Abstract
Traumatic digit amputation is the most common type of amputation injury, but the cost-effectiveness of its treatments is unknown. To assess the cost-effectiveness of finger replantation compared with revision amputation. This economic evaluation was conducted using data from the Finger Replantation and Amputation Challenges in Assessing Impairment, Satisfaction, and Effectiveness (FRANCHISE), a retrospective, multicenter cohort study at 19 centers in the United States and Asia that enrolled participants from August 1, 2016, to April 12, 2018. Model variables were based on the FRANCHISE database, Centers for Medicare & Medicaid Services, and published literature. A total of 257 participants with unilateral traumatic finger amputations treated with revision amputation or replantation distal to the metacarpophalangeal joint and at least 1 year of follow-up after treatment were included in the analysis. Revision amputation or replantation of traumatic finger amputations. Main outcome measures were quality-adjusted life-years (QALYs), total costs (in US dollars), and incremental cost-effectiveness ratios (ICERs). A willingness-to-pay threshold of $100 000 per QALY was used to assess cost-effectiveness. Of the 257 study participants (mean [SD] age, 46.7 [15.9] years; 221 [86.0%] male), 178 underwent finger replantation and 79 underwent revision amputation. In a base case of a 46.7-year-old patient, replantation was associated with QALY gains of 0.30 (95% credible interval [CrI], -0.72 to 1.38) for single-finger (not thumb), 0.39 (95% CrI, -1.00 to 1.90) for thumb, 1.69 (95% CrI, -0.13 to 3.76) for multifinger excluding thumb, and 1.27 (95% CrI, -2.21 to 5.04) for multifinger including thumb injury patterns. Corresponding ICERs for replantation compared with revision amputation were $99 157 per QALY for single-finger (not thumb), $66 278 per QALY for thumb, $18 388 per QALY for multifinger excluding thumb, and $21 528 per QALY for multifinger including thumb injury patterns. Sensitivity analysis revealed that age at time of injury, life expectancy, postinjury utility, wages, and time off work for recovery had the strongest associations with cost-effectiveness. Probabilistic sensitivity analysis revealed the following chances of replantation being cost-effective: 47% in single-finger (not thumb), 52% in thumb, 78% in multifinger excluding thumb, and 64% in multifinger including thumb injury patterns. With proper patient selection, replantation of all finger amputation patterns, whether single-finger or multifinger injuries, may be cost-effective compared with revision amputation. Multifinger replantations had a higher probability of being cost-effective than single-finger replantations. Cost-effectiveness may depend on injury pattern and patient factors and thus appears to be important for consideration when patients and surgeons are deciding whether to replant or amputate.
Highlights
Traumatic finger amputation represents more than 90% of all amputations in the United States and has a yearly incidence of 45 000.1,2 This injury disproportionately affects younger working class individuals who incur considerable economic burden and disability.[3,4] Traumatic finger amputations are treated with replantation or revision amputation
In a base case of a 46.7year-old patient, replantation was associated with quality-adjusted life-year (QALY) gains of 0.30 (95% credible interval [CrI], −0.72 to 1.38) for single-finger, 0.39 (95% CrI, −1.00 to 1.90) for thumb, 1.69 (95% CrI, −0.13 to 3.76) for multifinger excluding thumb, and 1.27 (95% CrI, −2.21 to 5.04) for multifinger including thumb injury patterns
Corresponding incremental cost-effectiveness ratio (ICER) for replantation compared with revision amputation were $99 157 per QALY for single-finger, $66 278 per QALY for thumb, $18 388 per QALY for multifinger excluding thumb, and $21 528 per QALY for multifinger including thumb injury patterns
Summary
Traumatic finger amputation represents more than 90% of all amputations in the United States and has a yearly incidence of 45 000.1,2 This injury disproportionately affects younger working class individuals who incur considerable economic burden and disability.[3,4] Traumatic finger amputations are treated with replantation or revision amputation. Revision amputation shortens the finger while achieving wound closure; this mode of treatment is less costly, is less complex, and requires less postoperative therapy than replantation. Previous studies[4,5,6,7,8,9] have evaluated the clinical outcomes associated with replantation and revision amputation. The only economic analysis comparing the 2 treatments is reported in the study by Sears et al,[10] in which a decision tree model based on a time trade-off survey of healthy individuals was used. That study[10] concluded that the number of fingers amputated is substantially associated with the cost-effectiveness of replantation. A limitation of that study was that the time trade-off survey was based on a healthy population, which may have biased and inaccurately assessed disease burden. Given the increasing scrutiny of health care expenditures and pressure to attain maximal clinical efficacy with minimal expense, cost-effectiveness is essential to consider in clinical practice
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