Dedicated to Lymphedema Patients and the Therapists Who Treat Them
An Estimate of Healthcare Savings Achievable through
Proper Lymphedema Management
The underlying principle behind the analysis is the assumption that management of lymphedema results in an immediate and significant reduction in the incidence of lymphedema-related infection. The ongoing cost of treatment of lymphedema is balanced out by the savings due to avoidance of the cost of treating recurring cellulitis, frequently on an emergency basis.
A number of separate approaches have been taken to arrive at a credible estimate of the potential savings to be achieved. The first approach (Appendix A) was to postulate two lymphedema treatment scenarios for a woman diagnosed with and treated for breast cancer. The first scenario postulates that she receives early and continued treatment of her lymphedema according to the recommended guidelines. The second scenario postulates that she receives no treatment for her lymphedema, but does receive medical treatment for her recurrent lymphedema-related infections. Data to support both scenarios are derived from statistics taken from recent scientific journals. The results of this study establishes, for this hypothetical case, a significant saving to her medical provider when the lymphedema is treated and managed.
Infection of the skin and lymphatic system (cellulitis/lymphangitis) is a major cause of lymphedema. It is also a major result of lymphedema. (Stoberl & Partsch 1987). Some 10-15% of lymphedema patients experience infections each year (Swenson et. al. 2002, Kasseroller 1998). Therefore one might expect 30,000-45,000 cellulitis cases yearly from 300,000 lymphedema patients in California. Hospital discharges for 2003 involving cellulitis of all sites and from all causes were 111,438. The average hospital stay for cellulitis was 5 days (Hospital Discharge Data 2002). At an average hospital stay cost per patient per day in California of $1763 (2003 AHA Annual Survey) this places the yearly burden for treatment of cellulitis in California at almost 1 Billion dollars, with $264-397 million estimated as related to lymphedema. If the incidence of cellulitis is reduced by 50% through the treatment of lymphedema (Ko et. al. 1998, Foeldi 1996) a $132-200 million saving would result, not accounting for medication cost savings or savings due to reduced disability.
Another approach taken was an attempt to extend this principle to a large population by examining actual hospital admissions data to attempt to size the burden of unmanaged lymphedema and the savings to be achieved for a larger population by treating the lymphedema. This study utilized the Patient Discharge Data for Calendar Year 2003 maintained by the California Office of Statewide Health Planning and Development. Total number of patient discharges in 2003 involving cellulitis of the arm or hand (ICD-9-CM Codes 682.3 and 682.4) were 18,876. Of this total, 307 cases involved upper limb lymphedema or swelling. These 307 cases involved an average hospital stay of 5.6 days for a total cost of $8,271,398. The total number of patient discharges in 2003 involving cellulitis of the leg and foot (ICD-9-CM Codes 682.6 and 682.7) were 62,056. Of this total, 1851 cases involved lower limb lymphedema or swelling. These 1851 cases involved an average hospital stay of 10.4 days for a total cost of $62,814,399. Similar relationships are shown between discharges with cellulitis of the lower limbs and various surgical procedures e.g.: hip and knee replacement and hysterectomy 224 cases at $25,262,301 cost; and coronary artery by-pass grafts 265 cases at $66,224,482 cost. Each of these infections is a lymphedema risk factor. Adding up the costs of only the cases of cellulitis documented as being related to lymphedema or swelling, yields a total of $162,571,000 in treatment of lymphedema-related cellulitis, well within the $132-200 million range of savings calculated using a different analysis using different data sets.
An estimate was made as to the cost of providing lymphedema treatment to the estimated lymphedema patients in California. Hinrichs found that the distribution of severities was 75% mild (Stage 1), 22% moderate (Stage 2) and 3% severe (Stage 3). Yearly costs of treatment developed in the hypothetical breast cancer scenario (Appendix A) were $200 for Stage 1, $1550 for Stage 2 and $5500 for Stage 3. Applying the observed distribution of severity of lymphedema [Hinrichs 2004] to the estimated 300,000 California lymphedema patients and using the estimated costs of treatment, yields an annual cost of lymphedema treatment if all patients were to be diagnosed and treated of $197 million. These estimated costs are in the range of estimated savings using statistics in scientific journals and hospital databases.
