Secondary Logo

Journal Logo

Health Care Economics in Lower-Limb Amputation Surgery, Prosthetics, and Rehabilitation

A Narrative Systematic Review of the Literature

Stevens, Phillip M., MEd, CPO, FAAOP; Sutton, Bryce S., PhD; Highsmith, M. Jason, PhD, DPT, CP, FAAOP

JPO: Journal of Prosthetics and Orthotics: January 2019 - Volume 31 - Issue 1S - p P13–P22
doi: 10.1097/JPO.0000000000000228
Proceedings
Free
SDC

PHILLIP M. STEVENS, MEd, CPO, FAAOP, is affiliated with the Hanger Clinic, Salt Lake City, Utah; and the Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah.

BRYCE S. SUTTON, PhD, is affiliated with the Avalere Health, Washington, District of Columbia.

M. JASON HIGHSMITH, PhD, DPT, CP, FAAOP, is affiliated with the Extremity Trauma & Amputation Center of Excellence (EACE), U.S. Department of Veterans’ Affairs, Tampa, Florida; the School of Physical Therapy and Rehabilitations Sciences, University of South Florida, Tampa, Florida; and the U.S. Army Reserves, 319th Minimal Care Detachment, Pinellas Park, Florida.

Disclosure: Contents of the manuscript represent the opinions of the authors and not necessarily those of any professional organization, academic institution, health care facility, or government agency including the Department of Defense, Department of Veterans Affairs, or the Department of the Army. Authors declare no conflict of interests. This project was unfunded.

Correspondence to: Phillip M. Stevens, MEd, CPO, FAAOP, Hanger Clinic, 2785 E 3300 S, Salt Lake City, UT 84109; email: philmstevens@hotmail.com

Health expenditures in the United States are substantial, accounting for 17.8% of gross domestic product (GDP) in 2015. These expenditures are expected to increase to nearly 20% of GDP by 2025. National health spending in the US is projected to grow at an average rate of 5.6% per year between 2016 and 2025 and a 4.7% rate annually on a per capita basis.1

The economic impact of lower-limb amputation (LLA) is variable, with estimated lifetime prosthetic costs for those who use them ranging from $0.5 to $1.8 million, depending upon the number and type of prostheses received, the number and type of limb amputations, and other factors.2 Collectively, Medicare reimbursed $655 million worth of lower-limb prosthetic services in 2009.3 However, prosthetic costs only constitute a portion of the full economic impact, with reported cumulative societal costs (United States) of an estimated $4.3 billion for persons with amputations of dysvascular etiology.4

Comparative health economic literature in prosthetic rehabilitation literature is relatively scarce and has been summarized.5 Given the dearth of comparative health economic literature, there is a need to expand the search for it within the larger body of prosthetic rehabilitation science including trends, insights, and practice guidance within these areas. A previous review of prosthetic health economic science recommended review of descriptive economic literature, citing a lack of comparative economic literature. Therefore, the purpose of this project was to systematically review the descriptive literature to determine if further economic observations in rehabilitative care for persons with LLA are available. Specifically, this review sought to formulate evidence-based economic observations (EBEOs) related to prosthetic interventions for persons with LLA from an economic evaluation perspective based solely on descriptive studies.

Back to Top | Article Outline

METHODS

On November 18, 2015, three databases—Medline (PubMed), CINAHL (Ovid), and the Cochrane Database of Systematic Reviews—were systematically searched for the following terms:

Primary Search Terms: (prosthe* OR “Prostheses and Implants” OR prosthesis OR prostheses OR preprosthe* OR pre-prosthe*)

AND

(((transtibial OR trans-tibial OR trans tibial OR below knee OR bka OR tta OR Leg[Mesh] OR leg OR legs OR lower limb OR lower limbs OR lower extremity OR lower extremit* OR “Lower Extremity”[Mesh])))

Primary search terms were combined systematically with the following secondary search terms:

Cost OR Econ* OR Efficacy OR “Cost Benefit” OR “Cost Effectiveness” OR “Cost Utility” OR “Health care Econ*”

The following date limits were implemented as part of the database search parameters: January 1, 1997, through November 15, 2015. Resulting articles’ reference lists were searched for potentially relevant articles.

