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Impact on costs of switching one-ray aponeurectomy to percutaneous needle aponeurotomy in Dupuytren's disease: A model analysis
Joint Bone Spine 82 (2015) 264–266
Available online at
ScienceDirect www.sciencedirect.com
Original article
Impact on costs of switching one-ray aponeurectomy to percutaneous needle aponeurotomy in Dupuytren’s disease: A model analysis Milka Maravic ∗ , Johann Beaudreuil Service de rhumatologie, hôpital Lariboisière, université Paris 7, AP–HP, 2, rue Ambroise-Paré, 75010 Paris, France
a r t i c l e
i n f o
Article history: Accepted 22 January 2015 Available online 6 April 2015 Keywords: Dupuytren’s disease Hospitalization Aponeurectomy Needle aponeurotomy Costs
a b s t r a c t Objective: To assess the cost of switching surgical aponeurectomy to percutaneous needle aponeurotomy in one-ray Dupuytren’s disease. Methods: A model analysis was performed with a cross-sectional national survey of public and private French hospitals in 2012. All stays for one-ray aponeurectomy were “virtually” replaced with 1, 2 or 3 outpatient sessions of percutaneous needle aponeurotomy. The costs were based on the hospital cost (tariff per disease-related group) and on common classification of medical procedures performed in outpatient care for 2013. Results: Dupuytren’s disease represented 18,707 hospitalizations (D26 million [2013 euros]) in France in 2012, 8534 hospitalizations for one-ray aponeurectomy (D11.9 million). By replacing surgical aponeurectomy with percutaneous needle aponeurotomy for one-ray Dupuytren’s disease, 91% to 97% and 56% to 59% of the treatment costs could be saved using hospitalizations for one-ray aponeurectomy or total hospital costs, respectively, as reference. Conclusions: Replacing aponeurectomy with percutaneous needle aponeurotomy for one-ray Dupuytren’s disease could greatly reduce the treatment costs for all Dupuytren’s disease. Effective alternatives to surgery for Dupuytren’s disease, such as needle aponeurotomy in an outpatient setting should be considered in the economic perspective. © 2015 Société franc¸aise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.
1. Introduction Treatment of flexion contracture in Dupuytren’s disease includes percutaneous and open surgery [1]. Surgery is performed during hospitalization. Aponeurectomy, also called fasciectomy, is the most frequently used open surgical technique [2–4]. Needle aponeurotomy is recommended for treating Dupuytren’s disease [5]. Replacing open surgery with percutaneous needle aponeurotomy in an outpatient setting has been proposed for non-advanced Dupuytren’s disease [6]. Half of the patients undergoing open surgery have one-ray involvement and about 95% have flexion contracture not exceeding 135◦ , which corresponds to Tubiana stages 1 to 3 [2,9], considered non-advanced forms [6]. Percutaneous needle aponeurotomy has been successful for non-advanced and advanced Dupuytren’s disease [6–8]. One to 3 outpatient sessions of the procedure are needed for one-ray involvement at Tubiana stages 1 to 3. We wondered whether switching aponeurectomy to outpatient needle aponeurotomy for Dupuytren’s disease with
∗ Corresponding author. Tel.: +33 1 49 95 63 08; fax: +33 01 49 95 86 31. E-mail address: [email protected] (M. Maravic).
one-ray involvement could reduce the number of hospitalizations and therefore, the costs needed to treat Dupuytren’s disease. We used the French National Hospital Database that includes data on surgical practices, namely aponeurectomy and treatment for one or more rays [2], and performed a model analysis to assess the impact on costs of switching one-ray aponeurectomy to percutaneous needle aponeurotomy. 2. Methods 2.1. Study design This study was based on a cross-sectional national survey performed in 2012 with planned selection criteria for data extraction. 2.2. French National Hospital Database The French National Hospital Database includes administrative information on patients, such as sex, age, and type of hospital, as well as medical information, including diagnosis and procedures encoded by the International Classification of Diseases-10 (ICD-10) codes and the French common classification of medical procedures.
http://dx.doi.org/10.1016/j.jbspin.2015.01.010 1297-319X/© 2015 Société franc¸aise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.
