Division of Plastic Surgery, Montreal Children's Hospital, McGill University Health Center, McGill University, Montreal, Canada.
J Craniofac Surg. 2020 Oct;31(7):1888-1894. doi: 10.1097/SCS.0000000000006622.
The cost-effectiveness, utility outcomes, and most optimal timing of mandibular distraction osteogenesis (MDO) in craniofacial microsomia (CFM) continue to be a topic of debate, especially in the population of patients with mild or nonsignificant functional issues. The objective of this study was to quantitatively assess the burden of mandibular asymmetry in CFM, and to accurately evaluate the impact of early MDO on patients' perceived quality of life and social acceptance, in addition to examining the cost-effectiveness of early MDO in CFM.
A validated crowdsourcing platform was utilized to recruit participants. Psychosocial acceptance and utility outcomes were assessed for patients with CFM. Participants were presented with health-state scenarios supplemented with pre- and postoperative images. Quality-adjusted life years (QALYs) were subsequently calculated and costs were estimated based on Medicare fee schedules using the Current Procedural Terminology codes. Incremental cost-effectiveness ratios for early MDO were calculated and plotted against a $100,000/QALY threshold.
: A total of 463 participants were included in the study. The mean visual analog scale score for untreated mandibular hypoplasia in CFM was 0.48 ± 0.24, which improved significantly (P < 0.0001) to 0.63 ± 0.20 following early MDO. Time trade-off scores for an imaginary surgery leading to perfect health with no complications were not statistically different from undergoing early MDO (P = 0.113). Early mandibular distraction decreased social distance in all 8 social situations assessed. Incremental cost-effectiveness ratios varied by the duration of time between early MDO and a potential second intervention, ranging from $148,142.09 per QALY gained at an interval of 1 year to $9876.14 per QALY gained after 15 years. Using a willingness-to-pay threshold of $100,000/QALY, early MDO in CFM becomes cost-effective when patients enjoy an improved health-state post-MDO for more than 1.48 years before a potential second intervention, if deemed necessary.
Early mandibular distraction may lead to tangible positive gains in CFM patients based on utility outcome scores, psychosocial acceptance, and social distance. Therefore, although further interventions may be needed at skeletal maturity, early MDO can improve the psychological well-being of CFM patients during their crucial developmental years in a cost-effective manner. The incremental cost per QALY gained post-early MDO correlates negatively with time until a second potential surgical intervention.
下颌骨牵引成骨术（MDO）在颅面畸形（CFM）中的成本效益、效用结果和最佳时机仍存在争议，尤其是在轻度或无明显功能问题的患者群体中。本研究的目的是定量评估 CFM 中下颌骨不对称的负担，并准确评估早期 MDO 对患者感知生活质量和社会接受度的影响，同时检查 CFM 中早期 MDO 的成本效益。
使用经过验证的众包平台招募参与者。评估 CFM 患者的社会心理接受度和效用结果。参与者被提供了健康状况情景，并补充了术前和术后的图像。随后计算了质量调整生命年（QALY），并根据医疗保险费用表，使用当前程序术语（Current Procedural Terminology，CPT）代码估算了成本。计算了早期 MDO 的增量成本效益比，并绘制在 10 万美元/QALY 的阈值上。
共有 463 名参与者纳入研究。未经治疗的 CFM 下颌骨发育不全的平均视觉模拟量表评分（visual analog scale，VAS）为 0.48±0.24，在早期 MDO 后显著改善（P<0.0001）至 0.63±0.20。进行理想手术达到完美健康且无并发症的假想手术时间权衡评分与进行早期 MDO 无统计学差异（P=0.113）。早期下颌骨牵引在评估的 8 种社交情况下均降低了社交距离。增量成本效益比因早期 MDO 与潜在二次干预之间的时间间隔而异，从 1 年后每获得 1 个 QALY 的成本效益比为 148142.09 美元到 15 年后每获得 1 个 QALY 的成本效益比为 9876.14 美元不等。如果认为有必要，在 10 万美元/QALY 的意愿支付阈值下，CFM 患者在接受 MDO 后改善健康状态的时间超过 1.48 年，那么早期 MDO 在 CFM 中具有成本效益。
基于效用结果评分、社会心理接受度和社交距离，早期下颌骨牵引可能会为 CFM 患者带来明显的积极收益。因此，尽管在骨骼成熟后可能需要进一步干预，但早期 MDO 可以以具有成本效益的方式改善 CFM 患者在其关键发育期间的心理健康。早期 MDO 后每获得 1 个 QALY 的增量成本与第二次潜在手术干预前的时间呈负相关。