Back to Top | Article Outline

ARTICLE SCREENING

Resulting references were exported to EndNote (vX6; Thompson, CA, USA) reference management software for stage 1 screening. This involved screening title and abstract and the elimination of duplicate references. Remaining prosthetic economic articles were sorted by topic. Exclusion criteria were applied starting at stage 1 to eliminate comparative studies as these have been previously reviewed. Articles published in a non-English language were eliminated relative to prohibitive translation fees. Articles were screened for exclusion using the following criteria within EndNote:

  1. Foreign language (i.e., non-English language)
  2. Economic evaluation or cost-comparison studies

After stage 1 screening, stage 2 screening was applied as outlined here. Remaining economic manuscripts were reviewed by two raters and screened independently to verify inclusion/exclusion and for classification as either: 1) pertinent, 2) not pertinent, or 3) uncertain pertinence. Full-text articles were reviewed for citations classified as pertinent or uncertain pertinence. Disagreements regarding citations of uncertain pertinence were resolved by discussion with a third rater. Review of full-text articles and associated discussion led to group consensus and ultimate inclusion/exclusion. To be included, the article had to be a descriptive manuscript including persons with lower extremity amputation or prosthetic care as a topic.6

Back to Top | Article Outline

DATA EXTRACTION

The following data were extracted: population, inclusive costs, reported costs, reported currency, and equivalent in 2017 US dollars (USD). Reported costs were converted to USD by dividing the local currency unit with the purchasing power parity rates for the mentioned price year and subsequently inflated to 2017 year dollars as defined by the World Bank Group.7,8 If the price-year was not stated in the study, cost in the publication year was used. Final costs displayed were rounded to the nearest whole number.

Back to Top | Article Outline

SORTING BY TOPIC

After screening for eligibility determination and data extraction, articles were sorted for pertinence into available topical areas.

Back to Top | Article Outline

SYNTHESIS OF EVIDENCE-BASED ECONOMIC OBSERVATIONS

Based on results from the included publications, EBEOs were developed that described LLA-related interventions economically. Reviewers rated the level of confidence of each EBEO as “low,” given the source manuscripts were descriptive or qualitative designs.

Back to Top | Article Outline

RESULTS

LITERATURE SEARCH

The search yielded 292 manuscripts (Figure 1). Stage 1 screening eliminated 263 manuscripts, and stage 2 screening eliminated an additional 13 manuscripts, leaving 16 articles meeting eligibility criteria. The remaining articles were published from 1996 to 2015 where most were published in 2013 (four manuscripts) and 2014 (three manuscripts). These were divided into the following three topical areas describing costs related to:

Figure 1

Figure 1

  1. Amputations resulting from diabetes mellitus (DM), peripheral arterial disease (PAD), and critical limb ischemia (CLI) (n = 6)
  2. Amputations in veterans related to military trauma (n = 3)
  3. Other miscellaneous prosthetic care issues including economic considerations in episodes of care where amputation represents one open care pathway, economic considerations in discrete treatment populations of persons with amputation, prosthetic componentry, and the financial impact when the wage earner loses a limb in resource-limited settings (n = 7).

Articles were published in multiple different journals including Prosthetics and Orthotics International, Journal of Rehabilitation Research & Development, Disability and Rehabilitation, and numerous others. From an economic evaluation type, all included articles were descriptive. Some used epidemiologic methods where others were purely narrative.

Back to Top | Article Outline

FUNDING

Twelve of the 16 manuscripts included a statement disclosing whether or not the study was funded. Eleven of these 12 were funded. Four were funded by the US Department of Veterans Affairs, one by the National Institutes of Health, one by the US Department of Education, three by nonprofit organizations (i.e., foundations, professional associations), and three were supported by their respective governments. Four of the 16 included studies did not indicate whether or not the studies were funded. Given that there was no industry funding and that all reported funding was governmental or nonprofit, the likelihood of funding bias was regarded to be low.

Back to Top | Article Outline

SOCIODEMOGRAPHIC AND ECONOMIC DATA

Key economic data regarding amputations resulting from DM, PAD, and CLI were extracted into Table 1. Values were listed as directly reported in the manuscript and as converted per the methods aforementioned to current values in USD. Observations were reported from the United States, Australia, Germany, and Sweden. Aggregation of economic data was precluded by the variability of reported information. Sample sizes were diverse, with some studies reporting amputation data in conjunction with data observed with other surgical procedures. Among defined populations that were clearly limited to those with LLA, sample sizes ranged from 95 to 9066 with a mean sample size of 2,124. Among studies that reported the variable, mean cohort ages ranged from 62 to 77 years.

