Initial Treatment Choice Affects Cost-effectiveness and Re-intervention Rates for Dupuytren's Contracture: A National Census Veterans Affairs Patients
James J. Drinane, DO1, Darren Gemoets, PhD2, Yannick Albert J. Hoftiezer, MD3, James G. Hoehn, MD1 and Kyle R. Eberlin, MD4, (1)Albany Medical Center, Albany, NY, (2)Albany Stratton VA Medical Center, Albany, NY, (3)Massachusetts General Hospital, Boston, MA, (4)Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Massachusetts General Hospital / Harvard Medical School, Boston, MA
Introduction: This study aims to compare the re-intervention rates and costs associated with various treatment options for Dupuytren's disease (DD) within the Veterans Affairs (VA) Health Administration.
Materials and Methods: A national census of the Veterans Affairs Health System was performed using the Corporate Data Warehouse (CDW) to obtain information about the treatment of all patients treated for DD in years 2014 - 2020. Patients were identified by ICD-9 (728.6) and ICD-10 (M 72.0) codes for DD, while their treatments were identified by their respective current procedural terminology (CPT) codes. Patients treated with CCH (CPTs 20527 plus 26341), percutaneous needle aponeurotomy (PNA, CPT 26040), operative fasciotomy (CPT 26045), palmar fasciectomy (CPT 26121), single finger fasciectomy (CPT 26123), and multi-finger fasciectomy (CPTs 26123 plus 26125) were compared. The total cost of initial treatment was obtained from the CDW, trended annually and compared between modalities. The re-intervention rates were compared using a Kaplan-Meier analysis.
Results: During the study period 8,530 patients were treated for DD of which 3,501 underwent fasciectomy, 3,351 received CCH, 798 underwent fasciotomy, and 880 underwent PNA. The median treatment costs changed during the study and differed between treatment modalities (Figure 1). The overall median treatment cost was found to be the least for PNA compared to all other treatment options (p<0.0001). The 5-year re-intervention rates differed significantly between treatment options (Figure 2), with lower re-intervention rates for single finger fasciectomy (6.5%), operative fasciotomy (8.2%) and palmar fasciectomy (9%) when compared with PNA (12.3%), multi-finger fasciectomy (13.1%) and CCH (14.4%) (p<0.001). However, re-intervention rates were comparable between patients treated with PNA, multi-finger fasciectomy, and CCH (p>0.05).
- PNA is the most affordable procedure per treatment episode and is associated with re-intervention rates that are comparable to those of CCH in the VA patient population.
- Multi-finger fasciectomy, CCH and PNA have comparable re-intervention rates in the VA population.
- The differences in re-intervention rates may partially be explained by patients' willingness to consider an additional treatment to correct any remaining or recurrent deformity.
- Further research may elucidate the recurrence rates of DD-related contractures after each of the available treatment modalities.
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