M. Maravic, J. Beaudreuil / Joint Bone Spine 82 (2015) 264–266
According to the French law, hospitals must keep complete and accurate databases to receive funding. 2.3. Data extraction We used the acute care data for 2012 from the database. The selection criteria for hospital stays were age ≥ 20 years, Dupuytren’s disease as primary diagnosis, and procedures encoded as aponeurectomy, aponeurotomy, arthrolysis, transplantation, amputation or arthrodesis, which could entail surgical treatment of Dupuytren’s disease [3]. We obtained data on public and private hospitalizations, length of hospital stays and one-day stays; age and male sex of patients; and type of surgical treatment.
265
Table 1 Hospitalizations for Dupuytren’s disease in 2012 in France. Hospitalization characteristics Hospitalizations for Dupuytren’s disease, n One-day stays, n (%) Length of stays more than 1 day, no. of days, mean (SD) Patient characteristics from hospitalization data Men, n (%) Age, mean (SD) Treatment (from hospitalization data) Aponeurectomy, n (%)a
18,707 14,257 (76) 1.6 (1.2) 15,138 (81) 62.9 (10.8) 16,587 (88.7)
Data extracted from the French National Database by use of codes from the International Classification of Diseases-10 and French common classification of medical procedures. a No. of procedures coded as aponeurectomy divided by all procedures related to the treatment of Dupuytren’s disease.
2.4. Study model In the model, all stays for one-ray aponeurectomy alone were “virtually” replaced by outpatient percutaneous needle aponeurotomy according to 3 hypotheses: requiring 1, 2 or 3 sessions of percutaneous needle aponeurotomy. The hospitalization costs were based on the 2013 public tariff per disease-related group (DRG), taking into account the duration of hospitalization (www.atih.fr). The costs for percutaneous needle aponeurotomy were obtained from the common classification of medical procedures (http://www.ameli.fr/professionnels-desante/medecins/exercer-au-quotidien/nomenclatures-et-codage/ index hainaut.php). The impact on costs of switching one-ray aponeurectomy to percutaneous needle aponeurotomy was the difference between the cost of hospitalization for one-ray aponeurectomy (near 28 different tariff according to the DRG and duration of the hospitalization, of which 93% of the 8534 stays had a tariff of D1351), and the cost of 1 to 3 outpatient sessions of percutaneous needle aponeurotomy (D42 for each session), in two ways using either overall costs for one-ray hospitalization or overall costs for hospitalization for Dupuytren’s disease as reference. Because tariff for the hospital and common classification of medical procedures depend on the French public health insurance, the cost impact reflects the French public health insurance perspective. 2.5. Statistical analysis Data are reported as number, percentage, and mean (SD) as appropriate. Analysis involved the use of R v2.9.0 [2009–04–17] for Windows (Insightful Corp., Seattle, WA). Costs reduction of switching one-ray aponeurectomy to percutaneous needle aponeurotomy was calculated using either costs due to one-ray aponeurectomy or total costs of Dupuytren’s disease. 3. Results We found 18,707 hospitalizations for Dupuytren’s disease with our selection criteria (Table 1). Aponeurectomy was the most reported treatment during hospitalization. Details of the therapeutic management are in Table 2. Aponeurectomy of 1 or ≥ 2 fingers was of equal frequency. The overall hospital costs were D26 million (26,037,550 2013 euros). The model costs for switching one-ray aponeurectomy to percutaneous needle aponeurotomy are in Table 3. The total hospitalization costs for one-ray aponeurectomy were D11.9 million. The cost for one outpatient session for percutaneous needle aponeurotomy was D42. In total, 91% to 97% of costs would be saved depending on the number of sessions required for percutaneous needle aponeurotomy for one-ray involvement as compared with aponeurectomy, for 56% to 59% reduced total hospitalization costs for treating one-ray Dupuytren’s disease.
