The prevalence, disease characteristics and treatment of chronic venous disease: an international web-based survey

This international online survey study highlights how common the signs and symptoms of CVD are in the general population, as well as the variability of CVD management practices. Based on patient self-report, the estimated prevalence of CVD symptoms in the general population was 22.0%. Individuals with CVD were generally older, female and obese, and had more comorbidities than the general population. The proportion of women who had been pregnant was also higher among those with CVD than in the general population. Most respondents had CVD of mild or moderate severity and of more than 1 year's duration. Approximately three-quarters had a family history of CVD. Analysis of the CVD treatment pathway showed that tiredness, heaviness and pain in legs, swollen legs and night cramps were the most common first symptoms of CVD. On average, the symptoms of CVD persisted for 1.0 year before respondents sought advice or treatment. Although consulting a physician was the single most popular option, most respondents sought information elsewhere. Respondents who sought help from a physician were older, more often overweight or obese, had more comorbidities and were more likely to use medicinal products and drugs or undergo interventions. There were differences in the characteristics of respondents, CVD and treatment patterns across the geographic regions studied, with Eastern European countries and Western European countries generally clustering together.

In the past decade, several studies have been conducted to assess the prevalence of CVD [10–14]. These studies reported widely different estimates ranging from 14.9% to 82.6% [10,14], likely due to the use of varying diagnostic criteria, target populations and methodologies [9]. The lowest estimate was reported in a study conducted in a random sample of 1500 Greek citizens; however, this was the only study that did not use the CEAP classification [10]. Another outlier was a study conducted in 3000 primary care patients in Pakistan, which reported a CVD prevalence of 34.8% [11]. This study also reported a higher prevalence of CVD in men (36.4%) than in women (33.0%) and of C₃ (36.7%) than symptomatic C₀ (C_0S) (14.6%), C₁ (13.8%) and C₂ (15.8%). Compared with other studies, the sample population of this study was younger (mean age 39 years) and consisted mostly of males (52.6%). Vein Consult and the study conducted by Vuylsteke and colleagues were most similar in terms of design [12,14]. Both used the CEAP classification and recruited adults who consulted a GP. Their sample populations consisted mostly of females (68.4 and 67.5%, respectively) and had a similar mean age (50.6 and 53.4 years, respectively). However, Vein Consult was an international study that recruited 91,545 patients from 20 countries in Europe, Latin America, Middle East and South East Asia, while the study conducted by Vuylsteke and colleagues included 6009 patients from Belgium and Luxembourg. Unsurprisingly, these two studies reported broadly similar estimates of CVD prevalence (82.6 and 75.6%, respectively). Although another study invited all residents of a rural Russian community to participate, its sample population was close to those in the two studies described above (mean age 53.5 years, 63.0% female), and it reported an estimate that was similar (69.3%) [13].

The present study was conducted in a representative sample of the general population of eight countries located in Europe and South America. As a result, the sample population had a similar number of males and females (48 and 52%, respectively) and was younger than the populations of most of the studies described above (mean age 44.9 years). It also did not use the CEAP classification. The estimate for the prevalence of CVD reported here most resembles that reported in the study by Dimakakos and colleagues [10], which was also closest to it in terms of design. Other studies described above enrolled populations that were older, had higher proportions of females and were more likely to have other health problems as they were recruited by GPs. Therefore, these studies were more likely to overestimate the prevalence of CVD in the general population.

There are several known risk factors for CVD, including genetic predisposition, age, female sex, obesity, pregnancy and standing for prolonged periods of time [2]. In the present study, individuals with CVD were older and greater proportions were female and obese than in the general population, confirming the importance of these risk factors for CVD. CVD is a progressive condition and, if left untreated, is likely to increase in severity [9]. Among individuals with up to C₂ CVD included in the Bonn Vein Study, 32% of those who had saphenous reflux, and 20% of those who did not, progressed to higher stages of CVD after 6 years [16].

Later stage CVD is associated with decreased quality of life and productivity, and represents a substantial burden on healthcare systems [6–8]. Therefore, early intervention is likely to prevent or delay later stage complications in a significant proportion of individuals with CVD. Despite this, there is some evidence that CVD is underdiagnosed and undertreated, especially at lower severity levels. For example, only approximately one-quarter of C_0S individuals are considered to have CVD by their GPs [17]. In addition, only 13% of C_0S individuals receive lifestyle advice and 8% are prescribed VADs [17]. The present study shows that individuals with mild or moderate symptoms of CVD often do not consult a physician, but instead seek advice and help from other sources such as the internet or friends and family. In addition, respondents waited on average 1.0 year from the occurrence of the first symptoms before seeking help. These findings support the notion that early-stage CVD may be underdiagnosed and undertreated. Improving the awareness of the burden of CVD among the public and physicians may help address this problem, particularly among high-risk individuals such as older people, women and those with a high BMI.

