Development of the Lymphoedema Patient Reported Outcome Measure (LYMPROM)

A new validated Lymphoedema-specific Patient Reported Outcome Measure (LYMPROM) for adults with Lymphoedema

BACKGROUND

A new lymphoedema-specific Patient Reported Outcome Measure (LYMPROM©) was developed to help patients easily report the impact of their lymphoedema and enable lymphoedema therapists to understand what matters most to patients.

AIMS

This paper describes the validation of LYMPROM© for adults with lymphoedema.

METHODS

A multi-phased iterative review was undertaken to investigate the reliability and validity of LYMPROM©. Face and content validity were reviewed by surveying patient representatives and healthcare professionals, along with the validity of LYMPROM© Cymraeg, a Welsh translation. Following COSMIN guidelines, validation study phases used anonymised routinely collected data to examine internal consistency, structural validity, construct validity (compared with the EQ5D-5L), measurement error, test-retest reliability and responsiveness.

RESULTS

LYMPROM© demonstrated validity (content and construct) and reliability (test-retest, internal consistency). All items were regarded as relevant, comprehensive and clear, with item content validity index (CVI) between 0.83 to 1.00, and average overall assessment of 0.94. Robust development of LYMPROM© Cymraeg ensured appropriate translation into Welsh. LYMPROM© item scores, with means and medians generally in the lower half of the scale, were positively correlated, as were three (Physical health, Social health and Emotional health) domain scores (domain correlations: 0.595 to 0.812). LYMPROM© total and domain scores showed moderate negative correlations (-0.577 to -0.435) with EQ5D-5L measures. LYMPROM© total and domain scores showed good test-retest (within two weeks) properties, with little or no change in mean or median scores, and strong positive correlations between test and retest scores (Total: 0.919; Physical health domain: 0.922; Social health domain: 0.889; Emotional health domain: 0.820). LYMPROM© showed good responsiveness, with strong, positive correlations between total and domain initial and repeat (between four weeks and seven months later) scores, with a slight reduction in scores (-3.8 to -2.0 units) and some indication of relationships between reduction and time interval (Total: p = 0.025; Physical health domain: 0.034; Social health domain: 0.181; Emotional health domain: 0.009).

CONCLUSION

Evidence shows that LYMPROM© offers a reliable and valid tool for use in clinical practice. Scores on three domains allow a more granular assessment of the patient's view of their condition; these scores and the total LYMPROM© score exhibit moderate correlations with more generic EQ5D-5L measures. Further research will explore relationships between patient-level characteristics and LYMPROM© responses, and extend initial work on its cross-cultural validity.

Cost-effectiveness analysis of lymphaticovenous anastomosis in reducing cellulitis recurrence in 150 lymphoedema cases followed-up over 24 months

BACKGROUND

Lymphoedema is a chronic condition that imposes ongoing costs on the patient and National Health Service (NHS). This study aimed to estimate the cost-effectiveness of lymphaticovenous anastomosis (LVA) in reducing cellulitis recurrence in 150 patients with lymphoedema who were followed-up for over 24 months.

METHODS

Data were prospectively captured pre- and post-LVA surgery in 150 patients with unilateral lower or upper limb lymphoedema in a centre in the UK. Data collection included cellulitis resource utilisation with costs identified from the British National Formulary, Personal Social Services Research Unit, and a quality-of-life questionnaire (EQ-5D-5L).

RESULTS

The mean overall costs for cellulitis and hospital admissions reduced by £1389.85, which was statistically significant (p < 0.001). Mean per patient reduction of costs across the 24-months was estimated at -£1405.62 (CI: -£1878.09, -£933.16). When the cost of LVA (£4551) was included, the reductions were offset to £3145.37 (CI: £2672.90, £3617.84). The mean EQ-5D-5L utility score (n = 143) increased from 0.743 (SD 0.168) to 0.800 (SD 0.196), being statistically significant (p = <0.001). The incremental cost-effectiveness ratio (ICER) through costs and EQ-5D-5L changes was £54231, indicating that LVA costs more, but is more effective. LVA benefits patients for more than the 24-months captured, thus costs would be reduced based on the patients' life expectancy.

