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Tibial nerve decompression for the prevention of the diabetic foot: a cost-utility analysis using Markov model simulations.

ABSTRACT: OBJECTIVE:To determine 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-effective when compared with the current prevention programme. DESIGN:A baseline analysis was built on a 5-year model to determine the cumulative incidence of foot ulcers and amputations with each strategy. Subsequently, a cost-effectiveness analysis and cohort-level Markov simulations were conducted with a model composed of 20 6-month cycles. A sensitivity analysis was also performed. SETTING:A Markov model was used to simulate the effects of standard prevention compared with tibial neurolysis on the long-term costs associated with foot ulcers and amputations. This model included eight health states. PARTICIPANTS:Each cohort includes simulated patients with diabetic neuropathy at different levels of risk of developing foot ulcers and amputations. PRIMARY AND SECONDARY OUTCOME MEASURES:The primary outcome was the long-term trends concerning the development of ulcers and amputations with each strategy. The secondary outcome measures were quality adjusted life years (QALYs), incremental cost-effectiveness and net monetary benefits of the optimal strategy. RESULTS:When compared with standard prevention, for a patient population of 10 000, surgery prevented a simulated total of 1447 ulcers and 409 amputations over a period of 5 years. In a subsequent analysis that consisted of 20 6-month cycles (10 years), the incremental cost of tibial neurolysis compared with current prevention was $12 772.28; the incremental effectiveness was 0.41 QALYs and the incremental cost-effectiveness ratio was $31?330.78. Survival was 73% for those receiving medical prevention compared with 95% for those undergoing 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.

SUBMITTER: Sarmiento S

PROVIDER: S-EPMC6429851 | biostudies-literature | 2019 Mar

REPOSITORIES: biostudies-literature

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Tibial nerve decompression for the prevention of the diabetic foot: a cost-utility analysis using Markov model simulations.

Sarmiento Samuel S Pierre James A JA Dellon A Lee AL Frick Kevin D KD

BMJ open 20190315 3

<h4>Objective</h4>To determine 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-effective when compared with the current prevention programme.<h4>Design</h4>A baseline analysis was built on a 5-year model to determine the cumulative incidence of foot ulcers and amputations with each strategy. Subsequently, a cost-effectiveness analysis and cohort-level Mark ...[more]

PMID: 30878982

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Project description:BackgroundEconomic evaluation of school-based obesity interventions could provide support for public health decision of obesity prevention. This study is to perform cost-utility and cost-benefit assessment of three school-based childhood obesity interventions including nutrition education intervention (NE), physical activity intervention (PA) and comprehensive intervention (both NE and PA, CNP) with secondary data analysis of one randomized controlled trial.MethodsThe standard cost-effectiveness analysis methods were employed from a societal perspective to the health outcome and costs that are attributable to the intervention. NE, PA and CNP were carried out separately for 2 semesters for childhood obesity interventions in primary schools. The additional quality-adjusted life years (QALYs) resulting from the interventions were measured as the health outcome. A cost-utility ratio (CUR) and A cost-benefit ratio (CBR) was calculated as the ratio of implementation costs to the total medical and productivity loss costs averted by the interventions.ResultsThe CUR and CBR were ¥11,505.9 ($1646.0) per QALY and ¥1.2 benefit per ¥1 cost respectively, and the net saving was ¥73,659.6 ($10,537.9). The CUR and CBR for nutrition education and physical activity interventions were ¥21,316.4 ($3049.6) per QALY and ¥0.7 benefit per ¥1 cost, ¥28,417.1 ($4065.4) per QALY and ¥0.4 benefit per ¥1 cost, respectively (in 2019 RMB). Compared with PA intervention, the ICERs were ¥10,335.2 ($1478.6) and 4626.3 ($661.8) for CNP and NE respectively. The CBR was ¥1.2, 0.7, and 0.4 benefits per ¥1 cost for CNP, NE, and PA interventions, respectively. Net estimated savings were achieved only through CNP intervention, amounting to ¥73,659.6 ($10,537.9).ConclusionsComprehensive school-based obesity intervention is a beneficial investment that is both cost-effective and cost saving. Compared with PA intervention, both CNP and NE intervention were more cost-effective.