Table 1

Table 1

Key economic data regarding amputations resulting from military trauma in both the veteran and service member populations were extracted into Table 2. Values were listed as directly reported in the manuscript and as converted per the methods aforementioned to current values in USD. The divergence of sample sizes and reported variables preclude meaningful aggregate analysis. Maynard et al.15 reported upon the largest sample size of 2,690 injured veterans. Blough et al.2 reported upon 245 veterans with amputation from the Vietnam conflict and 226 veterans with amputation from the Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) conflict that presented with either unilateral major LLA (350 subjects) or multiple major amputations (121 subjects) excluding bilateral upper-limb amputation. Edwards et al.16 reported upon 265 individuals with 416 amputations, but the reported data did not include the number of subjects with unilateral or bilateral LLA.

Table 2

Table 2

The remaining seven studies were too divergent to allow for meaningful aggregation. Two of these reported upon the niche populations of pediatric lawn mower injury17 and farmers,18 although with very different economic considerations. Two reported economic considerations as they relate to divergent care pathways in which amputation represents a route of care. These include the management of nonhealing tibial fractures19 and the management of the diabetic at-risk foot.20 The remaining 3 studies were highly divergent in their content and include socket fabrication methods,21 a low-cost suspension alternative,22 and financial constraints in a resource-limited practice environment.23

Back to Top | Article Outline

EVIDENCE-BASED ECONOMIC OBSERVATIONS

Thirteen EBEOs were synthesized from the results within the three topical areas previously identified and are listed below. Of these, 12 were only supported by a single study with the remaining statement supported by two articles.

Back to Top | Article Outline

AMPUTATIONS RESULTING FROM DIABETES MELLITUS, PERIPHERAL ARTERIAL DISEASE, AND CRITICAL LIMB ISCHEMIA

  1. Mean inpatient costs associated with LLA due to DM, PAD, or both range from $20,000 to $46,000 (2017 USD) depending upon the level of amputation and comorbid health conditions.9,10
  2. Average inpatient costs among patients with PAD are higher with major amputations and with comorbid DM.10
  3. The mean cumulative health care costs incurred during the 90-day acute stage of associated with DM averaged $65,000 (2017 USD) and increased with more proximal amputation levels.11
    • i. Those associated with transtibial amputation were approximately 60% higher than those observed with toe amputation and 20% less that those observed with transfemoral amputation.11
    • ii. After accounting for inflation, these costs increased 16% to 25% between 2004 and 2010.11
  4. For those undergoing LLA with comorbid DM, the cumulative health care costs incurred during the 24 weeks of acute postamputation rehabilitation are comparable to those incurred by individuals undergoing LLA without comorbid DM.12
    • i. The cumulative health care costs 1 year before LLA are approximately 30% higher among those with DM than among those without DM.13
    • ii. The cumulative health care costs in the first 3 years after amputation are 25% higher among those with DM than among those without DM.12
  5. Among patients with CLI, amputation surgeries are less expensive than either reconstructive or restorative vascular surgeries. However, in the Swedish health care system, amputation was associated with a longer hospital stay, such that cumulative surgical/hospital costs for those with primary amputation exceeded those observed with primary reconstructive or restorative vascular procedures.13
  6. Approximately 60% of the prostheses and 26% of the socket replacements provided within 8 years of unilateral transtibial amputation due to vascular disease are provided within the first year postamputation. Prosthetic maintenance costs are approximately 20% of primary prosthetic costs within the Swedish health care system.14
  7. Among those who undergo unilateral transtibial amputation due to vascular disease, approximately 40% will likely require subsequent amputation in the form of proximal revision amputation to the ipsilateral limb or contralateral amputation, with attendant impact on total health care costs.14
Back to Top | Article Outline

