Patients with serious lower-leg trauma have two main care options: limb preservation or transtibial amputation with the subsequent use of a prosthesis. A study in the September issue of Technology and Innovation, Journal of the National Academy of Inventors, “Economic Evaluations of Interventions for Transtibial Amputations: A Scoping Review of Comparative Studies,” takes on the task of defining the largely unknown economic aspects of transtibial amputations, including the cost effectiveness of prosthesis use within three topical areas: care models, prosthetic treatment, and prosthetic sockets.
In an effort to shed light on these unknowns, the study authors evaluated the impact and cost effectiveness of transtibial amputations through a scoping review of available reports and literature to determine if there was sufficient data to conduct a more formal, systematic review to develop an economic evaluation of interventions provided to this patient population.
A number of reports over the last decade added insight into cost issues. For example, the authors reported that Medicare reimbursed $655 million worth of lower-limb prosthetic services in 2009; however, a 2012 U.S. report found that about $4.7 million worth of Medicare billings were inappropriate. Some insurers were found to provide a one-limb-per-lifetime reimbursement limit. In addition, costs of secondary conditions suffered by patients with transtibial amputations, including degenerative joint disease and low back pain, had to be included in economic outcomes analyses.
The authors suggested that, given the recent reimbursement challenges based on a lack of clinical and economic evidence, there was a “need to understand and document cost effectiveness of prosthetic rehabilitation for [transtibial amputation] patients.” Some comparative cost analyses emerged that indicated the lower overall costs of transtibial amputations and prosthetic use.
Another contributing study reported that when compared to non-prosthetic users, Medicare beneficiaries with recent transtibial amputations who used prostheses had fewer emergency room visits. Patients who had transtibial amputations were also more likely to receive outpatient physical therapy, which was also associated with fewer acute care hospitalizations and less facility-based care. These reduced costs offset the initial high cost associated with prescription of a prosthetic limb.
“In other words, the higher initial costs decrease the burden on the healthcare system by decreasing utilization and adverse events,” said study lead author and special issue editor M. Jason Highsmith, DPT, PhD, CP, FAAOP, of the University of South Florida’s School of Physical Therapy & Rehabilitation Sciences and the Extremity Trauma and Amputation Center of Excellence at the U.S. Departments of Veterans Affairs and Defense.
Over the three topical areas represented in the review-care models, prosthetic use, and prosthetic sockets-analyses showed the following:
- Clinical outcomes were similar between the care models, but costs were found to be 29 percent lower per patient when care was received in the public rather than private sector.
- Limb salvage versus prosthetic use comparisons revealed average two-year costs that were 6 percent higher for those receiving transtibial amputations, but hospitalization times were similar; one study showed a 13 percent increase in one-year costs for limb salvage; the authors determined that “a definitive advantage to either has not been identified.”
- Analysis of prosthetic sockets (specific weight bearing) versus total-contact sockets for patients with transtibial amputations revealed 40 percent less cost for weight bearing sockets although they require up to three times longer to achieve proper fit.
“The comparative economic literature in transtibial prosthetics is presently insufficient for further review, conclusion, and policy guidance,” concluded the researchers. “Further and more sophisticated economic analyses of transtibial prosthetic interventions are needed in order to determine value related to device provision and maintenance, outcomes, and health…. Guidance from the profession may be useful in devising a strategy for how to assure economic analyses are a routine element of prosthetic science in the future.”
