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 $31,330.78. Survival was 73% for medical prevention versus 95% for surgery.
Conclusion: These results suggest that among patients with diabetic neuropathy and superimposed nerve compression, surgery is more effective at preventing serious comorbidities and is associated with a higher survival over time. It also generated greater long-term economic benefits.
| Table 1. Baseline cohort simulation results comparing the incidence of foot ulcers over 5 years by risk group between the two strategies at 80% and 25% reduction. The total number of ulcers and amputations that would be prevented by surgery is shown. | |||
| Current Prevention | Tibial Neurolysis | ||
| Foot ulcers by risk group | 80% | 25% | |
| 1—Low risk | 133 | 26 | 103 |
| 2—At risk | 2099 | 652 | 1825 |
| 3—Increased risk | 1892 | 645 | 1721 |
| 4—High risk | 5286 | 2705 | 5382 |
| Total ulcers prevented | - | 5382 | 379 |
| Total amputations prevented | - | 2154 | 932 |
| Cohort n=10,000. | |||
| Table 2. Cost effectiveness rankings. | ||||||
| Strategy | Cost ($) | Incremental Cost ($) | Effect (QALY) | Incremental Effect (QALY) | ICER ($/QALY) | Net Monetary Benefit |
| Current Prevention | 22,751.27 | 5.90 | 566,766.25 | |||
| Tibial Neurolysis | 35,523.55 | 12,772.28 | 6.30 | 0.41 | 31,330.78 | 594,759.88 |
| 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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