CONCLUSION

This cost-effectiveness analysis provided an in-depth examination of a large cohort of LVA patients who were followed up for 24 months, highlighting decreased cellulitis recurrence.

Development of an All-Wales National Health Service Surgical Lymphedema Supermicrosurgery Service

Background

The management of lymphedema includes an array of conservative measures, but must also include surgical intervention as a management option where appropriate. Within the National Health Service in Great Britain, the surgical provision for lymphedema patients is very minimal. This article provides a historical overview of the inception of the lymphedema service within Wales, which is the only holistic lymphedema service within the National Health Service.

Methods

All patients discussed at the lymphedema multidisciplinary team (MDT) meeting were included. Data were collected during a 5-year period from June 2017 to May 2022. MDT meeting outcomes were also recorded (conservative or surgical management), and if surgical intervention was used, the type of surgical procedure was documented.

Results

A total of 175 patients were discussed by the lymphedema surgical MDT. Of these, 129 (74%) were recommended for surgery and 46 (26%) were managed using conservative measures alone. The most common surgical recommendation was for lymphovenous anastomosis (61, 47%), followed by liposuction (40, 31%). Vascularized lymph node transfer was recommended in 19 (15%) cases.

Conclusions

The authors highlight the efficiency of the service, whereby despite more than 7500 referrals a year, only a small minority that are eligible for surgery undergo a surgical assessment. The authors hope that this article provides an impetus for such services to be similarly replicated across other nations.

Demonstrating the benefit of a cellulitis-specific patient reported outcome measure (CELLUPROM©) as part of the National Cellulitis Improvement Programme in Wales

PURPOSE

Despite a known risk of cellulitis recurrence, the management of the wider impact and risk factors has been neglected. The innovative National Cellulitis Improvement Programme (NCIP) addresses this by providing evidence-based and individualised care to improve patient reported outcomes and reduce the risk of recurrence. The aim of this paper is to examine the longer-term impact of cellulitis and to identify a suitable and clinically relevant Patient Reported Outcome Measure (PROM).

METHODS

A review of existing cellulitis-specific PROMs was undertaken, alongside literature detailing the patient-focused impact of cellulitis, to identify a suitable PROM for clinical use. A group of expert therapists and patient representatives (n = 14) shared their individual and collective experiences over a series of events to discuss and debate the impact of cellulitis and review available PROMs. CELLUPROM© is introduced with anonymised PROM data and case study information reported to establish the impact of CELLUPROM© within usual NCIP care.

RESULTS

No cellulitis-specific PROMs were identified. Literature focused on the signs and symptoms of an acute episode of cellulitis, with outcome measures primarily used to evidence the impact of an intervention. An enduring physical, social and emotional impact of cellulitis was identified in this study, providing the basis for the new cellulitis-specific PROM (CELLUPROM©), which has been implemented with good effect in clinical care.

CONCLUSION

This study has highlighted the lasting impact of cellulitis. Using CELLUPROM© within the risk-reduction NCIP has helped develop Value-Based Healthcare and support programme evaluation.

Lymphoedema specialists embedded into community nurse and wound services: impacts and outcomes

BACKGROUND

Lymphoedema is a progressive condition causing significant alterations to life, exerting pressures on unscheduled care from complications including cellulitis and wounds. An on the ground education programme (OGEP) was implemented to raise knowledge, competence and confidence in lymphoedema management in community clinical services. The aim of this study was to explore the impact and outcomes of the OGEP intervention.

METHODS

Data were captured before and after OGEP on 561 lymphoedema patients in the community setting. Data recorded included resource use, costs and outcomes (EQ-5D-5L and LYMPROM).

RESULTS

Data demonstrated statistically significant reductions in resource allocations including staff visits (P<0.001), cellulitis admissions (P<0.001), compression consumables and wound dressing costs (P<0.001). Overall, the total mean per patient cost decreased from £1457.10 to £964.40 (including intervention) with outcomes significantly improved in EQ-5D-5L/LYMPROM scores.