Table 2 Number of therapeutic procedures during hospitalization for Dupuytren’s disease in 2012 in France. Aponeurectomy 1 finger ≥ 2 fingers Aponeurotomy Percutaneous approach Open approach Other Arthrolysis Transplantation Arthrodesis Amputation Association of procedures Aponeurectomy + arthrolysis Aponeurectomy + transplantation Aponeurectomy + arthrodesis Aponeurectomy + amputation
8534 8063 990 1367 1123 434 47 30 1096 422 34 13
Data extracted from the French National Database with use of codes from the International Classification of Diseases and French common classification of medical procedures.
Table 3 Modeled costs of switching one-ray aponeurectomy to percutaneous needle aponeurotomy (8534 hospitalizations, D11,862,686 [2013 euros]). Parameters No. of sessions performed Costs of the procedure performed in outpatient care (2013 euros) Costs avoided with outpatient care (2013 euros) Cost-saving percentage with one-ray aponeurectomy using the costs of the 8534 hospitalizations for one-ray aponeurectomy as a reference (D11.9 million) Cost-saving percentage with one-ray aponeurectomy using the costs of the 18,707 hospitalizations for Dupuytren’s disease (D26 million) a b
Percutaneous needle aponeurotomy 1
2
3
358,428
716,856
1,075,284
11,504,258
11,145,830
10,787,402
97a
94
91
56b
57
59
(11,862,686 – 358,428)/11,862,686 = 97%. (26,037,550 – 11,504,258)/26,037,550 = 56%.
266
M. Maravic, J. Beaudreuil / Joint Bone Spine 82 (2015) 264–266
4. Discussion By replacing aponeurectomy, an open surgery procedure, with percutaneous needle aponeurotomy for one-ray Dupuytren’s disease, 97% or even 91% of the treatment costs could be saved, for 56% to 59% reduced total hospitalization costs for Dupuytren’s disease. Aponeurectomy remains the most practiced treatment for Duputren’s disease [2–4]. Alternatives are needle aponeurotomy and collagenase injection, both percutaneous procedures [1]. Aponeurectomy, percutaneous needle aponeurotomy and collagenase injection can improve flexion contracture of fingers induced by Dupuytren’s disease. Functional effects have been shown with surgery and percutaneous needle aponeurotomy [10]. Morphological and functional effects have been shown in non-advanced as well as advanced forms with percutaneous needle aponeurotomy [6–8]. The morphological effect of collagenase injection has not been specifically assessed in advanced Dupuytren’s disease and we have no data on functional results [10,11]. Percutaneous needle aponeurotomy should therefore be considered an alternative to open surgery for Dupuytren’s disease. One trial compared only aponeurectomy with percutaneous needle aponeurotomy [12,13]. The 5-year recurrence was higher with the percutaneous procedure [13]; the technical conditions of the needle aponeurotomy may explain the difference [14]. Furthermore, the comparative trial did not provide any functional results at 5-year follow-up. Conversely, other studies, which are case series, indicated recurrence rates with percutaneous needle aponeurotomy close to reported rates after surgery [6]. Therefore, the clinical results of percutaneous needle aponeurotomy and aponeurectomy remain to be comparatively investigated. However, even with increased recurrence with percutaneous needle aponeurotomy, the impact on costs largely allows for repeated sessions. Our study is a model analysis based on the hypothesis of treating Dupuytren’s disease with one-finger involvement by percutaneous needle aponeurotomy in lieu of open surgery. This hypothesis should be further investigated and validated in observational and interventional studies. However, the validity of the model is supported in that about 95% of cases of Dupuytren’s disease usually treated with open surgery are Tubiana stage 1 to 3 [9], known to be suitable for percutaneous needle aponeurotomy [6]. Furthermore, a recent cost-utility analysis approach identified percutaneous needle aponeurotomy as the most costeffective treatment for managing Dupuytren’s contracture with one-finger involvement as compared with surgery [15]. A limitation of our study is the database we used. We focused on hospital stays and did not record post-surgical care or indirect costs due to treatments. This choice likely contributed to underestimating