2009 Annual Meeting Posters

A Cost-Utility Analysis of Reconstruction vs Amputation for the Treatment of Type IIIB and IIIC Tibial Fractures
Hypothesis: The appropriate management of severe open tibial fractures remains uncertain. Although reconstruction is often the primary choice of surgeons, the literature has shown no evidence to support better outcomes following reconstruction over below-knee amputation. Furthermore, there is varying information regarding the cost differential of these two treatment options. In the short-term it appears that amputation is less costly, but data indicates that reconstruction is the less costly long-term option. We hypothesize that when cost data is combined with utility data, reconstruction will emerge as the dominant strategy for treatment of type IIIB and IIIC tibial fractures.
Methods: Reconstructive microsurgeons and physical medicine physicians completed a web-based standard gamble utility survey comparing reconstruction and primary amputation, along with their associated complications, with rates derived from the literature. A decision tree was constructed to generate quality-adjusted life years (QALYs). Cost data was derived from the Center for Medicare & Medicaid Services’ Physician Fee Schedule, as well as from the established literature. QALYs were then divided into cost data to produce cost per QALY for each treatment option.
Results: The decision tree showed a slight preference for reconstruction over amputation, with reconstruction garnering 33.93 QALYs and amputation 33.38 QALYs. Acute procedural costs averaged $3713 for reconstruction and $1096 for primary amputation. When combined with utility information this indicates a cost of $109/QALY for reconstruction and $32/QALY for amputation. Although reconstruction was slightly preferred by measurement of utility, it comes at a higher acute cost. However, long-term cost after 2 years for reconstruction and amputation were $85,088 and $86,244, respectively. In this case, the costs per QALY calculate to $2,508/QALY for reconstruction and $2,584/QALY for amputation. This long-term perspective indicates that for type IIIB and IIIC tibial fractures reconstruction is the dominant strategy. (Figure 1)
Conclusions: This study confirms that surgeons have frequently been implementing the dominant long-term treatment strategy for this injury. This information can be used to guide patient decision-making after this devastating injury.