A mathematical risk-benefit analysis of composite tissue allotransplantation.
BACKGROUND
Composite tissue allotransplantation (CTA) represents a surgical technology whose risks and benefits are unclear. This is problematic for clinicians with respect to patient selection and counseling, and for policy makers in evaluating its merits. Our analysis represents a mathematical approach to risk and benefit estimation in CTA.


METHODS
A Markov model was created to represent clinical and immunological outcomes after CTA. Esthetic outcomes were incorporated into the model by creating a disfigurement-related-disability severity score index based on existing literature. Composite tissue allotransplantation in a 30-year-old male was used as a base case analysis. We compared CTA against autogenous reconstruction as competing strategies. Sensitivity analyses were performed on the effect of preoperative esthetic morbidity and postoperative esthetic outcome.


RESULTS
Our base-case showed CTA to be the preferred strategy-conferring a benefit of 4.47 esthetic-outcome-adjusted life years. Sensitivity analyses showed CTA to be the preferred strategy if the preoperative disability severity score was greater than 5, and if the severity score after autogenous reconstruction was greater than 7.


CONCLUSIONS
Our model estimates a theoretical risk-benefit threshold for CTA. The model itself can be refined as clinical experience with CTA grows and can incorporate economic and quality-of-life parameters.
Khan
Aadil A
AA
Harvard School of Public Health, Harvard University, Boston, MA, USA.
Diver
Andrew J
AJ
Clarke
Alex
A
Butler
Peter E M
PE
D006801:Humans; D008390:Markov Chains; D008433:Mathematics; D011788:Quality of Life; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D016378:Tissue Transplantation / Q000009:adverse effects; D014184:Transplantation, Homologous / Q000009:adverse effects; D016896:Treatment Outcome