Which Treatment Is More Cost-Effectiveness for Recurrent Dupuytren's Depends on Severity

By Will Boggs MD

October 27, 2020

NEW YORK (Reuters Health) - Whether limited fasciectomy (LF) or percutaneous needle aponeurotomy (PNA) is the more cost-effective treatment of recurrent Dupuytren's contracture depends upon the severity of the contracture, according to a cost-effectiveness analysis.

"The most surprising finding was that limited fasciectomy was cost-effective for repeated high-severity metacarpophalangeal (MCP) contractures," Dr. Alfred P. Yoon of the University of Michigan Medical School, in Ann Arbor, told Reuters Health by email. "Our initial hypothesis was that limited fasciectomy would not be cost-effective compared to percutaneous needle aponeurotomy because of operating room and anesthesia cost involved with limited fasciectomy."

Commonly used approaches for treating Dupuytren's contracture include LF, PNA, and collagenase clostridium histolyticum (CCH) injection. But the recurrence risk might be greater with PNA and CCH, which also appear to be less effective for treating proximal-interphalangeal-joint contractures.

Previous cost-effectiveness studies on Dupuytren's contracture treatment yielded conflicting conclusions.

Dr. Yoon and colleagues used a microsimulation economic analysis incorporating patients' contracture severity, affected joint type, and number of joints affected to identify cost-effective treatment regimens for recurrent Dupuytren contracture.

For treating low-severity MCP joint contracture, PNA was the least expensive strategy and LF was the most expensive strategy, the team reports in JAMA Network Open.

In contrast, LF was cost-effective for high-severity MCP joint contracture, especially in younger patients.

PNA was the only cost-effective treatment for recurrent proximal-interphalangeal-joint contractures, regardless of severity.

No combination with CCH was cost-effective for any type of recurrent contractures.

"We believe our study can help clinicians and patients make a more educated decision when managing recurrent Dupuytren contracture," Dr. Yoon said. "The strength of cost-effectiveness studies is that the studies not only take into consideration cost of the compared interventions with the implications of decreasing overall U.S. healthcare expenditure, but also the clinical outcomes of the interventions."

"Physicians should be stewards of healthcare, and as such, we are responsible for conducting responsible and cost-effective medicine," he said. "This will help curtail the annual $3.5 trillion dollar healthcare expenditure in the U.S. (approximately 18% of the GDP), which exceeds twice that of other developed countries, with a fraction of return in healthcare outcomes."

Dr. Yoon added, "When deciding to adopt new medications, procedures, or medical innovations, physicians should carefully appraise the quality of the data surrounding these innovations (scrutinizing whether the studies were industry-sponsored) and critically weigh the value added to patient care against additional cost before adopting it in regular practice."

Dr. Brian J. Bear of the University of Illinois College of Medicine-Rockford and Rockford Orthopedic Associates, who has researched CCH treatment of primary and recurrent Dupuytren contracture, told Reuters Health by email, "PNA is only done in a small percentage of patients who have surgery for Dupuytren's. It is performed in the operating room without an anesthesiologist. The majority of Dupuytren's contractures surgery is performed with some of type of anesthesia: regional block or general anesthesia. This would add cost to the procedure for the anesthesiologist."

"My concern with the article is that the reader may interpret the information that surgery in general is more cost-effective than the LF procedure," he said. "Only the PNA technique has been shown to be more cost-effective, which is done under a local anesthetic injection done by the surgeon, thus saving cost when compared to the more common mini-open operations that are being performed which utilize anesthesia."

SOURCE: https://bit.ly/36X5rtH JAMA Network Open, online October 8, 2020.