At the 2018 annual congress of the American College of Phlebology (ACP), it was announced that the society would pursue changing its name to the American Vein and Lymphatic Society (AVLS). The membership voted to approve this action in December, and the name was legally changed on January 1, 2019. What first prompted this motion to be raised for consideration?

The AVLS was founded in 1985 as the North American Society of Phlebology to provide a forum for the exchange of scientific and practical knowledge related to the diagnosis and treatment of vein diseases. It was the first organization of its kind in North America. In 1997, the society leadership changed the name of the society to the “American College of Phlebology” to emphasize its educational mandate.

However, as the organization matured over the ensuing 2 decades, its reasons for existence diversified to include physician and patient advocacy, fostering scientific research as well as supporting patient care and research in lymphatic disease. It also became clear to leadership and our members that the term phlebology did not resonate well with patients or our colleagues in other disciplines in the United States.

In 2015, at the second Executive Leadership Summit hosted by the ACP, leaders from the ACP and industry executives gathered to discuss the future direction of the field of venous and lymphatic medicine. Among several key ideas and discussions was the need to establish an identity that better reflected the expanded mission of the society. In 2016, our board endorsed a strategic plan that included a mandate to propose a new name for our society that would be inclusive of our expanded societal activities. We think that the name AVLS represents the culmination of a long-term goal of the organization to develop a name that is congruent with its mission and vision.

What are the specific goals and potential advantages of increased name recognition with payers and providers?

The term phlebology is not as well known in the United States as it is in Europe. Consequently, American patients, payers, and physicians from other specialties did not immediately understand what our society was all about. We think that our new name conveys our commitment to vein and lymphatic disease and will help make our expertise more recognizable moving forward.

Aside from its name, do you think that the focus of the society itself has changed or expanded at all?

Education has remained a core mission of the AVLS, but our goals have expanded beyond hosting a single annual congress to also hosting smaller, topic-specific meetings throughout the year, such as those we are hosting on lymphedema and wound care this year. We are also continuing to engage our teammates in care—the United States technologists, nurses, advanced practice providers, and lymphedema therapists—to give them a multidisciplinary forum to exchange knowledge as well as opportunities to work as leaders within the organization. Deep and superficial venous disease and lymphatic disease education are integrated in our meetings, and content is being provided for caregivers of all levels of experience, from beginner to expert.

We are also promoting elevation of the quality of care by developing clinical practice guidelines, encouraging and financially supporting scientific research projects (including a registry) funded with grants from our foundation, and elevating the level of education for all physicians by supporting an independent American Board of Venous and Lymphatic Medicine, as well as fellowships in venous and lymphatic disease. We have also become very involved in health care advocacy, holding a seat on the American Medical Association (AMA) House of Delegates and increasingly engaging health care insurers and the Centers for Medicare & Medicaid Services to advocate for access to the advances in health care that we provide for our patients. As we like to point out, “We ARE the AVLS: Advocacy, Research, and Education are our missions.”

Please tell us more about the decision to emphasize lymphatic disease in the society. To what degree is the inclusion of lymphatic disease a new direction for the society versus one that was already in place?

In the United States, it is estimated that over 10 million people are living with lymphedema. However, in our health care system, the majority of these patients remain undiagnosed. Even when it is diagnosed, it is difficult for a patient to find a physician with an interest and background in providing appropriate care. Thus, most patients go on to suffer needlessly for years. As our understanding of lymphedema and venous disease has developed over the years, we’ve realized how intertwined these diseases are. The AVLS recognized this gap in care for patients with lymphedema about 10 years ago, and it has become a priority of the organization to develop into a professional medical society where those with an interest in lymphedema can advocate for their patients, be supported in research, and share knowledge through educational programs.

How would you summarize the field of lymphatic intervention in 2019, in terms of where it stands at present and what the near future holds?

In the last decade, there have been a number of exciting advances in surgery for lymphedema. In addition, innovations in the medical care of lymphedema have shown success in the laboratory and are close to moving to the bedside. However, at the present time, most of the intervention for lymphedema is literally “in the hands of therapists.” The lymphedema therapists continue to do yeoman’s work in caring for these patients and make a huge difference in their lives. It is an organizational priority for the AVLS to support the lymphedema therapist community and engage them with the physicians who are seeing patients with swollen legs and the scientists who are developing novel therapies, all in a continuing effort to improve the quality of life for patients with lymphedema.

