Pediatric Hand Transplantation: A Decision Analysis

Abstract

Background: The first successful bilateral pediatric hand transplant was performed in 2015. Previous hand transplant decision analysis models have focused on the adult population. This model principally aimed to determine whether adverse outcomes associated with immunosuppression outweigh the benefits of performing bilateral hand transplant surgery in a pediatric candidate. The model also conceptualized the valuation of losing years of life and sought to determine the impact of that valuation on the surgical decision. Methods: A decision model compared undergoing bilateral hand transplant surgery with using prosthetics for an 8-year-old patient. The outcome measure used was quality adjusted life years (QALYs), and sensitivity analysis was performed on the immunosuppressive risks associated with the surgical decision, as well as the perceived valuation of aversion to life years lost. Results: The decision to perform surgery was marginally optimal compared to the prosthetic decision (50.11 QALY vs. 47.95 QALY). A Monte Carlo simulation revealed that this difference may be too marginal to detect an optimal decision (50.14 ± 8.28 QALY vs. 47.95 ± 2.12 QALY). Sensitivity analysis identified decision thresholds related to immunosuppression risks (P = 29% vs. P = 33% modeled), and a trend of increasing risk as a patient is more averse to losing life years. Conclusions: The marginally optimal treatment strategy currently is bilateral hand transplant, compared to prosthetics for pediatric patients. Key determinants of the future optimal strategy will be whether immunosuppressive regimens become safer, with a reduced risk of losing life years due to immunosuppressive complications, and whether prosthetics become more acceptable and enable higher functioning.

Keywords: decision analysis; hand transplantation; pediatric; vascular composite allograph.

Figure 1.

Model decision tree structure.

Figure 2.

One-way sensitivity analysis on the number of life years lost due to a major adverse outcome. A significant threshold was identified at 8.07 (48 QALY), where if the lifespan is shortened by more than 8.3 years, prosthetics are the favorable decision. QALY = quality adjusted life year.

Figure 3.

One-way sensitivity analysis on the number of years in the life expectancy, assuming an age of 8 at the decision. A significant threshold is identified at 44.58 years, where once added to the age of decision (8), shows that the patient must live to the age of 52.58 in order for the transplant to be the preferred option. QALY = quality adjusted life year.

Figure 4.

A one-way sensitivity analysis of the probability of developing a major adverse outcome. A significant threshold was identified at 0.3 (48 QALY), where if the probability of developing a major adverse outcome exceeds 30%, then prosthetics are the favorable option. QALY = quality adjusted life year.

Figure 5.

One-way sensitivity analysis on the probability of developing a major adverse outcome, with 5 aversion weights. As the patients (and their family) are more averse to trading life years, the probability of developing a major adverse outcome must decrease in order for surgery to remain the favorable decision. QALY = quality adjusted life year.