Analyzing Cost-Effectiveness of Oberlin Nerve Transfer to Regain Forearm Flexion
Arvin Raj Wali, BA; Charlie C Park, BS; Justin M. Brown, MD; Ross Mandeville, MD
University of California, San Diego, San Diego, CA
Object:
Peripheral nerve transfers to regain elbow flexion via the ulnar and median nerve or variations of the “Oberlin nerve transfer” are surgical options that benefit patients. Prior studies have assessed the comparative effectiveness of the ulnar and median nerve transfers for upper trunk brachial plexus injury; yet no study has examined the cost-effectiveness of this surgery to improve quality of age-adjusted life years (QALY). We present a cost-effectiveness model of the Oberlin nerve transfer to restore elbow flexion for an adult population with upper brachial plexus injury.
Methods:
Using a Markov model, we simulated ulnar and median nerve transfer and conservative measures in terms of neurologic recovery and improvements in quality of life (QOL) for patients with upper brachial plexus injury. Transition probabilities were collected from prior studies assessing the surgical efficacy of ulnar and median nerve transfers, complication rates associated with comparable surgical interventions, and the natural history of conservative measures. Incremental cost-effectiveness ratios (ICER), defined as cost in dollars per QALY, were calculated. Incremental cost-effectiveness ratios less than $50,000/QALY were considered cost-effective. One-way and two-way sensitivity analyses were utilized to assess parameter uncertainty. Probabilistic sampling was utilized to assess ranges of outcomes across 100,000 trials.
Results:
Our base-case model demonstrated that Oberlin nerve transfer, with an estimated cost of $5066.19, improved effectiveness by 0.79 QALY over a lifetime compared with conservative management. Without modeling the indirect cost due to loss of income over lifetime associated with elbow function loss, surgical treatment strategy had an ICER of $6,453.41/QALY gained. Factoring in the loss of income as indirect cost, surgical treatment had an ICER of -$96,755.42/QALY gained, demonstrating an overall lifetime cost saving due to increased probability of returning to work. One-way sensitivity analysis demonstrated that the model was most sensitive to assumptions about cost of surgery, probability of good surgical outcome, and spontaneous recovery of neurologic function with conservative treatment. Two-way sensitivity analysis demonstrated that surgical intervention was cost-effective with an ICER of $18,828.06/QALY even with our most conservative parameters with surgical costs at $50,000 and probability of success of 50% when considering the potential income recovered through returning to work. Probabilistic sampling demonstrated that surgical intervention was cost-effective in 76% of cases at a willingness to pay threshold of $50,000/QALY gained.
Conclusion:
Our model demonstrates that Oberlin nerve transfer for upper brachial plexus injury improves QALY in a cost-effective manner.
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