So the bottom line is that treatment of lymphedema is cost neutral and has the potential of saving money, providing a significantly improved quality of life for lymphedema patients and reducing the burden of disabilities resulting from late-stage lymphedema. Further references to the cost-efficacy of lymphedema treatment are found in the annotated references of Appendix B.
Prepared by Robert Weiss, M.S.
Lymphedema Treatment Advocate
STRUCTURE FOR A COST-EFFICACY STUDY OF LYMPHEDEMA TREATMENT
The estimates for the cost of treating one infection are low, perhaps by a factor of two or three. The cost differentials would be much more dramatic if these higher figures were to be used. The above analysis does not include the disability and loss of wages or the pharmaceutical costs for pain management due to not treating or under-treating lymphedema.
LYMPHEDEMA TREATMENT IS GOOD BUSINESS AS WELL AS GOOD MEDICINE.
LYMPHEDEMA TREATMENT COST-EFFECTIVITY REFERENCES
Compiled by Robert Weiss 10/8/03
Boris, MD, M., Weindorf, MD, S., Lasinski, M.A., P.T., B.: "Persistence of Lymphedema Reduction After Complex Lymphedema Therapy", (1997)Oncology, Vol. 11, No. 1, January 1997, pp. 99-109, discussion pp. 110, 113-114. Three case reports document dramatic decreases in incidence of hospitalizations for treatment of cellulitis for three patients treated by CDT.
Campisi C, Boccardo F, Zilli A, Maccio A, Napoli F: "The use of vein grafts in the treatment of peripheral lymphedemas: long-term results", Microsurgery. 2001;21(4):143-7. Study of 665 patients with microsurgical lymphatic-venous anastomoses for obstructive lymphedema with 446 patients available for long-term follow-up. Average follow-up of greater than 7 years showed average reduction in excess volume of 69%. There was an 87% reduction in the incidence of cellulitis.
Campisi C, Boccardo F, Zilli A, Maccio A, Napoli F.: "Long-term results after lymphatic-venous anastomoses for the treatment of obstructive lymphedema". Microsurgery 2001;21(4):135-9. Over the past 25 years, 665 patients with obstructive lymphedema have been treated with microsurgical lymphatic-venous anastomoses; of these, 446 patients were available for long-term follow-up study. Objective assessment was undertaken by water volumetry and lymphoscintigraphy. Lymphangioscintigraphy, lymphangiography (in patients with gravitational reflux pathology), and echo-Doppler were used preoperatively. Subjective improvement was noted in 578 patients (87%). Objectively, volume changes showed a significant improvement in 552 patients (83%), with an average reduction of 67% of the excess volume. Of those patients followed up, 379 patients (85%) have been able to discontinue the use of conservative measures, with an average follow-up of more than 7 years and average reduction in excess volume of 69%. There was a 87% reduction in the incidence of cellulitis after microsurgery.
Casley-Smith, J. R. PhD, MD, Boris, M., MD, Weindorf, S. MD, Lasinski, B. MA, PT: "Treatment for Lymphedema of the Arm—The Casley-Smith Method, A Noninvasive Method Produces Continued Reduction", (1998) Cancer (Supplement) Vol. 83, No. 12, Dec 15, 1998, pp. 2843-2860. Costs per year and effectivities of a 4-week course of CDT treatment was presented, including costs of bandages and garments (Figure 9). Average costs for different treatments ranged from $2000-3000 per year with 40% to over 100% reductions of initial edema. Cost ranges from savings (negative costs) to $7000 per year for various alternative treatment protocols.
