Wednesday, September 22, 2010

Cost of Hand Transplantation?

The recent double hand transplant and catching up on my journal reading has prompted me to look into the cost of hand transplantation. My personal identity seems to me to be tied up in my hands. I am a surgeon. I cook for my husband. I am a quilter.

I have at times tried to imagine loosing a finger or a hand. It difficult to the point of almost being unimaginable for me. Which hand would I give up? Which digit?

I am so right handed, I find it difficult to brush my teeth using my left hand. Yes, I could learn in time. Same with using a pen. Even my limited use of my left arm when I had olecranon bursitis brings my dependency on my hands/arms into sharp focus. It was humbling.

The PRS article (first reference) in assigning utility surveyed participants asking them “to imagine as vividly as possible that they had experienced an amputation of the dominant hand or bilateral hand amputations.”

For example, our survey asks the respondent to choose between living for 40 years with a prosthetic hand and living for x years with a healthy hand. The value of x is varied until the respondent feels that the choices are equivalent. If the respondent judges that living for 40 years with a prosthetic hand is equivalent to living for 20 years with a healthy hand, the utility of living with a prosthetic hand is calculated as 20/40, or 0.50.

I have yet to decide what my answer would be. The article survey of 100 second-year, third-year, and fourth-year University of Michigan Medical School students determined utility as follows:

Transplantation with minor complications (unilateral = 0.78; bilateral = 0.73)

Transplantation with major complications (unilateral = 0.59; bilateral = 0.53)

Prosthetic device use (unilateral 0.75; bilateral 0.63)

Emotionally most would agree that hand transplantation is a worthy goal. Physically, it is possible. The outcome is not always as good as envisioned. Never is the transplanted hand as functional as a non-injured hand. Never.

The function of a transplanted hand has been found to be similar to a replanted hand.

to put it in the words of one physician from the Louisville team that performed the first U.S. hand transplant, the patient will likely “have difficulty with buttons, perhaps not be able to pick up a dime.”

Gerald Fisher, the second of the Louisville recipients, returned to work hanging gutters just two months after his operation
According to the Lyon team, the world’s first double-hand transplant recipient is able to shave and take care of other personal hygiene tasks that he was unable to do before his transplant

With much physical/occupation therapy afterwards, the transplanted hand can be functional. It’s not likely I would be able to pick up a needle to sew/hand quilt again, but I would be able to brush my hair and teeth.

The ethics of a non-life threatening diagnosis (loss of one or both hands) being treated with a procedure that requires immunosuppressive drugs for life is still being debated and should be. From the PRS article (first reference)

The toxicity of immunosuppressive medication, however, brings about an ethical dilemma. In solid organ transplantation, 40 percent of posttransplant deaths were attributed to infection; transplant recipients have a seven-fold 5-year risk over the general population of developing malignancies.

This all brings us back to the actual costs of hand transplantation which is very difficult to determine though Dr. Oda and colleagues have done a good job in attempting to do so. I think they may have underestimated the costs.

Lifetime costs for single hand transplantation average $528,293, whereas costs for double hand transplantation average $529,315.

Total costs of prosthesis adoption for unilateral and bilateral amputation are $20,653 and $41,305, respectively.

The mean surgical cost, including preoperative evaluation, hospitalization, and physician fee, are $13,796 for single hand transplantation and $14,608 for double hand transplantation.

The cost of immunosuppressive therapy for 40 years, including drugs and clinic visit, is $433,283 ($362,894-503,672).

The cost of productivity loss for hand transplantation and prosthetic adaptation are $42,265 and $9753, respectively.

Oda and colleagues doubled the traditionally cost-effectiveness threshold of $50,000/QALY (employed based on the acceptance of kidney transplantation) to $100,000 for their analysis.

For unilateral hand amputation, prosthetic use was favored over hand transplantation (30.00 QALYs versus 28.81 QALYs; p = 0.03).

Double hand transplantation was favored over the use of prostheses (26.73 QALYs versus 25.20 QALYs; p = 0.01). The incremental cost-utility ratio of double transplantation when compared with prostheses was $381,961/QALY, exceeding the accepted cost-effectiveness threshold of $100,000/QALY.

As pointed out by Dr. Concannon in the discussion of Oda’s article, I and others can muse all we want but it will most likely ultimately be out of our hands.

Ultimately, while the costs and worthiness of this technique may be debated in scientific journals, it will certainly not be decided in them. There are industry and governmental agencies with far sharper pencils than we have that will look very closely at the cost-benefit ratio before deciding whether this will be an acceptably “covered” procedure for their respective constituents. Perhaps the biggest hurdle in the implementation of limb transplantation will involve mastery not of the immune system but of actuarial tables.

REFERENCES

An Economic Analysis of Hand Transplantation in the United States; Chung, Kevin C.; Oda, Takashi; Saddawi-Konefka, Daniel; Shauver, Melissa J.; Plastic & Reconstructive Surgery. 125(2):589-598, February 2010.; doi: 10.1097/PRS.0b013e3181c82eb6

Discussion: An Economic Analysis of Hand Transplantation in the United States; Concannon, Matthew J.; Plastic & Reconstructive Surgery. 125(2):599-600, February 2010.; doi: 10.1097/PRS.0b013e3181c831e5

Hand transplantation not cost-effective; AAOS Now, January 2010 Issue; Peter Pollack

Hand Transplantation; Brown University Biomed Course Info (2001); accessed September 15, 2010

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