Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Department of Anesthesiology, University of Texas Health Science Center at Houston, Houston, Texas, USA.
BMJ Open. 2019 Mar 15;9(3):e024816. doi: 10.1136/bmjopen-2018-024816.
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.
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.
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.
Each cohort includes simulated patients with diabetic neuropathy at different levels of risk of developing foot ulcers and amputations.
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.
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.
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.
当与现行预防方案相比时，确定对于患有糖尿病神经病变和叠加性胫骨神经压迫的患者进行胫骨神经松解术作为外科干预是否在预防糖尿病足方面具有成本效益。
基于 5 年模型构建基线分析，以确定每种策略的足部溃疡和截肢的累积发生率。随后，使用由 20 个 6 个月周期组成的模型进行成本效益分析和队列水平马尔可夫模拟。还进行了敏感性分析。
使用 Markov 模型模拟标准预防与胫骨神经松解术对与足部溃疡和截肢相关的长期成本的影响。该模型包括 8 种健康状态。
每个队列包括处于不同足部溃疡和截肢风险水平的患有糖尿病神经病变的模拟患者。
主要结果是每种策略的溃疡和截肢的长期发展趋势。次要结果指标是质量调整生命年（QALYs）、最佳策略的增量成本效益和净货币收益。
与标准预防相比，对于 10000 名患者人群，手术在 5 年内总共预防了 1447 例溃疡和 409 例截肢。在随后的包括 20 个 6 个月周期（10 年）的分析中，与现行预防相比，胫骨神经松解术的增量成本为 12772.28 美元；增量效果为 0.41 QALY，增量成本效益比为 31330.78 美元。接受医学预防的患者的存活率为 73%，而接受手术的患者的存活率为 95%。
这些结果表明，对于患有糖尿病神经病变和叠加性神经压迫的患者，手术在预防严重合并症方面更有效，并且随着时间的推移具有更高的生存率。它还产生了更大的长期经济效益。
