title: Analyzing cost-effectiveness of ulnar and median nerve transfers to regain forearm flexion.
abstract: OBJECTIVE Peripheral nerve transfers to regain elbow flexion via the ulnar nerve (Oberlin nerve transfer) and median nerves are surgical options that benefit patients. Prior studies have assessed the comparative effectiveness of ulnar and median nerve transfers for upper trunk brachial plexus injury, yet no study has examined the cost-effectiveness of this surgery to improve quality-adjusted life years (QALYs). The authors present a cost-effectiveness model of the Oberlin nerve transfer and median nerve transfer to restore elbow flexion in the adult population with upper brachial plexus injury. METHODS Using a Markov model, the authors simulated ulnar and median nerve transfers and conservative measures in terms of neurological recovery and improvements in quality of life (QOL) for patients with upper brachial plexus injury. Transition probabilities were collected from previous studies that assessed the surgical efficacy of ulnar and median nerve transfers, complication rates associated with comparable surgical interventions, and the natural history of conservative measures. Incremental cost-effectiveness ratios (ICERs), defined as cost in dollars per QALY, were calculated. Incremental cost-effectiveness ratios less than $50,000/QALY were considered cost-effective. One-way and 2-way sensitivity analyses were used to assess parameter uncertainty. Probabilistic sampling was used to assess ranges of outcomes across 100,000 trials. RESULTS The authors' base-case model demonstrated that ulnar and median nerve transfers, with an estimated cost of $5066.19, improved effectiveness by 0.79 QALY over a lifetime compared with conservative management. Without modeling the indirect cost due to loss of income over lifetime associated with elbow function loss, surgical treatment had an ICER of $6453.41/QALY gained. Factoring in the loss of income as indirect cost, surgical treatment had an ICER of -$96,755.42/QALY gained, demonstrating an overall lifetime cost savings due to increased probability of returning to work. One-way sensitivity analysis demonstrated that the model was most sensitive to assumptions about cost of surgery, probability of good surgical outcome, and spontaneous recovery of neurological function with conservative treatment. Two-way sensitivity analysis demonstrated that surgical intervention was cost-effective with an ICER of $18,828.06/QALY even with the authors' most conservative parameters with surgical costs at $50,000 and probability of success of 50% when considering the potential income recovered through returning to work. Probabilistic sampling demonstrated that surgical intervention was cost-effective in 76% of cases at a willingness-to-pay threshold of $50,000/QALY gained. CONCLUSIONS The authors' model demonstrates that ulnar and median nerve transfers for upper brachial plexus injury improves QALY in a cost-effective manner.
authors.affiliation: Departments of 1 Neurological Surgery and.
authors.forename: Arvin R
authors.initials: AR
authors.lastname: Wali
authors.affiliation: Radiology, University of California, San Diego, California.
authors.forename: Charlie C
authors.initials: CC
authors.lastname: Park
authors.affiliation: Departments of 1 Neurological Surgery and.
authors.forename: Justin M
authors.initials: JM
authors.lastname: Brown
authors.affiliation: Departments of 1 Neurological Surgery and.
authors.forename: Ross
authors.initials: R
authors.lastname: Mandeville
mesh_terms: D000328:Adult; D001917:Brachial Plexus / Q000293:injuries* / Q000601:surgery; D020516:Brachial Plexus Neuropathies / Q000191:economics* / Q000601:surgery; D000066491:Clinical Decision-Making / Q000379:methods; D003362:Cost-Benefit Analysis / Q000379:methods*; D005260:Female; D005542:Forearm / Q000294:innervation / Q000601:surgery; D006801:Humans; D008297:Male; D008475:Median Nerve / Q000637:transplantation*; D016067:Nerve Transfer / Q000191:economics* / Q000379:methods; D016059:Range of Motion, Articular; D014459:Ulnar Nerve / Q000637:transplantation*; D055815:Young Adult
keywords: CPT = Current Procedural Terminology; EMG = electromyography; ICER = incremental cost-effectiveness ratio; MRC = Medical Research Council; Oberlin procedure; QALY = quality-adjusted life year; QOL = quality of life; WTP = willingness-to-pay; cost-effectiveness; median nerve transfer; nerve transfer; nerve transfer surgery; peripheral nerve surgery; upper brachial plexus injury