Liposuction (lipectomy) for the treatment of fat accumulation caused by chronic lymphoedema
Health technology assessment
|Published
The Commissioning Forum RHA in “Nye Metoder” commissioned the National Institute of Public Health to assess the efficacy, safety and the health economic consequences of liposuction (lipectomy) for the treatment of chronic lymphoedema.
Key message
About 10,000 Norwegians suffer from lymphoedema which, is a chronic and progressive condition. Liposuction of patients with fat accumulations caused by chronic lymphoedema may be a relevant method for patients experiencing this complication.
Liposuction for fat accumulation caused by chronic lymphoedema involves the use of suction to remove excess adipose tissue in limbs affected by lymphoedema. The method for this indication is not a treatment option in Norway today.
The Commissioning Forum RHA in “Nye Metoder” commissioned the National Institute of Public Health to assess the efficacy, safety and the health economic consequences of liposuction (lipectomy) for the treatment of chronic lymphoedema.
We found no comparative studies. We disseminated a NICE report from 2017 with summarized findings from eight patient series with a total of 649 patients. The evidence regarding effect and safety is therefore very uncertain.
The health economic model is based on uncertain input parameters but suggests that patients with fat accumulation caused by chronic lymphoedema may benefit from liposuction. The incremental effectiveness can be estimated to about 0,29 QALYs (Quality-Adjusted Life Years). Cost per QALY gain is estimated to between NOK 129,000 and NOK 315,000. This estimate is uncertain and must be interpreted with great caution.
Summary
Introduction
Lymphoedema is a chronic and progressive condition that affects about 10,000 Norwegians. Liposuction may be an appropriate treatment method in patients who have had inadequate or not responded to conventional treatment and have developed fat accumulation caused by chronic lymphoedema. This is estimated to be up to 20 patients in Norway, annually. Liposuction in treatment of fat accumulation caused by chronic lymphoedema involves the use of suction to remove excess fat tissue in limbs affected by lymphoedema. The method has not been used in Norway for this indication.
Method
We have prepared a rapid health technology assessment. We planned to include a systematic overview of efficacy, safety and a health economic analysis of liposuction in combination with conventional treatment of patients with fat accumulation caused by chronic lymphoedema compared to conventional treatment. As we did not identify newer research papers with a literature search after May 2017, we present the results from NICE interventional procedure overview, from 2017.
Our health economic analysis consisted of a cost-effectiveness analysis and a budget impact assessment.
We developed a straightforward Markov model with three health conditions: “fat accumulation in limb”, “fat accumulation removed/reduced” and “general mortality” (not treatment related). In our cost-effectiveness analysis, we included only women with a mean age of 64, who were diagnosed with chronic lymphoedema. We used the Markov model to estimate absolute shortfall for this population. We also assessed the budgetary consequences of adopting the implementation of liposuction for patients with fat accumulation caused by chronic lymphoedema at population level.
Results
We did not identify any studies that were comparing conventional treatment with and without liposuction. We therefore present the report “Interventional procedure overview of liposuction for chronic lymphoedema”. The report was published in May 2017, with the aim of helping members of the Interventional Procedures Advisory Committee (IPAC) to provide advice on the safety and efficacy of this procedure. The report contains a rapid overview of medical literature and experiences from invited specialists. None of the studies compared liposuction in combination with conventional treatment and conventional treatment only. The studies did include both primary and secondary lymphoedema, and lymphoedema in both arm and leg. The studies did not make any distinctions between these groups in the presentation of the outcomes. The NICE report can therefore not be used to conclude on the effectiveness or safety of liposuction for a specific situation.
We estimated absolute shortfall and found that patients with fat accumulation caused by chronic lymphoedema end up in severity class group 1, given that they are 64 years old. Our base case analysis shows that the costs associated with liposuction per patients are approximately NOK 89,000 higher than conventional treatment. However, efficacy is also higher in a patient undergoing liposuction in combination with conventional treatment, rather than conventional treatment only. The incremental effectiveness is 0.28 QALYs (Quality Adjusted Life Years). ICER is estimated to be about NOK 315,000 per QALY.
In our scenario analysis, we used physiotherapy consultation cost from the primary health care instead of the physiotherapy consultation cost from specialist health care (hospitals) in year 3-5. Further, we assumed that patients who had undergone liposuction in combination with conventional treatment would need fewer consultations than patients who had only been treated by conventional treatment in year 3-5 after treatment start. Conventional treatment only had a higher cost in the scenario analysis, compared to the cost in the base case analysis (approx. NOK 355,000) and the cost associated with liposuction in combination with conventional treatment had a lower cost in the scenario analysis compared to the cost in the base case analysis (approx. NOK 383,000). The incremental effectiveness of liposuction in combination with conventional treatment was somewhat higher in the scenario analysis compared to the base case analysis (0.30 QALYs). ICER was therefore estimated to be about NOK 129,000 per QALY in our scenario analysis.
Our budget impact assessment implies that the introduction of liposuction for treatment of 20 patients with fat accumulation caused by chronic lymphoedema can result in additional costs of about NOK 3.6 million in the first year after implementation. In year five, the additional cost may be about NOK 5 million for 20 new patients treated with liposuction in combination with conventional treatment, including 80 patients who receive maintenance therapy after having been treated with liposuction one of the previous years.
Discussion
We did not identify any studies comparing conventional treatment with and without liposuction for patients with fat accumulation caused by chronic lymphoedema. One reason for this may be that in some countries the conventional treatment of this patient group is not the same as in Norway. Another reason may be that liposuction is not offered to patients with chronic lymphoedema. A third reason may be that the effect itself is so obvious that “with vs. without”-comparisons are not worth the effort.
NICE’s procedure report from 2017 may indicate that there are more considerations about different surgical methods, different use of equipment or antibiotics during the implementation of liposuction.
Our health economic analysis did only include women aged 64 to 69 with fat accumulation in the arm caused by chronic lymphoedema, as we found the most relevant input data for this patient group.
Conclusion
The report from NICE only provides highly uncertain evidence about the effectiveness and safety of liposuction for patients with fat accumulation caused by chronic lymphoedema
Based on the uncertain input parameters, the health economic model suggests that patients with fat accumulation caused by chronic lymphoedema who receive liposuction in combination with conventional treatment, instead of conventional treatment only, may get an incremental effectiveness between 0.28 and 0.30 QALYs. Cost per QALY is estimated to be between NOK 129,000 and NOK 315,000. The additional cost of introducing liposuction in combination with conventional treatment for 20 patients with fat accumulation caused by chronic lymphoedema would be about NOK 3.6 million the first year after introduction, and about NOK 5 million five year later. It also appears that patients aged 64, with fat accumulation caused by chronic lymphoedema belong to severity class 1.