AMPUTATIONS IN VETERANS RELATED TO MILITARY TRAUMA

  • 8. The anticipated costs for prostheses and assistive devices for Vietnam-era veterans are roughly 60% higher for those with multiple amputations compared with those with unilateral LLA.2
  • 9. The anticipated costs for prostheses and assistive devices for OIF/OEF-era veterans are approximately 97% higher for those with multiple amputations compared with those with unilateral LLA.2
  • 10. Veterans who sustained LLA in Vietnam tend to have reduced prosthetic costs compared with those who sustained LLA in OIF/OEF due to their collective use of fewer, less technologically advanced prosthetic devices.2
    • i. Among veterans with major unilateral LLAs sustained in combat, the mean anticipated costs for prostheses and assistive devices are 178% to 327% higher for those sustained in OIF/OEF than those sustained in Vietnam.2
    • ii.Among veterans with multiple limb amputations sustained in combat, the mean anticipated costs for prostheses and assistive devices are 246% to 409% higher for those sustained in OIF/OEF than those sustained in Vietnam.2
  • 11. Among British war veterans who sustained major limb amputations, the anticipated 40-year health costs of an individual with unilateral transtibial amputation (US $1.4 million in 2017 currency) are 25% less than those associated with unilateral transfemoral amputation and 16% less than those associated with bilateral transtibial amputation.16
Back to Top | Article Outline

OTHER MISCELLANEOUS PROSTHETIC CARE CONSIDERATIONS

  • 12. The lifetime costs associated with amputation secondary to severe tibial fracture may be more than twice those associated with limb salvage due to the ongoing replacement costs associated with prostheses. This disparity reduces with advancing age at the time of amputation.19
  • 13. The costs associated with multidisciplinary foot protection clinics appear to be offset by the health care savings that accompany reduced rates of amputation and associated prosthetic care.20
Back to Top | Article Outline

DISCUSSION

IMPACT OF DIABETES MELLITUS, PERIPHERAL ARTERIAL DISEASE, AND CRITICAL LIMB ISCHEMIA ON AMPUTATION-RELATED HEALTH CARE COST

An area of prosthetic rehabilitation receiving a large amount of descriptive consideration related to health care costs associated with LLA was in individuals with the common predisposing conditions of DM, PAD, and/or CLI. Unfortunately, the economic data reported in these publications are difficult to aggregate and compare due to variation in specific costs included in each analysis. These ranged from operative costs only to inpatient costs, to aggregate health care costs across extended postamputation timelines. Although these articles include both US and international economic observations over the past 20 years, their respective findings have been converted to 2017 USD in Table 1.

Yin et al.9 reported inpatient costs of LLA among patients with DM in the United States. Their data, taken from the 2007 National Inpatient Sample of the Healthcare Cost and Utilization Project, reports on 9066 LLAs from DM from 39 states. The average inpatient cost was reported at $17,103 (2007 USD) of which 55.3% of the variance could be explained by the following patient and hospital factors: age, race, length of hospital stay, amputation level, in-patient mortality, primary payer, comorbidities, and type of hospital (i.e., rural, urban nonteaching, and urban teaching). Unfortunately, the directionality of the effects of these variables was not reported. By contrast, the variables of sex, hospital size, and a hospital’s volume of LLAs were nonsignificant in their contributions. This implies that nearly half of the variability in inpatient costs for LLAs from DM was not explained by these variables. After accounting for the known influences identified previously, the highest unexplained costs were observed in California, Oregon, and Washington, whereas the lowest amounts of unexplained costs were observed in Kentucky, Tennessee, and Arkansas.

Some directionality is suggested by Malone et al.,10 reporting on the length of hospital stay and associated costs among Australian patients with and without DM undergoing vascular surgeries secondary to PAD. Increased inpatient costs were reported for both minor (toe) and major (proximal to the toe) amputations when DM was comorbid with PAD. For minor amputations, the average inpatient costs rose from $21,849 (USD) among patients with PAD only to $27,068 for patients with PAD as well as DM. Similarly, for major amputations the associated inpatient costs were reported at $40,195 and $42,236, respectively. Notably, patients with both PAD and DM were three times more likely to require an amputation than those with PAD only. The comorbid patients in both groups (minor and major amputations) had increased lengths of stay and inpatient costs than their peers with PAD only, but these increases were not significantly different.