With lymphatic intervention on the rise, what can be done at the society level to ensure appropriate training and application?

This is exactly where we see the AVLS stepping up to the plate. Our goal is to provide educational opportunities for those interested in developing themselves into lymphatic specialists, so that they are not only able to manage vein disease but also the lymphatic disease they see on a routine basis.

As a society, we see the opportunity to bring the scientist, physician, and lymphedema therapist together much in the same way that all of the investigators and providers for patients with vein disease have been brought together in one society. The AVLS is able to provide the infrastructure and support for the development of new and expanded applications of care, where we can hopefully reach a larger portion of these patients and ultimately make a difference in their quality of life.

The ACP and other groups, such as the American Venous Forum (AVF), have been working to curb inappropriate use of superficial venous therapies. Acknowledging that progress on this front is hard to track, do you believe there has been improvement?

The AVLS is definitely committed to this issue. In regard to your question of whether progress been made, I would say no. Thus far, all that has been done is identifying that a problem exists and that it is worse than we thought. To address this, the AVLS initiated a project in 2018 called “Improving Wisely” to actually try and make a real difference. Improving Wisely is a partnership with Johns Hopkins University, with support from the Robert Wood Johnson Foundation and the Foundation for Venous and Lymphatic Disease (the previous ACP Foundation), based on the premise that individuals will improve their performance when provided with personal performance metrics and community benchmarks.

In this regard, the AVLS undertook a pilot project last year that provided a confidential report to each individual who performed thermal ablations in original Medicare beneficiaries. The report provided each physician with the average number of thermal ablations they performed per patient during the previous 12 months. It also provided them with a distribution curve for the average number of ablations per patient per year of all physicians who billed Medicare for thermal ablations during the same time period. In this first iteration, we found that the majority of providers are working well within what we would consider an appropriate range, but there were clear outliers. We and our partners in the AVF are making an effort to share these data and provide appropriateness of care recommendations with the hope that knowledge of personal performance benchmarked against their peers will serve as an opportunity to reconsider personal practice. The data for each provider will be recalculated annually and reports will be shared with them. Hopefully, we will see a change in performance with time, such that the outliers will begin to change their approach to care with respect to this and other metrics we plan to analyze.

It was interesting that of the more than 2,400 reports we mailed out in the Improving Wisely pilot project, 1,540 were sent to individuals who have never interacted with the AVLS; they had never been a member or attended a meeting. Given the large overlap of membership and meeting attendance between the AVLS and AVF, our educational efforts have been missing > 60% of the individuals that practice vein care in the United States. Our hope is that through the Improving Wisely project, we can begin to interact with these providers, encourage them to participate with educational programs in the AVLS and AVF, and over time, see an improvement in the overall quality and appropriateness of care for our patients.

What are the current research and advocacy initiatives of the AVLS?

Several years ago, the society recognized the need to advance our understanding of venous disease by providing “big data.” As such, the AVLS has invested in the development of the PRO Venous Registry, a patient-reported outcomes database that is currently the largest registry dedicated to venous and lymphatic disease. To further advance the registry, the AVLS acquired the Venous Patient Outcomes Registry in 2018 and is in the process of developing a new unified platform for the registry PRO 2.0, which will be launched this spring. As the registry continues to develop, we hope to be able to provide the evidence needed to support appropriate and beneficial care for our patients.

Although we have been involved with it for a long time, advocacy is the newest mandate of the AVLS. About 14 months ago, we made the commitment to play a more active role in advocating on behalf of our membership and the field when we hired our first Director of Healthcare Policy and Advocacy to our staff. With this full-time attention and the development of a very committed volunteer base, we are beginning to advance our cause. The AVLS has a seat on the AMA House of Delegates and is actively involved in the CPT (Current Procedural Terminology) and RUC (Relative Value Update Committee) committees of the AMA, where we can help shape the future. Additionally, we are involved across the country in dealing with local carriers and policies, providing our membership with support on specific issues as they arise. There is still much work to be done on this front, especially in light of the constantly changing health care reimbursement environment.

Neil Khilnani, MD, FSIR, FACPh
Immediate Past President, American College of Phlebology
Associate Professor of Clinical Radiology
Division of Vascular and Interventional Radiology
Weill Cornell Medical College
NewYork-Presbyterian Hospital
New York, New York
Disclosures: None.