Candidate for the Lee B. Lusted Student Prize Competition
Purpose: Ulnar neuropathy at the elbow (UNE) is the second most common compressive neuropathy of the upper extremity, but the most optimal treatment for this disease is uncertain. We performed a cost-utility analysis for four different surgical treatments for UNE.
Methods: A cost-utility analysis was performed from the societal perspective. A decision analytic model was designed comparing 4 surgical treatment strategies: (a) simple decompression followed by a salvage surgery (anterior submuscular transposition) for a bad outcome; (b) anterior subcutaneous transposition followed by a salvage surgery for a bad outcome; (c) medial epicondylectomy followed by a salvage surgery for a bad outcome; and (d) anterior submuscular transposition. A bad outcome after anterior submuscular transposition as the initial surgery was considered an end-point in the model. Preferences for temporary health states for UNE, the surgeries, and surgical complications were elicited through a time trade-off survey administered to a convenience sample of 102 caregivers accompanying patients to physician visits. Probabilities of clinical outcomes and complications were derived from a Cochrane Collaboration meta-analysis and a systematic MEDLINE and EMBASE search of the medical literature. Costs (2009 U.S. dollars) were derived from Medicare reimbursement rates. The model estimated quality-adjusted life-years (QALYs) and costs for a 3-year time horizon. A 3% annual discount rate was applied to costs and QALYs. Incremental cost-effectiveness ratios (ICERs) were calculated. Sensitivity analyses were performed to evaluate the effect of uncertainty for input parameters on model results.
Results: In the reference-case analysis, simple decompression as an initial procedure was the most effective treatment strategy (Table 1). Multi-way sensitivity analyses varying the preferences for the surgeries supported the robustness of the results. A model structure sensitivity analysis was also performed with a surgical re-exploration following a bad outcome for an initial anterior submuscular transposition. Under all evaluated scenarios, simple decompression yielded cost-effectiveness ratios less than $2,031/QALY.
Conclusions: These results suggest simple decompression surgery as an initial treatment option is the preferred option for treating UNE and is cost-effective according to commonly-used cost-effectiveness thresholds. However, further studies are needed to better understand whether the marginal differences in effectiveness are clinically significant.
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