American Association of Plastic Surgeons

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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 PreventionTibial Neurolysis
Foot ulcers by risk group80%25%
1—Low risk13326103
2—At risk20996521825
3—Increased risk18926451721
4—High risk528627055382
Total ulcers prevented-5382379
Total amputations prevented-2154932
Cohort n=10,000.

Table 2. Cost effectiveness rankings.
StrategyCost ($)Incremental Cost ($)Effect (QALY)Incremental Effect (QALY)ICER ($/QALY)Net Monetary Benefit
Current Prevention22,751.275.90566,766.25
Tibial Neurolysis35,523.5512,772.286.300.4131,330.78594,759.88
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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