Patients who have a hand condition called Dupuytren's contracture have three basic treatment choices. They can have an open partial fasciotomy (removal of the tissue), needle aponeurotomy (destruction of the connective tissue), or collagenase injection (needle injection of enzymes that break down the tissue.
Along with those three choices come some disappointing results -- recurrence of the problem. Let's take a look at what the problem is and then come back to this point. Dupuytren's contracture is a fairly common disorder of the fingers. It most often affects the palm side of the ring or little finger, sometimes both, and often in both hands.
Just under the palm is the palmar fascia, a thin sheet of connective tissue shaped somewhat like a triangle. This fascia covers the tendons of the palm of the hand and holds them in place. It also prevents the fingers from bending too far backward when pressure is placed against them. The fascia separates into thin bands of tissue at the fingers. These bands continue into the fingers where they wrap around the joints and bones. Dupuytren's contracture transforms the fascia into shortened cords.
As a result, a thick nodule (knob) or a short cord in the palm of the hand slowly forms, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. Dupuytren's contracture usually affects only the ring and little finger. The contracture spreads to the joints of the finger, which can become permanently immobilized.
The condition occurs most often in middle-aged, white men. The disease usually doesn't cause symptoms until after the age of 40. This condition is seven times more common in men than women. Although more common in men of Scottish, Scandinavian, Irish, or Eastern European ancestry researchers agree that genes are not a direct cause of this disease, but predisposes them to this condition.
Now what about the recurrence rate with each of the three treatments described? Well, studies show a 30 to 40 per cent return of the contracture with open partial fasciectomy. Since this is the treatment used most often for all levels of involvement (mild to severe) the result is less than satisfactory for one out of every three patients. And there are some serious complications with this technique including wound healing problems and loss of hand function due to nerve damage.
Let's take a look next at the recurrence rate with needle aponeurotomy. More than 60 per cent (almost two-thirds) of the patients with severe Dupuytren's who are treated with this approach experience a return of the problem.
That leaves the newest treatment (collagenase injection). This treatment method seems to have the best results (up to 100 per cent effective) but it is mostly used for single finger/single joint contractures. More studies are needed to really get a handle on how well collagenase injections are working and if it is cost-effective.
That's where this study comes in. They took a look at varying rates of disease recurrence with each of these treatment methods and compared the costs. A specific measure called quality-adjusted life years (QALY) was used in the cost-effective analysis. The QALY is a number value used to measure the quality of life or in measuring the opposite, it gives a number value to represent the burden of ill-health or disease.
The QALY is based on the number of years of life that would be added by the intervention. Health care researchers can use this measure to assess a monetary value on treatment methods such as the three used for Dupuytren's contracture. Studies like this help determine the best way to divide up healthcare resources.
There is one downside to using this type of cost-effective analysis. Perfect health is hard, if not impossible, to define. Some people believe that there are health problems worse than death. The measure as it stands now doesn't allow for negative values. The lowest value is zero and that value is given only to death. And the QALY system doesn't take into account the effect of a patient's health on others (e.g., partner, spouse, or other family members).
But having said that, let's look at what the QALY results do tell us from this study at least. The authors asked a total of 50 adults (men and women) between the ages of 50 and 80 to participate. None of these people had a hand problem of any kind (including Dupuytren's).
They were asked to speculate how they would feel about certain limitations in hand function if they had Dupuytren's (e.g., if they were unable to put their hand in a pocket, pick up a package, grasp a coin or key). The study involved analyzing the QALYs gained with treatment versus no treatment for each study participant. A cost value was given to each one. Recurrence and complication rates (as determined by other studies) were factored in as well.
Using this approach, the open partial fasciectomy (most commonly used treatment currently) was not cost-effective. This was true even if the procedure was 100 per cent successful with no complications. Needle aponeurotomy was cost-effective but only when it was 100 per cent successful. Collagenase injection was the most cost-effective but only if the price was less than $945.
The authors concluded that by using QALY to measure treatment success with Dupuytren's contracture, health economics suggests using collagenase injection as the first-line of treatment. If the problem comes back, open partial fasciectomy could be tried. But there's nothing to say needle collagenase in the treatment of any recurrence wouldn't be just as effective. Future studies are needed to sort this out.
Information from QALY studies helps health care providers form policies, make treatment decisions, evaluate results, and direct insurance companies as to which procedures to cover. Cost data should only be one method of analysis.
Other factors such as individual patient characteristics, surgeon's assessment of severity, joints affected, and need for hand therapy afterwards can alter the final treatment decision. This study only reflects the fees charged using Medicare costs and may not reflect treatment everywhere outside of the Medicare system.
The authors suggest this is just one model to use when comparing treatment effectiveness for Dupuytren's. There are other models and other considerations that should be addressed in future health economic studies of hand surgery.
Reference: Neal C. Chen, MD, et al. Cost-Effectiveness of Open Partial Fasciectomy, Needle Aponeurotomy, and Collagenase Injection for Dupuytren Contracture. In The Journal of Hand Surgery. November 2011. Vol. 36A. No. 11. Pp. 1826-1834.