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Lymphedema - Overview

Lymphedema - Overview

Lymphedema - Overview

INTRODUCTION 

Background

Lymphedema is defined as progressive swelling of a specific body part due to insufficiency of the lymphatic system.[1] The body part affected depends on the anatomic location of the disrupted lymphatics, and can involve the limbs, head and neck, genitals or abdomen. This progressive swelling eventually results in thickening of the skin and soft tissue underneath, which gives chronic lymphedema its characteristic appearance. Lymphedema is characterized by high-protein edema, with protein concentrations of 1.0-5.5 g/mL which drive the accumulation of water in the interstitial space. This is in contrast to other forms of edema which have protein concentrations below 1.0 g/mL.[1] Lymphedema of lower extremities is frequently associated with chronic venous insufficiency (CVI) in a condition known as phlebolymphedema. As such, when assessing venous ulcers clinicians should maintain a high level of suspicion for associated undiagnosed lymphedema, which will need to be treated as a key component of ulcer management. (Figure 1)

Guidelines, Quality Measures and resources for lymphedema prevention, assessment and management are listed below. See topic "Lymphedema - Introduction and Assessment" for a review and framework for assessment of lymphedema and its complications (e.g, ulcers, cellulitis), including epidemiology, risk factors, etiology, pathophysiology, history, physical examination, diagnosis, differential diagnoses, documentation and ICD-10 coding. For management of lymphedema, including algorithm/pathway for point-of-care use, see "Lymphedema - Treatment and Emerging Strategies for Prevention". For updates and specific indications for surgical management of lymphedema, along with guidance on preoperative evaluation, see "Lymphedema - Surgical Management". For patient education, see topic "Patient education - Lymphedema".

Figure 1. Right lower extremity lymphedema

Relevance 

  • Patients with lymphedema were reported to have more frequent overall hospitalizations and outpatient visits than non-lymphedema patients.[2]
  • Individuals with lymphedema report a poorer quality of life (QOL) on surveys compared to their non-diseased counterparts.[3] Impact on QOL frequently arise from feelings of decreased attractiveness, chronic pain and impaired motor function/mobility.[1][3][4]

EVIDENCE-BASED CLINICAL GUIDELINES

Below is a list of the some of the most recent evidence-based guidelines on lymphedema:  

Evidence-based guideline,  year Publishing Organization, country Links Comments

The diagnosis and treatment of peripheral lymphedema: 2016 consensus document of the International Society of Lymphology, 2016 [5]

International Society of Lymphology, International

Guideline (Free)

Focus on lymphedema in general (cancer and non-cancer related)
Diagnosis of upper quadrant lymphedema secondary to cancer: clinical practice guideline from the oncology section of the American Physical Therapy Association, 2017 [6]
American Physical Therapy Association
Guideline (Free)Focus on breast cancer-related upper extremity lymphedema
Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema: Recommendations from a Multidisciplinary Expert ASBrS Panel : Part 1: Definitions, Assessments, Education, and Future Directions, 2017  [7]
International consensusConsensus (Paid)Industry funded, focus on breast cancer-related upper extremity lymphedema
Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema: Recommendations from a Multidisciplinary Expert ASBrS Panel : Part 2: Preventive and Therapeutic Options, 2017 [8]
International consensusConsensus (Paid)Industry funded, focus on breast cancer-related upper extremity lymphedema 
The Dutch lymphedema guidelines based on the International Classification of Functioning, Disability, and Health and the chronic care model, 2017  [9]
Dutch Working Group on Lymphedema
Guidelines (Paid)Focus on lymphedema in general (cancer and non-cancer related)