The strengths of the present study include the fact that it was conducted in a large and representative sample of the general population and that it examined multiple demographic and clinical characteristics relevant to CVD. One of the limitations of the present study is that it relied on respondents to provide accurate information. In cases where respondents did not have an accurate recollection of past events, this could have affected the accuracy of the findings. This limitation is common to studies that rely on participant-reported information. Another limitation is the fact that the CVD diagnosis was based on signs and symptoms reported by the participants of the survey and not verified by a physician. Signs and symptoms do not always correlate with CVD [18], so it is possible that some of the signs and symptoms that the participants reported may have had a cause other than venous disease (e.g., diabetes or hypertensive drugs causing edema, other skin inflammation causing pigmentation). In addition, as a web-based survey, our research may be subject to selection bias, favoring individuals with the income and education to participate in internet research.

This survey study conducted using a representative sample of the general population of eight countries found that the prevalence of self-reported signs and symptoms of CVD is 22.0%. Individuals with these CVD symptoms tend to be older, female and obese, and have more comorbidities than the general population. Most individuals with CVD signs and symptoms do not seek help from a physician, and those who do, tend to have more severe disease. The results of this study reinforce the need for greater awareness of CVD and its consequences in order to ensure timely diagnosis and treatment.

G Salmat was involved in data processing, statistical calculations, checked the accuracy of the data and reviewed and approved drafts of the manuscript for statistical accuracy. F Goron was involved in the conception and design of the study, enrollment of participants, data analysis and reviewed and approved drafts of the manuscript, including checking the accuracy of the data. C Régnier was involved in the conception and design of the study, read and revised manuscript drafts and approved the final version. E Rabe and F Pannier reviewed the results of the study, read and revised manuscript drafts and approved the final version.

We would like to thank A Bothwell, who on behalf of Springer Healthcare communications wrote the first draft, and G Filatov and C Rees, both of Springer Healthcare Communications, who wrote the outline and assisted with revisions post submission, respectively.

C Régnier is an employee of Servier International. F Goron and G Salmat are employees of Harris Interactive (France). The study was funded by Servier. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Medical writing assistance was funded by Servier.

Participants provided informed consent prior to completing the survey.

As this was not an investigation of clinical outcomes with any particular intervention, neither Ethics Committee approval nor clinical trial registration was required.

Harris Interactive Europe is a full service, consultative custom market research agency. We comply with the Quality and Professional Code of Ethics published by Syntec Etudes and the ICC/ESOMAR International Code on Market, Opinion and Social Research and Data Analytics and other applicable guidelines and codes of conduct on market research. Harris Interactive uses market research industry standards, techniques and methodologies to ensure that respondents to market research studies are kept anonymous and the results are provided on an aggregated basis. Harris Interactive, its hosting and backup services, and any third-party suppliers are fully compliant with the General Data Protection Regulation 2016/679 (GDPR). Harris Interactive only accepts personal data via secure encrypted transfer protocols such as sFTP sites. Data will only be processed for the purposes for which they were provided and for no other reason. Access to the data is restricted to pre-defined and tightly controlled groups of employees on a ‘need to know’ basis only. The healthcare department is also a member of ASOCS and follows the EPHMRA regulation (without being a member). All data are located on a single secure server (never transferred) and none of the data can be personally identifiable. This includes personal socio-demographic data (gender, age, geography defined in zones and not at a finer level) which the respondent gave his consent to their use in a conglomerate and anonymized manner. All people completing surveys on health-related matters are asked a health consent question to make sure that the person knows that health questions will be asked and that they accept this condition before completing the questionnaire. These data are always collected on an anonymized basis. No information that can precisely identify the person is possible. The data are available to the sponsor for a maximum of 2 to 3 years after the end of the study for possible additional research requests or realization of barometric monitoring. At the end of this time, the database undergoes automatic destruction.

Data are available on request from Harris interactive (Fabienne Goron and Ghislaine Salmat).

This work is licensed under the Attribution-NonCommercial-NoDerivatives 4.0 Unported License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0/