An economic analysis of hand transplantation in the United States

Abstract

Background: Hand transplantation has received international attention in recent years; however, the economic impact of this innovative treatment is uncertain. The aim of this study was to assess the utility and estimate the costs of hand transplantation and the use of hand prostheses for forearm amputations.

Methods: One hundred medical students completed a time trade-off survey to assess the utilities of single and double hand transplantation and the use of hand prostheses. Quality-adjusted life years (QALYs) were calculated for each outcome to create decision trees. Cost data for medical care were estimated based on Medicare fee schedules using the Current Procedural Terminology code for forearm replantation. The cost of immunosuppressive therapy was estimated based on the wholesale price of drugs. The incremental cost-utility ratio was calculated from the differences in costs and utilities between transplantation and prosthesis. Sensitivity analyses were performed to assess the robustness of the results.

Results: For unilateral hand amputation, prosthetic use was favored over hand transplantation (30.00 QALYs versus 28.81 QALYs; p = 0.03). Double hand transplantation was favored over the use of prostheses (26.73 QALYs versus 25.20 QALYs; p = 0.01). The incremental cost-utility ratio of double transplantation when compared with prostheses was $381,961/QALY, exceeding the traditionally accepted cost-effectiveness threshold of $50,000/QALY.

Conclusions: Prosthetic adaption is the dominant strategy for unilateral hand amputation. For bilateral hand amputation, double hand transplantation exceeds the societally acceptable threshold for general adoption. Improvements in immunosuppressive strategies may change the incremental cost-utility ratio for hand transplantation.

Figure 1

QALY calculation

Figure 2

ICUR calculation

Figure 3

Decision tree for unilateral hand amputation

Figure 4

Decision tree for bilateral hand amputation

Figure 5

A sensitivity analysis varying the rate of major complications for bilateral hand transplantation

Figure 6

A sensitivity analysis varying the expected utility of bilateral hand transplantation