Latest / European Society for Vascular Surgery / Chronic Venous Disease: The Treatment is Clear… But Do Patients Follow It? - with D. Celovska & A. Pathak

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Chronic Venous Disease: The Treatment is Clear… But Do Patients Follow It? - with D. Celovska & A. Pathak · European Society for Vascular Surgery

0:00
Well, I don't usually wear compression therapy
0:03
stockings because they are very tight, they are
0:07
difficult to put on and they are not comfortable
0:10
to everyday use. Well, in my case, it doesn't
0:15
feel like necessary. And I try to avoid all sorts
0:19
of chemicals. I favor the mechanical procedures
0:22
like leggings, massages, exercise. I'm Joana
0:37
Ferreira, and today we're going to talk about
0:40
chronic venous disease and adherence to therapy,
0:43
an episode supported by Servier. The World Health
0:47
Organization underscores the critical importance
0:50
of adherence, stating that increasing the effectiveness
0:54
of adherence intervention may have a far greater
0:57
impact on the health of the populations than
1:02
any improvement in specific medical treatments.
1:05
More recent, World Health Organization data show
1:09
that nearly 50 % of patients do not take their
1:13
medication as prescribed and about 30 % never
1:17
filled their first prescription. This widespread
1:21
problem leads to serious public health consequences.
1:25
Chronic venous disease fits squarely into this
1:28
picture. Globally, it affects up to 40 % of adults
1:33
and its prevalence continues to rise with aging
1:36
and obesity. In the VAIN Act program, 90 % of
1:40
patients reported symptoms such as heaviness,
1:43
pain, swelling or cramps. In the United States
1:48
alone, CVD is responsible for an estimated $3
1:52
billion in annual costs. To help us explore the
1:57
topic of adherence on chronic venous disease,
2:01
we're delighted to welcome Professor Celovska
2:04
and Professor Pathak. Professor Celovska and
2:08
Professor Pathak. Would you like to introduce
2:11
yourself to our listeners? Yes, I'm Professor
2:14
Pathak. I'm a cardiologist and a pharmacologist.
2:17
I'm currently the head of the National Institute
2:20
for Cardiology, Cardiac Surgery and Interventional
2:24
Cardiology in Luxembourg. And I've been involved
2:27
a lot about patient care and patient education.
2:31
And I'm delighted to be with you. Hello. I'm
2:35
an associate professor of angiology and internal
2:38
medicine at the University Hospital and Comenius
2:42
University in Bratislava, Slovakia. I currently
2:46
serve as president of the Slovak Angiology Society
2:50
and it's a pleasure to join ESVS podcast and
2:54
contribute to today's discussion. Thank you very
2:58
much for joining us. We are going to talk about
3:01
chronic venous disease. We know that CVD is frequently
3:05
underdiagnosed and undertreated. In fact, according
3:10
to the Vane Act program, and I will share the
3:14
study on the show notes, Vane Act program is
3:18
an international prospective observational study
3:20
that enrolled adults with lower limb pain who
3:25
were consulting for any CVD -related clinical
3:28
presentation. What researchers found is striking.
3:33
Only about 31 % of these patients had ever consulted
3:38
a doctor for their leg problems before, and just
3:41
24 % received any form of treatment, which means,
3:46
we can say, that most patients are suffering
3:49
quietly. Professor Chalovska, why is CVD so underdiagnosed?
3:57
Yes, chronic venous disease is still underdiagnosed
4:01
for several reasons. First, people suffer quietly
4:06
because the symptoms seem normal. Patients often
4:10
underestimate symptoms like heaviness, pain,
4:13
swelling or visible veins are frequently considered
4:17
to be part of aging or simply the result of prolonged
4:21
standing. So many people don't seek medical attention
4:25
until the disease is more advanced. Secondly,
4:30
CVD is still considered to be an aesthetic problem
4:33
rather than a medical one. But we know that CVD
4:37
is a progressive inflammatory disease that significantly
4:41
impacts quality of life even in its early stages.
4:46
Early symptoms are nonspecific and subtle. can
4:50
easily be attributed to orthopedic, neurologic,
4:53
cardiac or lifestyle causes, unless we actively
4:57
think of venous disease. By the time CVD becomes
5:01
obvious, it's often already at a more advanced
5:04
stage, exactly what studies like VeinACT program
5:08
have shown. Okay, thank you very much. I think
5:11
that's go ahead with my experience, in fact,
5:15
for some people. Some patients think it's a static
5:18
reason, others consider that it's normal with
5:22
aging. So we are going to keep on with the Vane
5:26
Act program study. In this study, 78 % of patients
5:32
received conservative treatment alone. This means
5:36
lifestyle changes, vanoactive drugs, and compression
5:38
therapy. Impressive, 96 % of patients improved
5:43
with venoactive drugs and compression and 94
5:46
% reported being satisfied with two -thirds saying
5:50
that they were very or extremely satisfied. But
5:54
there is a paradox. Despite these high satisfaction
5:58
rates, only 65 % of patients actually took their
6:03
venoactive medication. Of course, these numbers
6:07
come from a study. But I would like to listen
6:11
to your opinion, Professor Chalovska, about your
6:14
own practice. Do you think that the results of
6:17
this study match with your own practice? And
6:21
why are the reasons patients do not take their
6:25
medication? What do you think? Yes, absolutely.