the economic impact of percutaneous needle aponeurotomy for one-ray disease as compared with fasciectomy. Contrary to open surgery, percutaneous needle aponeurotomy does not require nursing care, rehabilitation or sick leave. Another limitation concerned the fact that our data can not evaluate the exact number of fingers treated according to the description of the procedures. Dupuytren’s disease represented more than 18,000 hospitalizations in France in 2012, a meaningful economic burden. Management during hospitalization is surgery, mainly aponeurectomy. By replacing aponeurectomy with needle aponeurotomy for one-ray disease, more than 90% of the treatment costs could be saved, for 56% to 59% reduced total hospitalization costs for treating
Dupuytren’s disease. Knowing clinical practices at the national level is crucial in decision-making. Effective alternatives to surgery for Dupuytren’s disease, such as needle aponeurotomy in an outpatient setting should be considered in the economic perspective. Contributors Both authors (MM and JB) of this article directly participated in the planning, analysis, interpretation, and writing of the study and approved the final submitted version. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Acknowledgments This work is supported by the Collège Franc¸ais des Médecins Rhumatologues (CFMR, www.cfmr.fr). Laura Smales (BioMedEditing, Toronto, Canada) provided medical editing of the final version of the manuscript. References [1] Shih B, Bayat A. Scientific understanding and clinical management of Dupuytren disease. Nat Rev Rheumatol 2010;6:715–26. [2] Maravic M, Landais P. Dupuytren’s disease in France – 1831 to 2001 – from description to economic burden. J Hand Surg 2005;30B:484–7. [3] Maravic M, Lasbleiz S, Roulot E, et al. Hospitalization for Dupuytren’s disease: a French national descriptive analyses, 2002 to 2009. Orthop Traumatol Surg Res 2014;100:589–92. [4] Gerber RA, Perry R, Thompson R, et al. Dupuytren’s contracture: a retrospective database analysis to assess clinical management and costs in England. BMC Musculoskelet Disord 2011;12:73. [5] National Institute for Clinical Excellence. IPG043 Needle fasciotomy for Dupuytren’s contracture – guidance; 2004. Available from: http://guidance. nice.org.uk/IPG43/Guidance/pdf/English,. Accessed 26 May 2010. [6] Beaudreuil J, Lellouche H, Orcel P, et al. Needle aponeurotomy in Dupuytren’s disease. Joint Bone Spine 2012;79:13–6. [7] Beaudreuil J, Lermusiaux JL, Teyssedou JP, et al. Multi-needle aponeurotomy for advanced Dupuytren’s disease: preliminary results of safety and efficacy (MNA 1 Study). Joint Bone Spine 2011;78:625–8. [8] Beaudreuil J, Lermusiaux JL, Teyssedou JP. Multi-needle aponeurotomy for advanced Dupuytren’s disease: a 16-month follow-up study (MNA 2 Study). J Hand Surg 2012;37:795–6. [9] Dahlin LB, Bainbridge C, Leclercq C, et al. Dupuytren’s disease presentation, referral pathways and resource utilisation in Europe: regional analysis of a surgeon survey and patient chart review. Int J Clin Pract 2013;67: 261–70. [10] Ball C, Pratt AL, Nanchahal J. Optimal functional outcome measures for assessing treatment for Dupuytren’s disease: a systematic review and recommendations for future practice. Musculoskelet Disord 2013;14:131. [11] Hurst LC, Badalamente MA, Hentz VR, et al. Injectable collagenase clostridium hystolyticum for Dupuytren’s contracture. N Engl J Med 2009;361:968–79. [12] van Rijssen AL, Gerbrandy FS, Ter Linden H, et al. A comparison ofvthe direct outcomes of percutaneous needle fasciotomy and limited fasciectomy for Dupuytren’s disease: a 6-week follow-up study. J Hand Surg Am 2006;31:717–25. [13] van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: percutaneous fasciotomy versus limited facsiectomy. Plast Reconstr Surg 2012;129:469–77. [14] Beaudreuil J, Lellouche H, Orcel P, et al. Need for a standard procedure for needle aponeurotomy, consensus definbition of recurrence, and functional assessment in dupuytren contracture. Plast Reconstr Surg 2012;130:200e–1e. [15] Baltzer H, Binhammer PA. Cost-effectiveness in the management of Dupuytren’s contracture. A Canadian cost-utility analysis of current and future management strategies. J Bone Joint Surg 2013;95–B:1094–100.