A broader view of the comprehensive costs associated with LLAs among patients with DM is found in the work of Franklin et al.11 in their analysis of the subpopulation of US veterans meeting this description in fiscal years 2004 and 2010. Their analysis aggregated inpatient medical, inpatient surgical, outpatient care, and medication-related costs incurred between 30 days before and 60 days after LLA. The mean health care costs (2012 USD) for veterans who underwent LLAs in 2004 were $33,205, $53,261, and $69,726 at the toe, transtibial, and transfemoral amputation levels, respectively. These mean costs in 2010 were $41,484, $71,067, and $82,758, respectively. The mean cost of all amputations levels increased 20% during this interval, from $50,351 to $60,647.

A related study from Germany reported the impact of DM on health care costs before and after lower-limb surgery. As with the US veteran study described previously, Hoffmann et al.12 aggregated comprehensive health care costs including hospitalization, rehabilitation, outpatient care, pharmaceutical prescriptions, nonphysician services, durable medical equipment, and long-term care. These costs for those with and without DM were retrospectively aggregated for the year before amputation and then at defined intervals postamputation. During the year before amputation, health care costs were higher for those with DM ($37,427 vs. $28,961 2017 USD). Health care costs from the time of amputation through the first 24 weeks after amputation were similar between the two cohorts (approximately $55,000 2017 USD). Thereafter, the health care costs of those with DM began to exceed those of their peers with amputation that did not have DM. Three years postamputation, the average cumulative health care costs for those with DM exceeded those for patients without DM ($176,681 and $141,835, respectively, 2017 USD).

The economic implications of PAD in its advanced form of CLI can be inferred by a study of 321 Swedish patients managed surgically via reconstructive, restorative, or amputative procedures.13 Of note, these vascular procedures rarely occurred in isolation, evidenced by the fact that the 321 subjects ultimately underwent 978 surgical procedures. Major LLA was the primary operation in 36% of the reported cases and ultimately accounted for 38% of the reported procedures. Thus, it was also frequently indicated among those with reconstructive and restorative procedures as their primary operation. Among the former, 34% required amputation ipsilateral to the reconstruction procedure with an additional 20% requiring amputation contralateral to the reconstruction procedures. Among the latter, 48% required amputation ipsilateral to the restorative procedure and 14% required amputation to the contralateral limb. Ultimately, the surgical costs for reconstructive procedures were twice those reported for restorative procedures and more than three times higher than those reported for amputation. The average costs for major and minor amputation surgeries were reported at $1,500 and $984, respectively (in 1996 USD). Patients with amputation as their primary operation underwent fewer surgical procedures, but had longer length of stay in the hospital (152 days) compared with those undergoing primary reconstructive (101 days) or restorative vascular procedures (96 days). Ultimately, the mean surgical and hospital costs reported in patients undergoing primary amputation was $54,000 (in 1996 USD), compared with $46,000 in patients undergoing primary reconstructive vascular procedures and $41,000 in patients undergoing primary restorative vascular procedures.

A second Swedish study from the same period reported prosthetic costs incurred by patients with unilateral transtibial amputation due to vascular disease.14 This effort reported on 112 patients treated with unilateral transtibial amputation. At 6 and 12 months postamputation, 50% (n = 56) and 63% (n = 71), respectively, had been fitted with a prosthesis. Eight years postamputation, this fitting rate was unchanged (71 of 112 subjects). By this point, with an 8-year mortality rate of 92%, only 9 subjects were still alive. During the 8-year period, 137 prostheses and 54 socket replacements had been provided, facilitating the determination that 59% of the prostheses and 26% of the socket replacements provided within 8 years of an amputation were provided within the first year postamputation. Ultimately, nine of those subjects ultimately fitted with a prosthesis (13%) required revision amputation to the through-knee/transfemoral level and 20 subjects (28%) required contralateral major LLA. During this same 8-year period, the median cost of prosthetic care was $1,582 (in 1997 USD). Median costs for prostheses were reported at $898 for transtibial prostheses, $1,251 for through-knee prostheses, and $2,409 for transfemoral prostheses. Median costs for socket replacements were reported for transtibial ($733) and through-knee/transfemoral ($1,202) sockets. Reported maintenance costs during this period represented 20% of the total primary costs for prostheses and socket replacements. The authors also determined the functional level for patients who had received prostheses and reported that there was no difference in median prosthetic costs between the two groups.

