Utilization of Advanced Pneumatic Compression Devices in the Treatment of Lymphedema

Lymphedema is a chronic and often debilitating disease in which swelling, most often in the limbs, is caused by the accumulation of lymph fluid due to a disruption in the lymphatic system’s ability to drain excess fluid from the interstitium. This hindrance may be attributed to primary or secondary causes. There is no cure for lymphedema, a condition that affects more than 5 million Americans, and controlling the swelling requires consistent, ongoing treatment for a lifetime. 

The ongoing care of lymphedema is imperative to the well-being of the patient and to prevent complications and degradation in tissue health, which could lead to infections and ulceration. Ulceration due to inadequate treatment of lymphedema can be challenging to both the patient and healthcare providers. The lack of awareness as well as a lack of early diagnosis and coverage for early treatment often leads to the condition worsening before intervention is undertaken, which results in higher costs with poorer outcomes. This article will give an overview of appropriate treatment with a focus on the utilization of advanced pneumatic compression devices (APCDs). 

WOUND CLINIC CARE 
Open, chronic wounds often result in a referral to wound care clinics to treat and manage wounds before lymphedema therapists are willing to conduct complete decongestive therapy (CDT). CDT itself includes four components: 1) manual lymphatic drainage – a light skin-stretching technique that stimulates the lymphatic system; 2) compression – layered bandaging with foam or specially fitted garments that support the swollen area to control swelling; 3) exercise – with compression, special exercises will help to pump lymph out of the swollen area; and 4) skin care – keeping the skin clean and moisturized will help to prevent infections that often occur with lymphedema.1 

Wound clinic providers often find themselves caring for those patients living with the most severe presentations of lymphedema characterized by symptoms such as skin breakdown, presence of serious infections, deformities, and (often) loss of mobility. Since CDT is recognized as the “gold standard” for lymphedema treatment, wound clinics are faced with a difficult challenge: attempting to heal wounds caused by an underlying condition that is still largely untreated. 

Once lymphedema has led to open wounds, attention is turned to controlling any infection, ensuring proper blood flow, and utilizing appropriate dressings. However, controlling the underlying lymphedema is necessary to control and heal the wounds. Working with patients on basic elements of care such as diet and exercise may be a first step, but compression therapy and, ideally, CDT becomes essential to managing lymphedema. 

Compression bandaging systems requiring professional application are effective, but can be labor intensive and are not designed to accommodate wound care needs such as frequent wound access for dressing changes. Using APCDs to reduce edema and manage the underlying condition in conjunction with patient-applied compression, such as stockings and wraps, better facilitates access to and treatment of the wounds. Some newer pumps provide both therapies in one device – the intermittent compression found in classic pumps with built-in sustained compression applied while the patient is ambulatory. Addressing the wound and the underlying cause provides more holistic and higher quality of care to the patient. 

MANAGING SKIN INFECTIONS WITH APCDs 
Ongoing care of lymphedema is also imperative for managing costly complications. Skin infections such as cellulitis are a major health risk for individuals living with lymphedema. According to the Centers for Disease Control and Prevention, a single episode of cellulitis could result in hospitalization and thousands of dollars in resultant healthcare costs. In fact, New York State Public Health data on cellulitis shows that a single incident may result in four or more days of hospitalization and costs in excess of $16,000. 

APCDs in particular have been shown to reduce the rate of cellulitis episodes. A retrospective analysis of health claims2 conducted by experts from the University of Minnesota School of Public Health, University of Minnesota Medical School, Stanford University School of Medicine, and Vanderbilt University School of Nursing demonstrated that use of an APCD resulted in a 79% and 75% reduction in the rate of cellulitis episodes among cancer-related and noncancer-related lymphedema, respectively. 

The study analyzed de-identified health claims of 718 patients living with lymphedema who received an APCD (Flexitouch® System [Figure 1], Tactile Medical, Minneapolis) and had continuous insurance coverage during the period studied. Clinical outcomes and healthcare costs were analyzed for the 12-month period leading up to receipt of the APCD compared to outcomes and costs in the 12-month period after the receipt of the APCD. Of the 718 patients studied, 374 lived with cancer and 344 had noncancer-related lymphedema. The prevention of adverse clinical events associated with lymphedema for those prescribed the APCD led to improved patient health outcomes and decreased utilization of healthcare services. The noncancer-related lymphedema cohort saw a 40% reduction in the rate of outpatient hospital visits, a 34% reduction in the rate of physical therapy visits, and a 54% reduction in the rate of inpatient hospitalizations. The cancer group also experienced encouraging reductions in the rates of outpatient hospitalizations (29%) and physical therapy visits (30%). Together, these reductions resulted in a 36% decrease in the total healthcare cost for cancer-related lymphedema patients and a 37% reduction in total healthcare costs for those living with cancer-related lymphedema. 

This remarkable decrease in healthcare utilization among lymphedema patients using APCDs is encouraging evidence that ongoing home treatments complement in-clinic, therapist-directed therapy. With patients coming in less often for symptom care, cellulitis treatment, or physical therapy visits, outpatient care staff can dedicate time to the most at-need patients and progress treatment further with each visit. The advantages of APCDs meet today’s goals of quality-based healthcare measures. Not only is there demonstrated clinical efficacy, but the health outcomes impact individual patients as well as general population health. While individual patients experience quality of life improvements such as a reduction in infections and stymieing of symptoms that cause pain and impact mobility, overall the lymphedema patient population is better managed. The reduction in associated adverse clinical events and healthcare costs makes this a true public health success. 

ONLINE EXCLUSIVE
Patient Perspectives: Click here for a video that offers input from multiple patients.

Stakeholders agree that national healthcare spending, including Medicare costs, must be responsibly managed. While cuts in expenditures are necessary, it is important to ensure access to proven devices is preserved. The information previously stated demonstrates that investment in an APCD to treat lymphedema prevents the expenditure of significant healthcare dollars and improves clinical outcomes. However, in order to qualify for coverage of the APCD, the patient must still meet certain criteria required by the third-party payer. Commercial payers generally (and understandably) require proof the patient has tried and failed more conservative and less costly therapies prior to receiving the APCD. Medicare, on the other hand, has recently published increasingly restrictive criteria for pneumatic compression devices despite compelling evidence. These new criteria limit even basic pneumatic compression device (PCD) coverage to patients whose lymphedema has progressed to an irreversible state and display at least one of the following symptoms: hyperkeratosis, hyperplasia, hyperpigmentation, elephantiasis, papillomas, or skin breakdown with lymphorrhea. To qualify for an APCD, a Medicare patient must have lymphedema that extends into the chest or trunk and have also failed to improve with use of a basic PCD. Wound care clinicians play a key patient advocacy role in obtaining and preserving PCD access by understanding the patient’s specific insurance criteria and providing thorough, accurate documentation addressing those requirements. n 

Stephen G. Bergquist is the medical director of a wound management center in Jackson, TN. He is also a section editor for WOUNDS research journal in addition to being an active speaker and educator. 

References 

1. Branas A, Cohn J. Treatment for Lymphedema: Complete Decongestive Therapy. OncoLink, Penn Medicine. Accessed online: www.oncolink.org/ coping/article.cfm?c=362&id=1130 

2. Karaca-Mandic P, Hirsch AT, Rockson SG, Ridner SH. The cutaneous, net clinical, and health economic benefits of advanced pneumatic compression devices in patients with lymphedema. JAMA Dermatol. 2015;151(11):1187-93.