Available online at
ScienceDirect www.sciencedirect.com
Original article
Impact on costs of switching one-ray aponeurectomy to percutaneous needle aponeurotomy in Dupuytren’s disease: A model analysis Milka Maravic ∗ , Johann Beaudreuil Service de rhumatologie, hôpital Lariboisière, université Paris 7, AP–HP, 2, rue Ambroise-Paré, 75010 Paris, France
a r t i c l e
i n f o
Article history: Accepted 22 January 2015 Available online 6 April 2015 Keywords: Dupuytren’s disease Hospitalization Aponeurectomy Needle aponeurotomy Costs
a b s t r a c t Objective: To assess the cost of switching surgical aponeurectomy to percutaneous needle aponeurotomy in one-ray Dupuytren’s disease. Methods: A model analysis was performed with a cross-sectional national survey of public and private French hospitals in 2012. All stays for one-ray aponeurectomy were “virtually” replaced with 1, 2 or 3 outpatient sessions of percutaneous needle aponeurotomy. The costs were based on the hospital cost (tariff per disease-related group) and on common classification of medical procedures performed in outpatient care for 2013. Results: Dupuytren’s disease represented 18,707 hospitalizations (D26 million [2013 euros]) in France in 2012, 8534 hospitalizations for one-ray aponeurectomy (D11.9 million). By replacing surgical aponeurectomy with percutaneous needle aponeurotomy for one-ray Dupuytren’s disease, 91% to 97% and 56% to 59% of the treatment costs could be saved using hospitalizations for one-ray aponeurectomy or total hospital costs, respectively, as reference. Conclusions: Replacing aponeurectomy with percutaneous needle aponeurotomy for one-ray Dupuytren’s disease could greatly reduce the treatment costs for all Dupuytren’s disease. Effective alternatives to surgery for Dupuytren’s disease, such as needle aponeurotomy in an outpatient setting should be considered in the economic perspective. © 2015 Société franc¸aise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.
1. Introduction Treatment of flexion contracture in Dupuytren’s disease includes percutaneous and open surgery [1]. Surgery is performed during hospitalization. Aponeurectomy, also called fasciectomy, is the most frequently used open surgical technique [2–4]. Needle aponeurotomy is recommended for treating Dupuytren’s disease [5]. Replacing open surgery with percutaneous needle aponeurotomy in an outpatient setting has been proposed for non-advanced Dupuytren’s disease [6]. Half of the patients undergoing open surgery have one-ray involvement and about 95% have flexion contracture not exceeding 135◦ , which corresponds to Tubiana stages 1 to 3 [2,9], considered non-advanced forms [6]. Percutaneous needle aponeurotomy has been successful for non-advanced and advanced Dupuytren’s disease [6–8]. One to 3 outpatient sessions of the procedure are needed for one-ray involvement at Tubiana stages 1 to 3. We wondered whether switching aponeurectomy to outpatient needle aponeurotomy for Dupuytren’s disease with
∗ Corresponding author. Tel.: +33 1 49 95 63 08; fax: +33 01 49 95 86 31. E-mail address: [email protected] (M. Maravic).
one-ray involvement could reduce the number of hospitalizations and therefore, the costs needed to treat Dupuytren’s disease. We used the French National Hospital Database that includes data on surgical practices, namely aponeurectomy and treatment for one or more rays [2], and performed a model analysis to assess the impact on costs of switching one-ray aponeurectomy to percutaneous needle aponeurotomy. 2. Methods 2.1. Study design This study was based on a cross-sectional national survey performed in 2012 with planned selection criteria for data extraction. 2.2. French National Hospital Database The French National Hospital Database includes administrative information on patients, such as sex, age, and type of hospital, as well as medical information, including diagnosis and procedures encoded by the International Classification of Diseases-10 (ICD-10) codes and the French common classification of medical procedures.
http://dx.doi.org/10.1016/j.jbspin.2015.01.010 1297-319X/© 2015 Société franc¸aise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.