Back to Top | Article Outline

HEALTH CARE COSTS OBSERVED AMONG VETERANS WITH MILITARY TRAUMA-RELATED AMPUTATIONS

Blough et al.2 surveyed 581 service members with major traumatic amputations acquired in the Vietnam War and OIF/OEF to determine prosthetic utilization. Then, establishing the associated prosthetic costs in 2005 USD, they attempted to project future prosthetic costs for these wounded veterans at 5 years, 10 years, 20 years, and lifetime projections. Their findings are summarized in Table 2. Those veterans who sustained amputations in Vietnam had reduced prosthetic costs due to their collective use of fewer, less technologically advanced prosthetic devices, and higher rates of prosthetic abandonment.

In addition to the costs of prostheses, when amputations occur in the line of duty, the military also provides financial compensation, which is tied to the level of disability. Maynard et al.15 reported the monthly compensations paid to veterans with amputations sustained during the Vietnam, Desert Shield/Desert Storm, and OIF/OEF conflicts. Notably, 94% of those veterans studied had disabilities beyond their amputations with posttraumatic stress disorder being the most frequently observed. Monthly mean compensation values, reported in 2007 USD, were similar for veterans from all three military operations, reported at just over $3,000 for the half of all veterans with a 100% disability rating and just under $2,000 for their peers with disability ratings less than 100%. These are summarized in Table 2.

In a final article, Edwards et al.16 report on their efforts to project the lifetime health care costs of British veterans who sustained at least one major amputation in Afghanistan. Utilizing a systematic review of existing literature on care costs for persons with amputation, the authors determined and reported the anticipated health care costs for these veterans based on amputation level. These ranged from $1.34 million for unilateral transtibial amputation to $2.47 million for bilateral transfemoral amputation. These are shown in Table 2.

Back to Top | Article Outline

OTHER MISCELLANEOUS PROSTHETIC CARE CONSIDERATIONS

HEALTH CARE COSTS ASSOCIATED WITH OTHER DISCRETE TREATMENT POPULATIONS

In addition to DM, PAD, CLI, and traumatic military amputations, two additional niche populations, children with traumatic amputations secondary to lawnmower injury and farmers and ranchers who have sustained major amputations, have been reported in the literature. Loder et al.17 attempted to project the long-term lower-limb prosthetic costs in the United States among children who sustain traumatic lawnmower amputation. They determined that the prosthetic costs from the time of injury to the age of 18 ranged from $73,140 to $116,040 (2003 USD). Using amputation prevalence data, they estimated the annual burden for prosthetic costs due to lawnmower amputation to range from $43.88 to $75.42 million (2003 USD).

Waldera et al.18 reported a set of structured interviews that took place with 40 farms and 26 prosthetists. Cost was among the common themes identified through this effort. The authors provided generic cost-related summarizing statements from these interviews. For example, most farmers do not receive workers’ compensation benefits because they are small business owners. Farmers and clinicians agreed that insurance coverage is often inadequate for this population with high deductibles and low lifetime coverage limits. Poor durability trends observed in this vocation constituted another cost-related concern. Finally, because of their rural living environments, several farmers reported long travel distances to see their prosthetist and receive prosthetic care. However, outside of these general trends and concerns, no actual costs were reported.

Back to Top | Article Outline

COST CONSIDERATIONS WHERE AMPUTATION REPRESENTS ONE OPTION ACROSS A SPECTRUM OF CARE

Two common causes of LLA are severe tibial fractures and nonhealing ulceration. In both cases, amputation represents one course of intervention. When selecting between treatment options, health care costs are reasonably considered.

Chung et al.19 reported the comparative costs observed between limb salvage and amputation in the management of severe, open tibial fractures. They assert that the average lifetime cost of limb salvage in such cases is $163,282 (2002 USD). By contrast, the average lifetime cost of limb amputation was reported at $509,275 (2002 USD). Within this figure, they assert that prostheses will be replaced every 2.3 years with annual maintenance costs of 20%. Using an average prosthetic cost of $10,232, this equates to $181,500 in prosthetic costs over 40 years. The cost differential between limb salvage and amputation decreases with increasing age at the time of the event and life expectancy after injury.