Daane, S. MD, Poltoratszy, P. RPT, CPT, Rockwell, W. B. MD: "Post-mastectomy Lymphedema Management: Evolution of the Complex Decongestive Therapy Technique", Ann Plast Surg, Feb 1998, Vol 40, No. 2, pp. 128-134. Treatment was an average of 15.3 visits per patient over a period of 3-4 weeks, with an average cost of $1513. The duration of each treatment session was from 45 minutes to 1 hour. The goals of therapy are to control edema, to prevent infection and to improve function. Each inflammatory episode can exacerbate lymphatic fibrosis.
Földi MD, E.: "Prevention of Dermatolymphangioadenitis by Combined Physiotherapy of the Swollen Arm after Treatment of Breast Cancer", Lymphology, 1996, Vol. 29, pp. 91-94. Study of medical records of 150 breast cancer patients with arm lymphedema in the years 1990-1994. Conclusion were that in women with arm lymphedema after treatment of breast cancer, recurrent Dermatolymphangioadenitis (DLA) attacks [cellulitis/lymphangitis infections] can nearly be eliminated by improvement in arm swelling by combined physiotherapy (CPT) Phase I. If these women are free of skin risk factors [unrelated to the lymphedema] such as psoriasis, neurodermatitis, vericose lymphatics, lymph fistulae and/or fungal overgrowth, continued CPT (Phase II) maintains reduction of edema and prevents further DLA episodes.
Ko, MD, D. S. C., Lerner, MD, R., Klose, CCDPI, G.; Cosimi, MD, A. B.: "Effective Treatment of Lymphedema of the Extremities", Arch of Surgery, April 1998; Vol. 133, pp. 452-458. 299 patients referred for evaluation of lymphedema of the upper or lower extrematies were treated with CDT for an average duration of 15.7 days. Lymphedema reduction was measured following treatment and at 6- and 12-month follow-up visits. The incidence of infections decreased from 1.10 infections per patient year to 0.65 infections per patient year after a complete course of CDP [Phase I and Phase II] (Table 2).
Krishnamoorthy K: "Estimated costs of acute adenolymphangitis to patients with chronic manifestations of bancroftian filariasis in India."Indian J Public Health 1999 Apr-Jun;43(2):58-63.
In India, lymphatic filariasis persists as a major cause of clinical morbidity and as an impediment to socio-economic development. The direct costs incurred for the treatment of adeno-lymphangitis (ADL) episodes and the consequent indirect costs due to loss of income were determined from selected agricultural labour-intensive rural endemic pockets in Tamil Nadu. Information on the occurrence of ADL, its frequency and duration were collected using semi-structured questionnaire from randomly selected patients afflicted with chronic manifestations of bancroftian filariasis. Direct (treatment) cost per year per patient was found to range from Rs. 30 to 101 among patients with different manifestations. Income foregone (indirect cost) annually by each patient, which is a function of frequency and duration of ADL ranged from Rs. 182 to 702. ADL episodes among filarial patients alone cost a minimum of Rs. 4515 million for the nation every year. Cost benefit analysis of filariasis control programme in India showed that the benefits in terms of savings on treatment and work lost due ADL alone exceeded the cost by 24%. The per capita cost of the National Filaria Control Programme was calculated to be Rs. 2.6 per annuam.
Lerner, R. MD: "Complete Decongestive Pysiotherapy and the Lerner Lymphedema Services Academy of Lymphatic Studies (the Lerner School)", (1998) Cancer (Supplement) Vol. 83, No. 12, Dec 15, 1998, pp. 2861-2863. "By employing [the Foeldi] method of CDP we have been given a treatment modality that achieves a greater than 80% long term success rate without morbidity or mortality and without disfigurement of any kind. We have been able to do this for a reasonable cost, and, by transferring the future care of the lymphedema patient away from the doctor/hospital setting, we have produced a very cost effective method of caring for this long-term, chronic disease."
