, church gatherings, diabetic education classes, places of employment (such as the hospital or assembly line workers), community events, and in our office. Spring and summer are great times for a patient seminar on CVI because people tend to be more active and their symptoms (such as heaviness and swelling) become more apparent. Also, people start thinking about shorts and exposing their legs.

Our next endeavor will be to conduct an event focusing on general leg health, which may also include a podiatrist, to allow us to address both PAD and CVI at one event. Such value-added services—referral physician education and support, patient screening and education, and community outreach—enhance your reputation. It brands your practice and gives you name recognition among the community you serve and other health care providers.

INGREDIENTS FOR SUCCESS

There are a number of important ingredients for successfully integrating venous disease and its treatment into a cardiovascular practice. I believe three of the most important are passion, dedication, and persistence. It can take a great deal of time and energy to become established among your peers, patients, and the community as a respected leader. It is not enough to just say you are a peripheral center of excellence. You and your practice need to showcase a united culture internally and externally, with a common philosophy shared throughout the office. A physician with the ability and passion needs to lead others in the office who can assist in promoting the awareness, outreach, and logistics of an internal and external action plan. It is growth through enlightenment and alignment. A champion of venous offerings must want to learn about varicose veins and CVI, educate practice physicians and staff, institute venous disease screening tools and protocols and other procedural changes, develop or identify relevant materials— such as patient education posters and brochures—and spearhead approaches to identify patients.

Tracking the path a patient takes in finding your practice, and their movement through your office, is important. A simple question from the receptionist or on a new patient questionnaire can provide insight as to which avenues are most effective in treating your patients. Tracking this information can help you channel your efforts toward the appropriate programs.

Finally, cardiology practices seeking to add venous disease treatment to their practice can be comforted in knowing you do not have to recreate the wheel to expand opportunities for your patients. Many industry leaders and coalitions in the peripheral space have a variety of marketing and educational resources to assist with practice development and community outreach.

To treat venous reflux or CVI, our practice offers Venefit targeted endovenous therapy using the Covidien ClosureFast catheter. It delivers energy using radiofrequency to ablate the refluxing superficial vein. Covidien provides a wealth of excellent information and materials on its website to help customers with market development, including educational modules for both treating and referring physicians, and in-office materials including templates for newsletters, posters, and patient education brochures.

Educational materials are also available from the Society for Vascular Nursing, the Vascular Disease Foundation, the American Venous Forum, and Rethink Varicose Veins—an educational campaign sponsored by Covidien that aims to raise community awareness of the health implications of varicose veins and CVI.

SUMMARY

Many cardiology practices have successfully integrated PAD treatment into their offerings. Now, they are beginning to add the treatment of venous disease. CVI is a serious, often debilitating condition, and early treatment can make an immense difference in the quality of life of our patients. Offering complete circulatory care can accomplish this.

Patients with CVI include a large portion of those already seen in most cardiology practices. In addition, referrals from other providers, patients, and the broader community can help bridge the gap between presence of symptoms to diagnosis and from diagnosis to treatment.

Many excellent resources are readily available that can help smooth the integration and create the internal culture for your practice. Having a venous disease champion in a practice is invaluable for facilitating, educating, organizing, marketing, and making structural and procedural modifications to the program, and ensuring sustainability can often be an overlooked and underappreciated responsibility. One individual or a focused and dedicated team of people can carry out these responsibilities. You will go further and be stronger with the energy this person can bring to your mission.

If you are thinking of expanding your practice to include venous disease treatment, have a vision, set goals, create a plan, and develop a team. Working this plan will help you successfully expand your practice's peripheral vision.

Michelle Sloan, RN, MSN, APN-BC, is with Eastlake Cardiovascular in St. Clair Shores, Michigan. She has disclosed that she is a consultant to Covidien. She may be reached at michellesloan.np@gmail.com.

  1. Smith JJ, Garratt, AM, Guest, M, et al. Evaluating and improving health-related quality of life in patients with varicose veins. J Vasc Surg 1999; 30: 710-719.
  2. Cleveland Clinic 90th anniversary page. Cleveland Clinic Web site. http://my.clevelandclinic.org/90th-anniversary. aspx. Accessed July 10, 2012.
  3. Kaplan RM, Criqui MH, Denenberg JO, et al. Quality of life in patients with chronic venous disease: a San Diego population study. J Vasc Surg. 2003;37:1047-1053.
  4. Smith JJ, Guest MG, Greenhalgh RM, et al. Measuring the quality of life in patients with venous ulcers. J Vasc Surg. 2000;31:642-649.
  5. Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53(5 suppl):2S-48S.
  6. Lee A. US markets for varicose vein treatment devices. Millennium Research Group. 2011.