M. Maravic, J. Beaudreuil / Joint Bone Spine 82 (2015) 264–266
According to the French law, hospitals must keep complete and accurate databases to receive funding. 2.3. Data extraction We used the acute care data for 2012 from the database. The selection criteria for hospital stays were age ≥ 20 years, Dupuytren’s disease as primary diagnosis, and procedures encoded as aponeurectomy, aponeurotomy, arthrolysis, transplantation, amputation or arthrodesis, which could entail surgical treatment of Dupuytren’s disease [3]. We obtained data on public and private hospitalizations, length of hospital stays and one-day stays; age and male sex of patients; and type of surgical treatment.
265
Table 1 Hospitalizations for Dupuytren’s disease in 2012 in France. Hospitalization characteristics Hospitalizations for Dupuytren’s disease, n One-day stays, n (%) Length of stays more than 1 day, no. of days, mean (SD) Patient characteristics from hospitalization data Men, n (%) Age, mean (SD) Treatment (from hospitalization data) Aponeurectomy, n (%)a
18,707 14,257 (76) 1.6 (1.2) 15,138 (81) 62.9 (10.8) 16,587 (88.7)
Data extracted from the French National Database by use of codes from the International Classification of Diseases-10 and French common classification of medical procedures. a No. of procedures coded as aponeurectomy divided by all procedures related to the treatment of Dupuytren’s disease.
2.4. Study model In the model, all stays for one-ray aponeurectomy alone were “virtually” replaced by outpatient percutaneous needle aponeurotomy according to 3 hypotheses: requiring 1, 2 or 3 sessions of percutaneous needle aponeurotomy. The hospitalization costs were based on the 2013 public tariff per disease-related group (DRG), taking into account the duration of hospitalization (www.atih.fr). The costs for percutaneous needle aponeurotomy were obtained from the common classification of medical procedures (http://www.ameli.fr/professionnels-desante/medecins/exercer-au-quotidien/nomenclatures-et-codage/ index hainaut.php). The impact on costs of switching one-ray aponeurectomy to percutaneous needle aponeurotomy was the difference between the cost of hospitalization for one-ray aponeurectomy (near 28 different tariff according to the DRG and duration of the hospitalization, of which 93% of the 8534 stays had a tariff of D1351), and the cost of 1 to 3 outpatient sessions of percutaneous needle aponeurotomy (D42 for each session), in two ways using either overall costs for one-ray hospitalization or overall costs for hospitalization for Dupuytren’s disease as reference. Because tariff for the hospital and common classification of medical procedures depend on the French public health insurance, the cost impact reflects the French public health insurance perspective. 2.5. Statistical analysis Data are reported as number, percentage, and mean (SD) as appropriate. Analysis involved the use of R v2.9.0 [2009–04–17] for Windows (Insightful Corp., Seattle, WA). Costs reduction of switching one-ray aponeurectomy to percutaneous needle aponeurotomy was calculated using either costs due to one-ray aponeurectomy or total costs of Dupuytren’s disease. 3. Results We found 18,707 hospitalizations for Dupuytren’s disease with our selection criteria (Table 1). Aponeurectomy was the most reported treatment during hospitalization. Details of the therapeutic management are in Table 2. Aponeurectomy of 1 or ≥ 2 fingers was of equal frequency. The overall hospital costs were D26 million (26,037,550 2013 euros). The model costs for switching one-ray aponeurectomy to percutaneous needle aponeurotomy are in Table 3. The total hospitalization costs for one-ray aponeurectomy were D11.9 million. The cost for one outpatient session for percutaneous needle aponeurotomy was D42. In total, 91% to 97% of costs would be saved depending on the number of sessions required for percutaneous needle aponeurotomy for one-ray involvement as compared with aponeurectomy, for 56% to 59% reduced total hospitalization costs for treating one-ray Dupuytren’s disease.
Table 2 Number of therapeutic procedures during hospitalization for Dupuytren’s disease in 2012 in France. Aponeurectomy 1 finger ≥ 2 fingers Aponeurotomy Percutaneous approach Open approach Other Arthrolysis Transplantation Arthrodesis Amputation Association of procedures Aponeurectomy + arthrolysis Aponeurectomy + transplantation Aponeurectomy + arthrodesis Aponeurectomy + amputation
8534 8063 990 1367 1123 434 47 30 1096 422 34 13
Data extracted from the French National Database with use of codes from the International Classification of Diseases and French common classification of medical procedures.
