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.
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
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.
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.
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.
REFERENCESUltimately, 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.