ABSTRACT
Alexandra Tedesco, MD
Resident Physician
Tufts Medical Center
Boston, Massachusetts, United States
Cellulitis is the most common morbid complication of lymphedema (LED), but the incidence of cellulitis with LED and its relationship to the cause of LED is not well defined in a large real world population. Moreover, quantifying the contemporary financial burden of treatment, both hospital and ambulatory, is essential in developing cellulitis prevention strategies.
Methods: The IBM MarketScan® Research Database was examined from April 2013 to March 2019 for patients with a new diagnosis of LED (the index date).
Based on ICD-9/ICD-10 diagnosis codes, the incidence and cost of cellulitis were ascertained during the 3-year follow-up period. Demographic profiles, comorbidities (including previous evidence of cellulitis), and cause of LED were
characterized during the 12-month “history” period preceding the index date. Incidence rates and 95% confidence intervals [CI] (per 100 patient-years [PYs]) and cost (per patient per year) of cellulitis were evaluated on an overall basis and by care setting among all LED patients within subgroups of LED patients defined by their cause of LED.
Results: The rate of cellulitis for all LED patients (N =85.601) was 25.4/100 PYs, 95% CI = [25.1, 25.6]. Among the three most common etiologies (breast cancer related lymphedema [BCRL], N=17,954; gynecological cancer related LED [GCRL], N=1,256; and Phlebolymphedema [PLED], N=8,406), rates were markedly lower for BCRL (8.9 [8.7, 9.2]) and GCRL (14.8, [13.4, 16.4]), versus PLED (47.7, [46.7, 48.8]). Patients with a history of cellulitis had markedly higher cellulitis rates during follow-up than those without: overall, 74.0 vs. 16.4; BCRL, 42.9 [39.7, 46.3] vs. 7.6 [7.3, 7.9]; GCRL, 67.5 [56.4, 80.8] vs. 11.0 [9.8, 12.4]; and PLED 81.7 [79.4, 84.1] vs. 30.4 [29.4, 31.4] respectively. Both BCRL and GCRL had low rates of cellulitis-related hospitalization per 100 PYs (0.7 [.6, .8] and 1.6 [1.2, 2.2], respectively) compared to PLED (5.7 [5.4, 6.1]). The mean $/patient/year cellulitis-related costs for a patient sustaining one or more episodes of Cellulitis for PLED ($6348) was nearly two-fold greater than that for BCRL ($3673). This cost was increased by 36% in PLED patients ($8665) with a previous episode of cellulitis, but a lower 16% in BCRL patients ($4264).
Conclusions: The incidence of LED associated cellulitis varies based upon the etiology of the disease. PLED has the highest rates of both an initial cellulitis episode as well as a recurrent cellulitis events. In addition, PLED had not only the highest hospitalization rates but also one of the greatest Cellulitis related total cost per patient per year. Prevention, as well as early identification and treatment of PLED associated cellulitis could significantly decrease healthcare costs and improve patient quality of life.