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Purpose: Finger replantation has become commonplace in hand and reconstructive surgery. Thumb replantation and multiple digit replantation are clear indications for replantation in adults. However, the societal impact of marginal indications for replantation, such as in fingertip amputations, is not clearly understood. The purpose of this study was to perform an economic analysis of finger amputation treatment comparing revision amputation and replantation. Specifically, we studied the impact of patient preference, cost of treatment, complications, and injury characteristics on overall cost and utility in order to compare instances in which replantation is clearly indicated to scenarios in which replantation is not standardly performed.
Methods: We developed a base case decision analysis model containing the most common health states associated with revision amputation and replantation. Probabilities of health states were estimated from an extensive literature review. The cost of each health state was estimated by Medicare reimbursement for direct health costs and indirect health costs. We designed a time trade-off questionnaire to evaluate 21 health states associated with both treatments. Health states included complications, long-term sequelae of treatments without complications, and variations in injury patterns. 685 individuals belonging to a nationally representative panel of US households were invited to participate. Each respondent received 8 scenarios to rate. The mean remaining quality adjusted life years (QALYs) were calculated from the mean duration of time that respondents were willing to trade from the end of their life to avoid each scenario. Incremental cost-effectiveness ratios (ICERs) were calculated for a treatment if it was more effective but more costly.
Results: We had a 64% response rate, with 437 survey respondents participating in the survey. Replantation was more costly in all scenarios. However, in each scenario patients preferred replantation of finger amputations when compared to revision amputation (Table 1). $50,000 is a commonly cited threshold for cost-effective treatments. With this standard, proximal and distal thumb replantation and multiple finger replantation were found to be cost-effective, whereas two digit fingertip replantation and single (index) finger proximal replantation were not cost-effective when compared to revision amputation treatment. Replantation of single-finger amputations had the greatest ICER among all injury scenarios studied.
Conclusions: Our findings reflect societal preferences based on sampling representative of the US population. In our sample, scenarios in which replantation is clearly indicated were also cost-effective, including replantation of proximal thumb and multiple-finger amputations. The finding of single finger replantation being the least cost-effective scenario supports the current practice of not performing replantation for single-digit amputations in adults. Further understanding of preferences in other cultures would help to understand how US preferences differ from other groups, such as in Asian populations where integrity of bodily structures may be viewed differently. Better understanding of perceived preference for various clinical scenarios surrounding finger amputation injuries can help to guide policy, inform decision-making, and to counsel patients at the time of injury.