6:30
This gap between high satisfaction in studies
6:33
and non -adherence is absolutely real and it
6:38
reflects very well what we see in the daily practice.
6:42
In the clinic patients often report that they
6:45
feel better and are satisfied with the treatment
6:48
but at the same time they don't take the medication
6:53
consistently or for the full recommended duration
6:56
or they gradually drift away from the plan. The
7:01
most common reasons are quite practical. Many
7:04
patients don't perceive CVD as a serious medical
7:08
condition, so they don't see the treatment as
7:12
essential. Some simply forget or lose their routine
7:16
over time, others are concerned about side effects
7:20
or stop therapy at the first minor discomfort.
7:25
Cost can also be an important factor, especially
7:28
when medication is not fully reimbursed. And
7:33
importantly, there is often a lack of understanding
7:36
of the treatment goal. So that's it. That's the
7:40
main reason. And what, in your clinical practice,
7:44
what strategies do you recommend to increase
7:47
the adherence to venoactive drugs? What do you
7:49
do? Good CVD management isn't just about prescribing
7:55
right treatment. Long -term engagement is much
8:00
harder. It's also about explaining the nature
8:04
of the disease, creating a holistic patient -centered
8:07
strategy and realistic treatment plan that patients
8:12
can truly adhere to. Once the patient understands
8:16
the disease, the medication makes sense. In CBD
8:21
management, education is the most powerful tool
8:26
what we have. So I recommend to use simple things
8:30
like reminders on your phone, app, combine taking
8:35
your medication with other daily activities that
8:39
you do automatically. Try to understand why it
8:43
is important to follow your treatment plan and,
8:46
for example, share your treatment goals with
8:49
family or friends who can support your plan.
8:54
Okay, that's our really good advisors. I really
8:58
like them. So I want to share with you, Professor
9:02
Chalovska, and also with our listeners, a paper
9:05
I came across while preparing this episode. It
9:09
is a national -wide study from South Korea published
9:12
in 2023 that looked at compliance with vanoactive
9:16
drugs. One interesting finding was that the risk
9:20
of adverse events and rates of drug compliance
9:24
did not align. According to the authors, this
9:27
may be because the adverse events were not severe
9:30
enough to significantly impact adherence. Another
9:34
important point was that compliance was higher
9:38
when the medication was prescribed by a physician.
9:42
Professor Chalopska, do you have any comments
9:46
about this paper? This nationwide study from
9:51
South Korea is really telling. The fact that
9:55
side effects don't drive adherence suggests most
9:59
of them were probably mild and manageable. But
10:03
the key message for me is this. Patients stick
10:07
to treatment more when it's prescribed by a physician.
10:10
That's a strong reminder that adherence isn't
10:14
just about the pill, it's about communication,
10:17
trust, explanation. It's about how well the patient
10:21
understands why they are taking it and feels
10:25
guided through the treatment. To understand what
10:29
actually happened between a prescription and
10:32
a patient, we went to a community pharmacy. Community
10:38
pharmacists are well positioned for this proposed
10:42
as 80 % of medication treatments involve drugs
10:46
prescription. Among healthcare professionals,
10:50
the pharmacist may be the most accessible healthcare
10:53
provider who maintains regular contact with patients.
10:58
Hi, my name is Antonio. I'm a pharmacist in Portugal,
11:01
in our home city, that is, Porto. Well, about
11:04
the chronic venous disease, the importance of
11:08
the pharmacist is really relevant. Another thing
11:12
that's really important is to explain why the
11:16
customer, the patient, is having another pill
11:20
on there. medicine plan because it's really important
11:27
it's really important to explain what's the role
11:29
of the medicine and what to expect about the
11:33
that medicine and many times in our daily life
11:39
on our daily professional activity we see many
11:42
people having the the medicines on summertime
11:46
but on winter time that doesn't happen or they
11:50
should have for instance 1 ,000 milligrams daily
11:54
and they cut it by half for many, many several
11:59
reasons. In that sense, the role of the pharmacist
12:03
is really important because he can access the
12:06
pattern of how often he is buying the boxes of
12:10
the venoactive. drug and it can help and to dialogue
12:17
with the patient in this trustful relation what's
12:22
happening for him not to take and how important
12:25
is it for him to take medicine. What Dr. Liberal
12:28
just described isn't unique to his pharmacy.