Table 3 Modeled costs of switching one-ray aponeurectomy to percutaneous needle aponeurotomy (8534 hospitalizations, D11,862,686 [2013 euros]). Parameters No. of sessions performed Costs of the procedure performed in outpatient care (2013 euros) Costs avoided with outpatient care (2013 euros) Cost-saving percentage with one-ray aponeurectomy using the costs of the 8534 hospitalizations for one-ray aponeurectomy as a reference (D11.9 million) Cost-saving percentage with one-ray aponeurectomy using the costs of the 18,707 hospitalizations for Dupuytren’s disease (D26 million) a b
Percutaneous needle aponeurotomy 1
2
3
358,428
716,856
1,075,284
11,504,258
11,145,830
10,787,402
97a
94
91
56b
57
59
(11,862,686 – 358,428)/11,862,686 = 97%. (26,037,550 – 11,504,258)/26,037,550 = 56%.
266
M. Maravic, J. Beaudreuil / Joint Bone Spine 82 (2015) 264–266
4. Discussion By replacing aponeurectomy, an open surgery procedure, with percutaneous needle aponeurotomy for one-ray Dupuytren’s disease, 97% or even 91% of the treatment costs could be saved, for 56% to 59% reduced total hospitalization costs for Dupuytren’s disease. Aponeurectomy remains the most practiced treatment for Duputren’s disease [2–4]. Alternatives are needle aponeurotomy and collagenase injection, both percutaneous procedures [1]. Aponeurectomy, percutaneous needle aponeurotomy and collagenase injection can improve flexion contracture of fingers induced by Dupuytren’s disease. Functional effects have been shown with surgery and percutaneous needle aponeurotomy [10]. Morphological and functional effects have been shown in non-advanced as well as advanced forms with percutaneous needle aponeurotomy [6–8]. The morphological effect of collagenase injection has not been specifically assessed in advanced Dupuytren’s disease and we have no data on functional results [10,11]. Percutaneous needle aponeurotomy should therefore be considered an alternative to open surgery for Dupuytren’s disease. One trial compared only aponeurectomy with percutaneous needle aponeurotomy [12,13]. The 5-year recurrence was higher with the percutaneous procedure [13]; the technical conditions of the needle aponeurotomy may explain the difference [14]. Furthermore, the comparative trial did not provide any functional results at 5-year follow-up. Conversely, other studies, which are case series, indicated recurrence rates with percutaneous needle aponeurotomy close to reported rates after surgery [6]. Therefore, the clinical results of percutaneous needle aponeurotomy and aponeurectomy remain to be comparatively investigated. However, even with increased recurrence with percutaneous needle aponeurotomy, the impact on costs largely allows for repeated sessions. Our study is a model analysis based on the hypothesis of treating Dupuytren’s disease with one-finger involvement by percutaneous needle aponeurotomy in lieu of open surgery. This hypothesis should be further investigated and validated in observational and interventional studies. However, the validity of the model is supported in that about 95% of cases of Dupuytren’s disease usually treated with open surgery are Tubiana stage 1 to 3 [9], known to be suitable for percutaneous needle aponeurotomy [6]. Furthermore, a recent cost-utility analysis approach identified percutaneous needle aponeurotomy as the most costeffective treatment for managing Dupuytren’s contracture with one-finger involvement as compared with surgery [15]. A limitation of our study is the database we used. We focused on hospital stays and did not record post-surgical care or indirect costs due to treatments. This choice likely contributed to underestimating the economic impact of percutaneous needle aponeurotomy for one-ray disease as compared with fasciectomy. Contrary to open surgery, percutaneous needle aponeurotomy does not require nursing care, rehabilitation or sick leave. Another limitation concerned the fact that our data can not evaluate the exact number of fingers treated according to the description of the procedures. Dupuytren’s disease represented more than 18,000 hospitalizations in France in 2012, a meaningful economic burden. Management during hospitalization is surgery, mainly aponeurectomy. By replacing aponeurectomy with needle aponeurotomy for one-ray disease, more than 90% of the treatment costs could be saved, for 56% to 59% reduced total hospitalization costs for treating