At the institutional level, Nason et al.20 examined the 2-year costs at an Irish university hospital setting before and immediately after the implementation of a multidisciplinary foot protection clinic. Their findings are reported in Euros, presumably in 2010 currency, but for the sake of this review, they are presented as percentages of baseline costs. The authors report that the implementation of the clinic resulted in a decrease in both hospital and prosthesis costs of 13.6%. These health care savings were partially offset by the addition of multidisciplinary human resources (i.e., consultant, administrators, nurses) and total contact footwear, casts, and other orthoses. Ultimately, the number of amputations reduced from 12 cases before the clinic implementation to seven cases after the establishment of the clinic. Total costs (i.e., hospital, prostheses, staff, and footwear) ultimately decreased by 9% in the 2 years following the implementation of the multidisciplinary foot clinic.

Back to Top | Article Outline

ADDITIONAL PROSTHETIC-RELATED ECONOMIC CONSIDERATIONS

Beyond the articles cited previously, three additional publications were identified that included economic considerations relative to lower-limb prosthetic intervention. Rogers et al.,21 in their description of transtibial socket fabrication using selective laser sintering, refer to the potential scale economies that would increase the viability of additive manufacturing by reducing fabrication costs. Authors were unable to find evidence of widespread adoption of this technique in current practice.

In a separate Malaysian publication, Gholizadeh et al. describe the HOLO suspension system. This Velcro-based suspensions system is described and evaluated in terms of mechanical testing and patient questionnaire.22 In addition, the authors describe the associated economic considerations by pointing out that the cost of the HOLO system at US $5 is 1/35th the cost relative to widely used pin lock systems, a consideration of substantial importance in resource-limited practice settings.

Finally, Paul et al.23 reported upon the rehabilitation of persons with bilateral LLAs in India including the impact of severe resource limitations on outcomes. They report on 25 individuals with bilateral amputations of whom 11 (44%) attained successful prosthetic ambulation. Six of the subjects were not fitted with prostheses due to the extremely short nature of their bilateral transfemoral amputation. An additional 5 subjects (20%) failed to attain prosthetic ambulation because they simply could not afford prostheses. These were day laborers and unskilled workers who had been the primary wage earners in their homes and could no longer work. Their wives attempted to supplement the resultant financial deficits, but were able to earn just enough income to feed immediate family members. These individuals attained wheelchair mobility, not because of physical limitation, but due to simple financial constraint.

Back to Top | Article Outline

LIMITATIONS

The EBEOs derived from this narrative review of descriptive literature are inherently limited by the scarcity of existing economic literature associated with prosthetic rehabilitation. Thus, the aim of this review was not to provide a comprehensive overview of such economics, but rather, to summarize existing resources.

Back to Top | Article Outline

CONCLUSIONS

This project systematically reviewed the narrative literature related to transtibial and lower-limb prosthetic health economics and produced 13 EBEOs. Specifically, the review indicates a broad range of expected inpatient costs associated with LLA associated with DM, PAD, or both, as well as those health care costs associated with the 90-day acute stage beginning 30 days before LLA associated with DM. Although comorbid DM appears to increase health care costs before amputation and during chronic prosthetic rehabilitation, during the first 24 weeks after amputation, cumulative health care costs are comparable to those experienced by patients without DM. Among patients with CLI, amputation surgery is less expensive than reconstructive or restorative vascular surgeries, but has been associated with longer hospitalization and increased overall health care costs. The majority of primary prosthetic costs are experienced in the first year after unilateral amputation due to vascular disease. However, revision amputation and amputation of the contralateral limb are not uncommon and include additional economic impact.

Among US veterans who sustained a major amputation in conflict, those injured in Vietnam have lower projected prosthetic costs than those injured in OIF/OEF due to the use of fewer, less advanced prosthetic technologies. Among British veterans injured in combat, the lifetime costs following unilateral transtibial amputation are 25% less than those associated with unilateral transfemoral amputation and 16% less than those associated with bilateral transtibial amputation. With exclusive regard to economic implications, limb salvage has been associated with reduced lifetime health care costs relative to amputation and the costs of wound care/foot protection clinics appear to be offset by reduced health care expenses associated with amputation and subsequent prosthetic rehabilitation.