12:32
It reflects what many patients experience every
12:36
day once they leave the consultation room. this
12:40
really world experience is now being supported
12:44
by solid evidence a large prospective study from
12:48
greece published in patient preference and adherence
12:50
in 2023 showed that in more than 1100 patients
12:55
including those with chronic venous disease simply
12:59
pharmacists interventions such as reminders brief
13:03
education and follow -up significantly improve
13:06
medication adherence without changing treatment
13:09
itself professor patak building on both this
13:13
evidence and what we've just heard from the community
13:17
pharmacy what do you see as role of pharmacists
13:21
in improving adherence to therapy yeah i think
13:25
that the role of the pharmacist is is a key role
13:29
and it's driven by the need to interact with
13:32
the patient, mainly by what we call the therapy
13:36
-related factors, which are the factors which
13:40
could lead to low adherence, but which are directly
13:43
influenced by the treatment. And this is particularly
13:47
true for patients with chronic venous diseases.
13:51
For example, in this setting, adherence to treatment
13:55
is not just about adherence to drug, but it's
13:58
also adherence to... all the proposals made by
14:01
the pharmacist, so the management of lifestyle,
14:06
but also the way you might use devices beyond
14:10
drugs. And in this setting, it's important to
14:13
try to help the patient by looking at the complexity
14:18
of the treatment. for example, by reducing the
14:21
pill burden or the number of drugs or the time
14:24
you are taking the drugs throughout the day.
14:27
Also take the time to discuss about side effects,
14:30
but also about convenience of use. So these are
14:33
probably the key role of the pharmacist in the
14:36
settings to improve adherence. That's a great
14:39
point. Thank you. One concept I've heard discussed
14:42
in relation to adherence is the idea of an adherent
14:46
patient. Essentially, That is, a patient who
14:50
adheres to a placebo is also a patient who will
14:54
adhere to all kinds of treatment. Could you elaborate
14:58
on this concept and how it applies to chronic
15:02
venous disease? Yeah, you made a good point.
15:06
Well, adherence, in fact, is a behavior. So,
15:09
basically, when you are adherent to the placebo,
15:13
it means that you are also adherent to other
15:16
offers. And what you are describing comes from
15:19
a trial done in heart failure, which is also
15:22
a chronic disease like chronic venous disease.
15:25
In this trial, the patient who were in the placebo
15:28
arm and were adherent to the placebo had a better
15:32
outcome than the patients who were in the treated
15:35
arm. And the explanation is that when you are
15:38
adherent to the placebo, you are also adherent
15:40
to all other. advices provided by the doctors,
15:44
whether lifestyle modification or adherence to
15:47
other drugs. So I think that the concept behind
15:51
that is that when you try to apply this to patients
15:56
with chronic venous diseases, you need to be
15:59
able to change the behavior toward the disease
16:02
by focusing on what we call patient -related
16:06
factors and therapy -related factors. So try
16:09
to understand. If your patient is aware of his
16:13
disease, how long has he been living with the
16:15
diseases? What are the factors which allow him
16:18
to better live with the diseases? And this will
16:21
indeed allow to be more adherent to what we are
16:26
offering to the patient, whether we are talking
16:29
about stockings, we are talking about drugs,
16:32
we are talking about lifestyle modification.
16:34
We know that patients often tend to please their
16:37
physicians. which can make self -reporting unreliable.
16:42
What questions would you suggest for us as physicians
16:47
to ask our patients in order to assess adherence?
16:52
Yes, when you want to assess adherence, there
16:54
are a lot of ways to assess adherence. You can
16:56
test drugs in the urine, in the plasma, you can
17:00
use smart boxes, but the most important thing
17:03
is you need to use the time. you have with the
17:06
patient. And there are some questions which can
17:09
help you to effectively assess adherence. Because
17:13
as I mentioned, adherence is a behavior. So if
17:17
you try to classify the behavior, there are usually
17:20
four important situations. One situation where
17:25
the patient is not taking the pills, is not changing
17:28
his behavior, he is what we call into denial.
17:32
There is a second phase where the patient might
17:35
be hesitating. He agrees to take the drug, but
17:37
he's not sure. He wants to take the drugs, but
17:40
he fears the side effects. Then there is a stage
17:43
where the patient is starting to stick to what
17:46
you're offering to him, and then he will do it
17:48
for a longer time. Sometimes there might be relapses,
17:51
but let's say that there are these four important
17:54
phases to assess. where your patient stands regarding
17:57
adherence. So there are a couple of questions
18:00
you can ask him. First, is he aware of his disease?