QUALITY MEASURES

Setting CMS Program Developed by Measure ID Title Description
OutpatientQuality Payment Program - Merit-based incentive payment system (MIPS) (***)
US Wound RegistryUSWR22Patient Reported Measure: Patient Reported Nutritional Assessment in Patients with Wounds and Ulcers
The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who self-report nutritional screening with a validated tool (such as the Self-MNA® by Nestlé) as well as food insecurity assessment, AND for whom the clinician provides and documents  a follow up/ intervention plan within the 12-month reporting period.
OutpatientQuality Payment Program - Merit-based incentive payment system (MIPS) (***)
US Wound Registry
USWR23
Non Invasive Arterial Assessment of patients with lower extremity wounds or ulcers for determination of healing potential
Percentage of patients aged 18 years or older with a non healing lower extremity wounds or ulcers that underwent a non-invasive arterial assessment once in a 12 month period, stratified by ABI, perfusion pressure, or oximetry
OutpatientQuality Payment Program - Merit-based incentive payment system (MIPS) (***)
US Wound Registry
USWR24Patient Reported Experience of Care: Wound Outcome
All eligible patients with wounds or ulcers who completed of Wound Outcome Questionnaire who showed 10% improvement at discharge or transfer to another site of care during the 12 month reporting period
OutpatientQuality Payment Program - Merit-based incentive payment system (MIPS) (***)
US Wound Registry
USWR25Outcome measure: Non-lower extremity Pressure Ulcer* (PU) Healing or Closure 
Percentage of Stage 2, 3, or 4 pressure ulcers among patients age 18 or older that have achieved healing or closure within 6 months, stratified by the Wound Healing Index. Healing or closure may occur by secondary intention or may be the result of surgical intervention (e.g. rotational flap or skin graft).
OutpatientQuality Payment Program - Merit-based incentive payment system (MIPS) (***)
MedicareMIPS 128
Process: Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter  
Outpatient
Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
MedicareMIPS 130Process: Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration
OutpatientQuality Payment Program - Merit-based incentive payment system (MIPS) (***)
MedicareMIPS 131Process: Pain Assessment and Follow-Up
Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present
Outpatient
Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
Medicare
MIPS 134Process:Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen
Outpatient
Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
Medicare
MIPS 154,5Process: Falls: Risk AssessmentPercentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months// Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months
Outpatient
Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
Medicare
MIPS 431Process: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief CounselingPercentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user
Outpatient
Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
Medicare
MIPS 181Process: Elder Maltreatment Screen and Follow-Up PlanPercentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen
Outpatient
Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
Medicare
MIPS 182Process: Functional Outcome AssessmentPercentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies
Outpatient
Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
Medicare
MIPS 217-223Outcome: Functional Status ChangeSee Quality Payment Program website for descriptions related to functional status change of various body sites
Outpatient
Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
Medicare
MIPS 226Process: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user
Outpatient
Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
Medicare
MIPS 236Intermediate outcome: Controlling High Blood PressurePercentage of patients 18 - 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period

The Quality Payment Program (for eligible providers and medical groups) currently does not have quality measures related to lymphedema. Providers can use other measures that may apply to their patient population

*** The Quality Payment Program (QPP) was implemented in the U.S. by Medicare in 2017. Merit-based incentive payment system (MIPS) is designed for eligible clinicians who bill under Medicare Part B. 

RESOURCES


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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

REFERENCES

  1. Lee B-B, Rockson SG, Bergan J, et al. A Concise Compendium of Theory and Practice . 2018;.
  2. Brayton KM, Hirsch AT, O Brien PJ, Cheville A, Karaca-Mandic P, Rockson SG et al. Lymphedema prevalence and treatment benefits in cancer: impact of a therapeutic intervention on health outcomes and costs. PloS one. 2014;volume 9(12):e114597.
  3. Fu MR, Ridner SH, Hu SH, Stewart BR, Cormier JN, Armer JM et al. Psychosocial impact of lymphedema: a systematic review of literature from 2004 to 2011. Psycho-oncology. 2013;volume 22(7):1466-84.
  4. Executive Committee.. The Diagnosis and Treatment of Peripheral Lymphedema: 2016 Consensus Document of the International Society of Lymphology. Lymphology. 2016;volume 49(4):170-84.
  5. Levenhagen K, Davies C, Perdomo M, Ryans K, Gilchrist L et al. Diagnosis of Upper Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of the American Physical Therapy Association. Physical therapy. 2017;volume 97(7):729-745.
  6. McLaughlin SA, Staley AC, Vicini F, Thiruchelvam P, Hutchison NA, Mendez J, MacNeill F, Rockson SG, DeSnyder SM, Klimberg S, Alatriste M, Boccardo F, Smith ML, Feldman SM et al. Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema: Recommendations from a Multidisciplinary Expert ASBrS Panel : Part 1: Definitions, Assessments, Education, and Future Directions. Annals of surgical oncology. 2017;volume 24(10):2818-2826.
  7. McLaughlin SA, DeSnyder SM, Klimberg S, Alatriste M, Boccardo F, Smith ML, Staley AC, Thiruchelvam PTR, Hutchison NA, Mendez J, MacNeill F, Vicini F, Rockson SG, Feldman SM et al. Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema, Recommendations from an Expert Panel: Part 2: Preventive and Therapeutic Options. Annals of surgical oncology. 2017;volume 24(10):2827-2835.
  8. Damstra RJ, Halk AB, Dutch Working Group on Lymphedema. et al. The Dutch lymphedema guidelines based on the International Classification of Functioning, Disability, and Health and the chronic care model. Journal of vascular surgery. Venous and lymphatic disorders. 2017;volume 5(5):756-765.
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