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Decision Analysis of Upper Extremity Transplantation
Brett Wade McClelland, BMed; Steve McCabe
Toronto Western Hospital, Toronto, Canada

Purpose: Over the last fifteen years, upper extremity transplantation has become a clinical reality. The practice remains controversial, however, with some parties citing ethical, psychological, and financial reasons against transplantation. We wanted to utilize established health economic principles of expected value decision making to assist in prioritizing which patients would benefit most from an upper extremity transplant.
Method: We created a decision tree model for upper extremity transplantation. Current literature has established health utility values for single and double extremity transplantation. We combined this with data from the transplant registry on survival rates, together with the incorporation of Chen's functional outcome probabilities. This data was used to establish expected values, after which a sensitivity analysis was performed to demonstrate association with major complication rates.
Results: The health utility values of patients living with single and double amputations are 0.75 and 0.63 respectively. Using a hypothetical major complication rate of 20%, unilateral humeral level transplantation had a lower expected value of 0.72. Unilateral wrist level transplantation was slightly higher at 0.74. With double amputees, expected values were more favorable at much higher hypothetical complication rates. At 40% risk of major complication, bilateral humeral level expected value was 0.632, and bilateral wrist level was 0.643.
Conclusions: Expected values show that upper arm transplantations need ideal conditions in order to be favorable. Even at the functionally ideal wrist level, risks of major complications need to be strictly controlled to around 10% or lower. Increasing the likelihood of a Chen 1 or 2 functional level result can allow up to a 6 percent increase in major complication risk. Bilateral amputees demonstrate far more favorable expected values up to almost 50% major risk level.


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