Analysis of Effect of National Institute for Health and Care Excellence Clinical Guideline CG168 on Management of Varicose Veins in Primary Care Using the Health Improvement Network Database

Abstract

In July 2013, new UK guidelines recommended that all patients with symptomatic varicose veins (VV) be referred to a specialist vascular service for consideration of superficial venous intervention (SVI). In the UK, general practitioners (GPs) in primary care control access to publicly funded vascular services provided through the National Health Service. GP awareness and concordance with Clinical Guideline (CG)168 recommendations is vital if patients with VV are to receive evidence-based treatment in line with national recommendations. The aim was to assess the UK-wide impact of new guidelines on GP management of VV using a large database of electronic GP records. An eligible population of patients aged ≥ 18 years was analysed over two 18-month periods, before and after guideline publication. Those with a new diagnosis of VV in each time period were analysed in terms of demographics, specialist referral, compression hosiery prescriptions, and recorded SVI. Analysis included approximately two million patients from 285GP practices. Before and after CG168 cohorts were well matched. Study populations included 13,014 patients before and 12,466 patients after guideline publication. There was an increase in specialist referrals from 24% (n=3173) to 28% (n=3457) (Cox hazard ratio [HR] 1.15, 95% confidence interval [CI] 1.09-1.20; p<.001). Median time to referral was 1.5 days. Prescribed compression hosiery declined from 20% (n=2558) before the new guidelines to 18% (n=2292) after the new guidelines (HR 0.93, 95% CI 0.88-0.98; p=.008). There were similar increases in proportions recorded as having SVI, from 3.6% (n=469) before the new guidelines to 4.2% (n=526) after the new guidelines (HR 1.16, 95% CI 1.02-1.31; p=.023). There was a statistically significant increase in endothermal ablation after CG168. In Cox models, age, sex, Townsend quintile, and body mass index were significantly related to the chance of referral and SVI. Encouragingly, following publication of National Institute for Health and Care Excellence CG168, there has been a statistically significant improvement in the management of VV in primary care in line with the CG recommendations.