Tibial Nerve Decompression for the Prevention of the Diabetic Foot: A Cost-Utility Analysis Using Markov Model Simulations
Samuel Sarmiento, MD, MPH, MBA1, Kevin D. Frick, PhD2, A Lee Dellon, MD, PhD1.
1Johns Hopkins University School of Medicine, Baltimore, MD, USA, 2Johns Hopkins University School of Business, Baltimore, MD, USA.
Purpose: We examined whether tibial neurolysis performed as a surgical intervention for patients with diabetic neuropathy and superimposed tibial nerve compression in the prevention of the diabetic foot is cost saving when compared to the current prevention program.
Methods: A Markov model was used to simulate the effects of standard prevention compared to tibial neurolysis on the long-term costs associated with foot ulcers and amputations. This model included eight health states. A baseline analysis was built on a five-year model to determine the cumulative incidence of foot ulcers and amputations. Subsequently, a cost-effectiveness analysis and cohort-level Markov simulations were conducted with a model composed of 20 six-month cycles. A sensitivity analysis was also performed.
Results: For a patient population of 10,000, surgery prevented a total of 1,447 ulcers and 409 amputations. The incremental cost of surgery was $12,772.28; the incremental effectiveness was 0.41 QALYs; and the incremental cost-effectiveness ratio (ICER) was $31,330.78. Survival was 73% for medical prevention versus 95% for surgery.
Conclusion: These results suggest that among patients with diabetic neuropathy and superimposed nerve compression, surgery is more effective at preventing serious comorbidities and is associated with a higher survival over time. It also generated greater long-term economic benefits.
|Table 1. Baseline cohort simulation results comparing the incidence of foot ulcers over 5 years by risk group between the two strategies at 80% and 25% reduction. The total number of ulcers and amputations that would be prevented by surgery is shown.|
|Current Prevention||Tibial Neurolysis|
|Foot ulcers by risk group||80%||25%|
|Total ulcers prevented||-||5382||379|
|Total amputations prevented||-||2154||932|
|Table 2. Cost effectiveness rankings.|
|Strategy||Cost ($)||Incremental Cost ($)||Effect (QALY)||Incremental Effect (QALY)||ICER ($/QALY)||Net Monetary Benefit|
|Costs in US dollars. Net monetary benefit uses a willingness-to-pay of $100,000. QALY, quality-adjusted life years. ICER, incremental cost-effectiveness ratio.|
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