CONCLUSION

The analysis suggests the OGEP intervention may offer reductions in resource costs and improvements in patient outcomes. OGEP may therefore provide an innovative solution in future care delivery.

Impact and outcomes after lymphaticovenous anastomosis for 150 cases of lymphoedema followed up over 24 months

BACKGROUND

Lymphoedema is a chronic condition affecting daily activities of life, causing significant alterations and adjustments. Since 2015, lymphaticovenous anastomosis (LVA) has been available on the National Health Service for people with lymphoedema in Wales, United Kingdom. This study aimed to explore the impact and outcomes after LVA over a 24-month follow-up.

METHODS

Data were prospectively captured before and after LVA surgery on 150 patients with unilateral upper or lower limb lymphoedema. The same team (three lymphoedema specialists and two plastic surgeons) assessed/operated on all patients. Data captured included a quality of life tool (EQ5D5L), circumferential measurements (tape measure/perometer), compression garment usage, occurrence of cellulitis and a range of patient-reported outcome measures.

RESULTS

People who underwent LVA surgery had predominantly cancer-related lymphoedema (n = 118). Reviewing baseline data and 24-months after LVA, quality of life statistically improved (p = <0.005), as well as pain, heaviness, anxiety, impact on hobbies, work, purchasing clothes and intimacy/desirability. Mean perometer and circumferential measurements did not reduce over the 24 months. Number of days per week and hours that the patient wore compression garments did lessen and was statistically significant (p = <0.001). The quantity of cellulitis episodes captured from two years before and two years after LVA decreased from 4.22 to 0.10 (p = <0.001). Significant results (p = <0.001) were also found in a reduction in patients taking days off work due to cellulitis (5.81 to 0.16).

CONCLUSION

LVA resulted in significant improvements in patient-reported outcome measures, cellulitis episodes and reduced need for compression garments. Limb circumference via tape measure/perometer did not alter, yet the patient's quality of life considerably improved.

A spotlight on lymphoedema Did Not Attends: Demographics and workforce costs

This unique evaluation aimed to estimate, the financial impact of non-attendance on a nation-wide hospital lymphoedema service. Along with gaining some understanding of patient characteristics of those who Did Not Attend (DNA) and were subsequently discharged. The evaluation design interrogated existing performance data from 2012 to 2022. This information was used to estimate the costs incurred based on national published sources and pay scales. Staffing costs of over £1.1 m in one decade related to the financial impact of over 23 000 unattended lymphoedema appointments. The characteristics of 870 patients from 2019/2020 were also evaluated suggesting that those with a wound alongside complex lymphoedema were less likely to DNA appointments. Two-thirds of patients were managing two or more comorbidities-obesity, cardiac conditions and diabetes being the most common. It seems likely that some DNAs are avoidable by adapting appointment administrative processes and greater understanding of patients' perception of value. However, the reasons for DNA are likely to be varied and nuanced so potentially a small proportion are unavoidable. Modernising appointment processes and identifying patient value may help minimise DNA costs in the future.

Introducing the new Chronic Oedema Wet Leg Pathway

Reticence to apply compression therapy has been widely observed in clinical practice, compounded by an absence of evidenced-based pathways for application of prompt compression prior to measuring ankle brachial pressure index (ABPI). Importantly, delaying compression therapy for patients with chronic oedema and lymphorrhoea causes many avoidable complications. In 2017, Lymphoedema Network Wales (LNW) developed an evidenced-based pathway to improve the management of chronic oedema and wet legs (lymphorrhoea) for community nurses. During the past 4 years, the Chronic Oedema Wet Leg Pathway has been presented, published and used internationally, as well as being translated into different languages. It is commonly used in community nursing Teams as an evidenced-based document. However, like all documents and guidelines, when more evidence becomes available, the pathway needs updating. Therefore, this clinical focus article will present the new and enhanced Chronic Oedema Wet Leg Pathway, introducing a new level four compression section, which increases the layers of compression bandaging for patients with venous insufficiency or who are morbidly obese.