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Hand transplantation not cost-effective

By Peter Pollack

Prosthetics more effective from a cost standpoint

Prosthetic adaptation is a more cost-effective treatment for patients who may be candidates for hand transplantation, according to data from a cost/utility study presented at the annual meeting American Society for Surgery of the Hand, by Takashi Oda, MD, PhD, of the University of Michigan.

“To date, 43 hand transplantations have been performed worldwide,” said Dr. Oda. “Graft survival and functional recovery have been achieved, but the procedure’s utility and economic impact remain uncertain.”

How much does it cost?
To assess the benefits of hand transplantation with regard to cost, the research team asked 100 medical students to complete a time trade-off survey to assess the utilities of single and double hand transplantations and the use of prosthetics or no prosthetics with regard to function, appearance, and potential complications. From that survey, the researchers were able to calculate remaining quality-adjusted life years (QALYs) for various patients.

The researchers estimated cost by drawing data from the Medicare Resource-Based Relative Value Scale, using complication costs for kidney transplant and forearm replantation procedures, which they determined to be similar to hand transplantation.

For simplicity, the only complications taken into account were diabetes and hypertension, and the researchers assumed that the complications would continue throughout a patient’s remaining life span, which was calculated at 40 years.

The researchers generated a decision tree based on various possible outcomes. Overall, use of prosthetics in unilateral procedures was associated with 30.00 QALYs, while hand transplantation was calculated to be, on average, 28.81 QALYs (p = 0.03). Hand transplantation was further broken down into major complications (23.60 QALYs), minor complications (31.20 QALYs), death (0.0 QALYs), and graft failure (29.20 QALYs).

In bilateral procedures, the use of prosthetics was calculated at 25.20 QALYs, with hand transplantation calculated at 26.73 QALYs (p = 0.01) overall, and further broken down into major complications (21.20 QALYs), minor complications (29.20 QALYs), death (0.0 QALYs), and graft failure (24.80 QALYs).

Cost over a lifetime
Based on a 40-year life span, the researchers estimated lifetime costs for prosthetic adaptation to average $14,596 unilaterally and $26,113 bilaterally. In comparison, lifetime costs for single hand transplantation were estimated to average $758,916, whereas double hand transplantation averaged $761,671.

Finally, the study authors calculated incremental cost-utility ratios (ICURs) from differences in costs and utilities between transplantation and prosthesis, and performed sensitivity analyses to assess the robustness of the results. In unilateral procedures, the combination of greater QALYs and lower expense made prosthesis the dominant option. In bilateral procedures, based only on QALYs, hand transplantation was the best option, but when researchers took cost into account, the ICUR of double transplantation compared with prostheses was $381,961/ QALY, which greatly exceeds the commonly accepted cost-effectiveness threshold of $50,000/ QALY for medical procedures.

In their study, the authors admit that cost is not the only factor that needs to be taken into account. In kidney transplants, for example, society has determined that the cost of the procedure is offset by the major increase in quality of life. Other, even more expensive, procedures such as heart and liver transplants have found wide acceptance due to a lack of alternative treatments for life-threatening conditions. However, they argue that cost is a viable consideration in hand amputation, given its non–life-threatening nature.

Dr. Oda’s co-authors in this study include: Melissa J. Shauver, MPH, and Kevin C. Chung, MD, MS. Dr. Oda reports no conflicts of interest. Dr. Chung reports ties with Stryker.

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org

AAOS Now
January 2010 Issue
http://www.aaos.org/news/aaosnow/jan10/clinical10.asp