Comment to: Interobserver variability in the assessment of the clinical severity of superficial venous insufficiency by Sinabulya H, Holmberg A, Blomgren L. Phlebology 2013. [Epub ahead of print] doi:10.1177/0268355513515474

The study took place between August 2011 and February 2012 at Venous centre, a private, specialist clinic for treatment of VV in Stockholm. The aim of this study was to test the inter-observer reproducibility of the C of CEAP when used in a clinical setting where the patients’ clinical signs and symptoms were evaluated if severe enough for treatment within the national health insurance system. Strict medical indication for treatment consisted of at least one of the following: present or previous venous ulcers, venous skin changes, significant edema, thrombophlebitis, or bleeding from VV. Patients with VV without skin changes but with symptoms from their legs were considered to have a medical indication if they either had severe symptoms affecting their quality of life, no other obvious cause of leg symptoms, improvement of symptoms with compression stockings, or significant venous reflux found on examination with duplex or Doppler. Three physicians, consisting of a surgical resident (HS), a consultant vascular surgeon from a university hospital (LB), and a consultant vascular surgeon from the private clinic, assessed the patients independently and their respective assessments were blinded to each other. A total of 78 patients (106 limbs) agreed to participate in this study [11 men and 67 women; median age 58.5 (23-91) years]. Total agreement between the three observers was obtained in 61% of all cases suggesting moderate to substantial agreement. Least agreement was seen for class C3, followed by C2 and C4. The number of patients with a medical indication for treatment for each observer was 57, 44, and 33, respectively. Agreement between all three observers occurred in 60% of all cases suggesting fair to moderate agreement. This study shows that assessments differed considerably for both C of CEAP and assessment for the medical indication for treatment. Possible cause: lack of training among the participating doctors or the simultaneous assessment of reimbursement that may influence the clinical classification may influence the individual doctor differently depending on where he or she is employed (waiting list, reimbursement policy). Least agreement was seen for C3, as defining edema was difficult. Another difficulty is the discrimination between hyperpigmentation and extensive telangiectasies, where the latter would sometimes be classified as C4.Skin changes, such as eczema, can be present on other parts of the body besides the legs and have other causes than venous insufficiency, thus, the class may either be C2 or C4. As a consequence, scientific studies using the CEAP may not be reliable if the participating doctors are classifying differently. Patients are disappointed with the decision refusing reimbursement seek a second opinion in another clinic where the doctor might judge differently (the so called post code lottery). In spite of the results in this study, the authors still consider the CEAP classification as the best available, and intention is to find a way to practice CEAP together for more reproducible assessments.