Miller SR, Mondry T, Reed JS, Findley A, Johnstone PA.Delayed cellulitis associated with conservative therapy for breast cancer. J Surg Oncol. 1998 Apr;67(4):242-5.
Delayed breast cellulitis is an infrequently reported entity after conservation therapy for breast cancer. We describe our experience with this entity at Naval Medical Center, San Diego. Eight patients who presented with delayed cellulitis after wide local excision/axillary dissection and breast radiotherapy (RT) are presented. Their clinical characteristics and therapy are described and possible causative factors are analyzed. The latency of breast cellulitis is variable after breast conservation therapy, although most cases in our experience and in the literature occur within a year post-RT. These infections are frequently refractory to a single course of antibiotics (n = 4 cases in our experience). Some patients suffer multiple episodes separated by months. Breast cancer patients are at risk for delayed cellulitis after conservative surgery and RT. The mechanism of such events probably involves lymph stasis, however, therapy is no different from the more frequently occurring cases of cellulitis presenting perioperatively.
O'Brien BM, Mellow CG, Khazanchi RK, Dvir E, Kumar V, Pederson WC.: "Long-Term Results after Microlymphaticovenous Anastomoses for the Treatment of Obstructive Lymphedema," J Plastic and Reconstr Surg, 1990, Vol. 85, No. 4, pp. 562-72. Over the last 14 years, 134 patients with obstructive lymphedema have been treated with microlymphaticovenous anastomoses. Ninety patients were available for long-term follow-up study. Of these, 52 patients were treated by microlymphatic surgery only and 38 of them also had segmental or radical reduction surgery, either at the same time or secondarily. Objective assessment was undertaken by volume and circumferential measurements. Initially, lymphangiography was used, but a study demonstrated increased edema immediately following the investigation in one-third of the patients and it was abandoned, both preoperatively and postoperatively. In the microlymphaticovenous anastomoses only group (N = 52), subjective improvement occurred in 38 patients (73 percent). Objectively, volume changes showed a significant improvement in 22 patients (42 percent), with an average reduction of 44 percent of the excess volume. In the microlymphaticovenous anastomoses and reduction surgery, usually segmental, group (N = 38), subjective improvement occurred in 30 patients (78 percent) and objective improvement occurred in 23 patients (60 percent), with an average reduction of 44 percent of the excess volume. Of those followed up, 67 patients (74 percent) have been able to discontinue the use of conservative measures, with an average follow-up of 4.0 years and average reduction in excess volume of 26 percent. There was a 58 percent reduction in the incidence of cellulitis following surgery. In those patients who were improved, drainage resulted in increased softness of the limbs. Edema of the hand diminished considerably in most patients, although this was difficult to measure. These long-term results indicate that microlymphaticovenous anastomoses have a valuable place in the treatment of obstructive lymphedema and should be the treatment of choice in these patients. Reduction surgery can be used as an adjunct in some of these patients, especially in the posteromedial aspect of the upper arm. Liposuction has been used in failed cases or in patients in whom no lymphatics could be found. Improved results can be expected with earlier operations because patients referred earlier usually have less lymphatic disruption.
Reid T: "Treatment of Lymphedema and Recurrent Cellulitis", Case Report presented at the Second National Lymphedema Network Conference, Sept 1996. 31 year old patient with lymphedema due to multiple knee injuries and surgeries spent 152 days in hospital between May 1994 and November 1995. After 5 months of treatment with Reid manually-adjustable compression sleeve, she had no further events of cellulitis and was able to be taken off antibiotics. Cost effectiveness analysis showed savings over 5 months to exceed $90,000-$130-000 based on hospital cost of $2-3,000/day.
Thiadens SRJ, Rooke TW, Cooke JP: "Lymphedema" in Current Management of Hypertensive and Vascular Diseases (1992) Mosby Yearbeck, Inc., St. Louis, MO. pp. 314-319. In a retrospective study of 304 lymphedema patients, over 25 percent had incurred an episode of cellulitis over a period of 3 years.