Project description:Background and objectiveUnipolar depression is the most common form of depression and demand for treatment, such as psychotherapy, is high. However, waiting times for psychotherapy often considerably exceed their recommended maximum. As a potentially less costly alternative treatment, internet-based cognitive behavior therapy (ICBT) might help reduce waiting times. We therefore analyzed the cost-utility of ICBT compared to face-to-face CBT (FCBT) as an active control treatment, taking differences in waiting time into account.MethodsWe constructed a Markov model to simulate costs and health outcomes measured in quality-adjusted life years (QALYs) for ICBT and FCBT in Germany. We modeled a time horizon of 3 years using six states (remission, depressed, spontaneous remission, undergoing treatment, treatment finished, death). The societal perspective was adopted. We obtained parameters for transition probabilities, depression-specific QoL, and cost data from the literature. Deterministic and probabilistic sensitivity analyses were conducted. Within a scenario analysis, we simulated different time-to-treatment combinations. Half-cycle correction was applied.ResultsIn our simulation, ICBT generated 0.260 QALYs and saved €2536 per patient compared to FCBT. Our deterministic sensitivity analysis suggests that the base-case results were largely unaffected by parameter uncertainty and are therefore robust. Our probabilistic sensitivity analysis suggests that ICBT is highly likely to be more effective (91.5%), less costly (76.0%), and the dominant strategy (69.7%) compared to FCBT. The scenario analysis revealed that the base-case results are robust to variations in time-to-treatment differences.ConclusionICBT has a strong potential to balance demand and supply of CBT in unipolar depression by reducing therapist time per patient. It is highly likely to generate more QALYs and reduce health care expenditure. In addition, ICBT may have further positive external effects, such as freeing up capacities for the most severely depressed patients.

Project description:INTRODUCTION:The peripheral nerves of patients with diabetes are often pathologically swollen, which results in entrapment at places of anatomical narrowing. This results in nerve dysfunction. Surgical treatment of compression neuropathies in the lower extremities (lower extremity nerve decompression (LEND)) results in relief of symptoms and gain in peripheral nerve function, which may lead to less sensory loss (short term) and less associated detrimental effects including foot ulceration and amputations, and lower costs (long term). The aim of the DeCompression trial is to evaluate the effectiveness and (cost-)effectiveness of surgical decompression of compressed lower extremity nerves (LEND surgery) compared with patients treated with conventional (non-surgical) care. METHODS AND ANALYSIS:A stratified randomised (1 to 1) controlled trial comparing LEND surgery (intervention) with conventional non-surgical care (control strategy) in subjects with diabetes with problems of neuropathy due to compression neuropathies in the lower extremity. Randomisation is stratified for participating hospital (n=11) and gender. Patients and controls have the same follow-up at 1.5, 3, 6, 9, 12, 18, 24 and 48 months. Participants (n=344) will be recruited in 12 months and enrolled in all affiliated hospitals in which they receive both the intervention or conventional non-surgical care and follow-up. Outcome assessors are blinded to group assignment. PRIMARY OUTCOME:disease-specific quality of life (Norfolk Quality of Life Questionnaire-Diabetic Neuropathy). SECONDARY OUTCOMES:health-related quality of life (EuroQoL 5-dimension 5-level (EQ-5D5L), 36-item Short Form (SF-36)), plantar sensation (Rotterdam Diabetic Foot Test Battery), incidence of ulcerations/amputations, resource use and productivity loss (Medical Cost Questionnaire, Productivity Cost Questionnaire) during follow-up. The incremental cost-effectiveness ratio will be estimated on the basis of the collected empirical data and a cost-utility model. ETHICS AND DISSEMINATION:Ethics approval has been granted by the Medical Research Ethics Committee of Utrecht University Medical Center (reference: NL68312.041.19v5, protocol number: 19-335/M). Dissemination of results will be via journal articles and presentations at national and international conferences. TRIAL REGISTRATION NUMBER:NetherlandsTrial Registry NL7664.

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Tibial nerve decompression for the prevention of the diabetic foot: a cost-utility analysis using Markov model simulations.

Publications

Tibial nerve decompression for the prevention of the diabetic foot: a cost-utility analysis using Markov model simulations.

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