Dupuytren’s disease. Knowing clinical practices at the national level is crucial in decision-making. Effective alternatives to surgery for Dupuytren’s disease, such as needle aponeurotomy in an outpatient setting should be considered in the economic perspective. Contributors Both authors (MM and JB) of this article directly participated in the planning, analysis, interpretation, and writing of the study and approved the final submitted version. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Acknowledgments This work is supported by the Collège Franc¸ais des Médecins Rhumatologues (CFMR, www.cfmr.fr). Laura Smales (BioMedEditing, Toronto, Canada) provided medical editing of the final version of the manuscript. References [1] Shih B, Bayat A. Scientific understanding and clinical management of Dupuytren disease. Nat Rev Rheumatol 2010;6:715–26. [2] Maravic M, Landais P. Dupuytren’s disease in France – 1831 to 2001 – from description to economic burden. J Hand Surg 2005;30B:484–7. [3] Maravic M, Lasbleiz S, Roulot E, et al. Hospitalization for Dupuytren’s disease: a French national descriptive analyses, 2002 to 2009. Orthop Traumatol Surg Res 2014;100:589–92. [4] Gerber RA, Perry R, Thompson R, et al. Dupuytren’s contracture: a retrospective database analysis to assess clinical management and costs in England. BMC Musculoskelet Disord 2011;12:73. [5] National Institute for Clinical Excellence. IPG043 Needle fasciotomy for Dupuytren’s contracture – guidance; 2004. Available from: http://guidance. nice.org.uk/IPG43/Guidance/pdf/English,. Accessed 26 May 2010. [6] Beaudreuil J, Lellouche H, Orcel P, et al. Needle aponeurotomy in Dupuytren’s disease. Joint Bone Spine 2012;79:13–6. [7] Beaudreuil J, Lermusiaux JL, Teyssedou JP, et al. Multi-needle aponeurotomy for advanced Dupuytren’s disease: preliminary results of safety and efficacy (MNA 1 Study). Joint Bone Spine 2011;78:625–8. [8] Beaudreuil J, Lermusiaux JL, Teyssedou JP. Multi-needle aponeurotomy for advanced Dupuytren’s disease: a 16-month follow-up study (MNA 2 Study). J Hand Surg 2012;37:795–6. [9] Dahlin LB, Bainbridge C, Leclercq C, et al. Dupuytren’s disease presentation, referral pathways and resource utilisation in Europe: regional analysis of a surgeon survey and patient chart review. Int J Clin Pract 2013;67: 261–70. [10] Ball C, Pratt AL, Nanchahal J. Optimal functional outcome measures for assessing treatment for Dupuytren’s disease: a systematic review and recommendations for future practice. Musculoskelet Disord 2013;14:131. [11] Hurst LC, Badalamente MA, Hentz VR, et al. Injectable collagenase clostridium hystolyticum for Dupuytren’s contracture. N Engl J Med 2009;361:968–79. [12] van Rijssen AL, Gerbrandy FS, Ter Linden H, et al. A comparison ofvthe direct outcomes of percutaneous needle fasciotomy and limited fasciectomy for Dupuytren’s disease: a 6-week follow-up study. J Hand Surg Am 2006;31:717–25. [13] van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: percutaneous fasciotomy versus limited facsiectomy. Plast Reconstr Surg 2012;129:469–77. [14] Beaudreuil J, Lellouche H, Orcel P, et al. Need for a standard procedure for needle aponeurotomy, consensus definbition of recurrence, and functional assessment in dupuytren contracture. Plast Reconstr Surg 2012;130:200e–1e. [15] Baltzer H, Binhammer PA. Cost-effectiveness in the management of Dupuytren’s contracture. A Canadian cost-utility analysis of current and future management strategies. J Bone Joint Surg 2013;95–B:1094–100.