Back to Top | Article Outline

REFERENCES

1. Centers for Medicare and Medicaid Services. National Health Expenditure Projections 2016-2025. Forecast Summary. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html. Accessed June 8, 2017.
2. Blough DK, Hubbard S, McFarland LV, et al. Prosthetic cost projections for servicemembers with major limb loss from Vietnam and OIF/OEF. J Rehabil Res Dev 2010;47(4):387–402.
3. Levinson DR. Questionable billing by suppliers of lower limb prostheses. U.S. Dept. of Health and Human Services. Office of the Inspector General 2011.
4. Dillingham TR, Pezzin LE, Shore AD. Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputations. Arch Phys Med Rehabil 2005;86(3):480–486.
5. Highsmith MJ, Kahle JT, Lewandowski A, et al. Economic evaluations of interventions for transtibial amputees: a scoping review of comparative studies. Technol Innov 2016;18(2–3):85–98.
6. Yong YV, Shafie AA. Economic evaluation of enhanced asthma management: a systematic review. Pharm Pract (Granada) 2014;12(4):493.
7. World Development Indicators. PPP conversion factor (GDP) to market exchange rate ratio. The World Bank Group; 2017. Available at: http://data.worldbank.org. Accessed October 12, 2017.
8. World Development Indicators. Inflation, GDP deflator (annual %). The World Bank Group; 2017. Available at: http://data.worldbank.org. Accessed October 12, 2017.
9. Yin H, Radican L, Kong SX. A study of regional variation in the inpatient cost of lower extremity amputation among patients with diabetes in the United States. J Med Econ 2013;16(6):820–827.
10. Malone M, Lau NS, White J, et al. The effect of diabetes mellitus on costs and length of stay in patients with peripheral arterial disease undergoing vascular surgery. Eur J Vasc Endovasc Surg 2014;48(4):447–451.
11. Franklin H, Rajan M, Tseng CL, et al. Cost of lower-limb amputation in U.S. veterans with diabetes using health services data in fiscal years 2004 and 2010. J Rehabil Res Dev 2014;51(8):1325–1330.
12. Hoffmann F, Claessen H, Morbach S, et al. Impact of diabetes on costs before and after major lower extremity amputations in Germany. J Diabetes Complications 2013;27(5):467–472.
13. Eneroth M, Apelqvist J, Troëng T, Persson BM. Operations, total hospital stay and costs of critical leg ischemia. A population-based longitudinal outcome study of 321 patients. Acta Orthop Scand 1996;67(5):459–465.
14. Hermodsson Y, Persson BM. Cost of prostheses in patients with unilateral transtibial amputation for vascular disease. A population-based follow-up during 8 years of 112 patients. Acta Orthop Scand 1998;69(6):603–607.
15. Maynard C, Flohr B, Guagliardo TA, et al. Department of Veterans Affairs compensation and medical care benefits accorded to veterans with major limb loss. J Rehabil Res Dev 2010;47(4):403–408.
16. Edwards DS, Phillip RD, Bosanquet N, et al. What is the magnitude and long-term economic cost of care of the British Military Afghanistan amputee cohort? Clin Orthop Relat Res 2015;473(9):2848–2855.
17. Loder RT, Dikos GD, Taylor DA. Long-term lower extremity prosthetic costs in children with traumatic lawnmower amputations. Arch Pediatr Adolesc Med 2004;158(12):1177–1181.
18. Waldera KE, Heckathorne CW, Parker M, Fatone S. Assessing the prosthetic needs of farmers and ranchers with amputations. Disabil Rehabil Assist Technol 2013;8(3):204–212.
19. Chung KC, Saddawi-Konefka D, Haase SC, Kaul G. A cost-utility analysis of amputation versus salvage for Gustilo type IIIB and IIIC open tibial fractures. Plast Reconstr Surg 2009;124(6):1965–1973.
20. Nason GJ, Strapp H, Kiernan C, et al. The cost utility of a multi-disciplinary foot protection clinic (MDFPC) in an Irish hospital setting. Ir J Med Sci 2013;182(1):41–45.
21. Rogers B, Bosker GW, Crawford RH, et al. Advanced trans-tibial socket fabrication using selective laser sintering. Prosthet Orthot Int 2007;31(1):88–100.
22. Gholizadeh H, Abu Osman NA, Eshraghi A, et al. Evaluation of new suspension system for limb prosthetics. Biomed Eng Online 2014;13:1.
23. Paul R, Masilamani S, Dwyer AJ. Evaluation of rehabilitated bilateral lower limb amputees—an Indian study. Disabil Rehabil 2012;34(12):1005–1009.
© 2019 by the American Academy of Orthotists and Prosthetists.