18:05
Is he concerned by his disease? Second, is he
18:08
doing something for that? And third, how long
18:12
has he been doing that? So imagine your patient
18:14
is not concerned at all by his disease and he's
18:17
not doing anything. He's in the denial phase.
18:20
And in this case, it's difficult to change his
18:23
behavior. You have to accept. to see the patient
18:26
again, and time will be your best ally. If your
18:29
patient is aware about the disease, but he has
18:32
difficulty to do so, he's into what we call the
18:35
ambivalence phase, he's hesitating to drink drugs,
18:38
then you have to increase the benefits of what
18:41
you could offer for this patient with chronic
18:43
venous diseases and answer the question about
18:46
what the risks are, what could decrease the adherence.
18:51
Finally... How long is the patient doing things?
18:54
Is it less or more than six months? If you are
18:56
above six months, it means that you have been
18:59
able to help your patient to be adjuvant for
19:02
the long term. If it's below to six months, then
19:05
you're also to help and guide the patient. Sometimes
19:08
also use the family so that he's sticking to
19:10
what you are offering him in order to avoid relapse.
19:15
Thank you. That's good advice. But medication.
19:20
is only one piece of the puzzle. Adherence to
19:23
compression therapy is even lower. According
19:27
to the VAIN Act study, only about 29 % of patients
19:32
wore compression exactly as prescribed, while
19:35
another 28 % wore it most days, 23 % wore it
19:40
intermittently, and more than 10 % didn't wear
19:44
it at all. We And our listeners know that patients
19:49
often have resistance to using compression therapy.
19:53
So coming back to you, Professor Shelovska, I
19:57
have two questions. First, do your patients give
20:01
specific reasons for not using compression? And
20:06
second, how do you motivate them? Yes, patients
20:11
are sometimes honest about why they don't wear
20:14
compression. The big ones are discomfort, heat,
20:19
sweating, difficulty putting it on and look.
20:22
Some say it feels too tight and some just don't
20:26
feel an immediate benefit so they slowly stop
20:30
using it. And how do I motivate them? first i
20:35
connect it to their goal less pain less swelling
20:39
better looking legs fewer complication and then
20:43
i make it practical we try different times different
20:47
pressures different materials we can switch to
20:50
summer friendly options because not all stockings
20:54
are the same there are lighter more breathable
20:58
materials open toe versions so it is very important
21:04
also to check the compression level because clinicians
21:07
should sometimes consider to prescribe lower
21:12
degrees of compression or just knee -high compression
21:17
for some patients. So the best compression therapy
21:21
is one you'll actually wear and your legs will
21:25
thank you for it. Could you share some innovative
21:31
approaches to improve adherence, particularly
21:35
in the context of silent disease such as CVD,
21:38
and how we might combat false information on
21:42
social media? Yes, I think you are absolutely
21:46
right. There are a lot of innovations in the
21:49
field. What we need to understand is that innovations
21:53
are dedicated to health behavior. So, ideally,
21:59
Today, what is really changing the way we are
22:02
interacting with our patients are mainly innovations
22:04
in the field of digital therapy. And one thing
22:08
which has really been striking me are all the
22:11
tools which are using gamification. In fact,
22:15
surprisingly, if you use the game tool, it's
22:18
a very nice way to interact with the patient
22:20
and to motivate the patient. Because by accumulating,
22:24
for example, life points, by providing him with
22:27
rewards, by helping him to move forward, gamification
22:30
is really a very strong tool beyond, I would
22:34
say, classical digital and also ai derived tools
22:39
you also mentioned a very important feature which
22:43
is the impact of information and also of false
22:48
information on social media so you need to educate
22:50
your patient to do what we call fast check And
22:53
also to go on dedicated websites which are validated.
22:58
There are codes, for example, the HON code. So
23:01
when you see that there is a logo, HON, it means
23:04
health on net. It means that this site has been
23:06
validated. And finally, the best way to fight
23:10
against false information or fake news is to
23:13
discuss with your doctor, is to discuss with
23:16
your physician, is to discuss with your health
23:18
care provider. Thank you very much, Professor
23:20
Shelowska and Professor Patak, for your time
23:24
and expertise. And thank you to all the other
23:29
participants, our patients and pharmacists, Dr.
23:33
Liberal. And if there is one message to take
23:37
home today, it's this one. Effective treatment
23:40
does not end with a prescription. It continues
23:44
with education, follow -up, collaboration. And
23:49
above all, a human connection that empowers patients
23:54
to stay on track. Thanks for listening to the
23:59
ESVS podcasts. Don't forget to follow us on Spotify,
24:03
SoundCloud, Apple Podcasts, and through the ESVS
24:06
library. And if you found this episode helpful,
24:10
please share it with your colleagues. And next
24:14
time, stay adherent, stay informed, and don't
24:18
skip the next episode of the ESVS podcast.