Applying Health Utility Outcome Measures and Quality-Adjusted Life-Years to Compare Hand Allotransplantation and Myoelectric Prostheses for Upper Extremity Amputations.

BACKGROUND: An amputation of the upper extremity not only is devastating for the patient's physical, emotional, and social well-being but also constitutes a financial stress for both the patient and the health care system. The objective of this study was to determine the utility and quality-adjusted life-years of hand allotransplantation versus myoelectric prostheses and to compare these measures in patients afflicted with unilateral versus bilateral amputations. METHODS: A survey was administered on bilateral amputees, unilateral amputees, replantation patients, and healthy controls. Patient demographics, functional patient-reported outcomes, quality-of-life questionnaires, and utility outcome measures were calculated for four different scenarios: hand transplantation and myoelectric prostheses with or without complications. RESULTS: Five bilateral amputees, 12 unilateral amputees, nine replantation patients, and 45 healthy controls completed the survey. The highest quality-adjusted life-years were obtained in the replantation patient group for the scenario of myoelectric prosthesis without complications (mean, 34.8 years). Altogether, there was no statistically significant difference between hand transplantation and myoelectric prostheses (p = 0.36). On subgroup analysis, unilateral amputees reported significantly higher quality-adjusted life-years for myoelectric prostheses rather than hand transplantation (6.4; p = 0.0015), whereas bilateral amputees did not demonstrate a significant difference (-2.4; p = 0.299). CONCLUSIONS: Utility and quality-adjusted life-years do not differ significantly between hand transplantation and myoelectric prostheses, except in unilateral amputees with myoelectric prostheses, who had higher quality-of-life scores. Based on trends from this pilot study, myoelectric prostheses may be considered for unilateral amputees, whereas no superiority can be demonstrated between both treatments in bilateral amputees. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Analysis of Utility Assessment Scores to Objectify the Health Burden Caused by Breast Conservation Therapy.

BACKGROUND: Lumpectomy followed by radiation, known as breast conservation therapy (BCT), is a viable surgical treatment option for early-stage breast cancer. However, the current literature suggests that patients prefer mastectomy over BCT, likely due to the wide variety of postmastectomy reconstructive options. Our aim is to investigate the objective health burden of living with BCT to help surgeons gain a better understanding of patient treatment preferences. METHODS: Three validated health state utility tools were used to objectify the burden of living with post-BCT results: visual analogue scale (VAS), time trade-off (TTO), and standard gamble (SG). A prospective sample of the general population and medical students were recruited, and their responses analyzed to attain these scores. RESULTS: Utility scores for living with BCT are VAS 0.81 ± 0.19, TTO 0.93 ± 0.10, and SG 0.92 ± 0.14. The TTO and SG suggest a willingness to trade 2.5 years of life years and an 8% chance of death undergoing reconstructive procedures to correct a BCT defect, respectively. Age, gender, race, education, and income were not statistically significant independent predictors for higher or lower utility scores. CONCLUSION: The impact of the health burden of BCT was ascertained using validated objective numeric utility scores. These indices demonstrate a willingness to trade less life years to undergo correction of a BCT defect than reconstruction following unilateral mastectomy. They can provide surgeons with the best objective understanding of patient preferences for shared decision-making in the management of breast cancer.

HISTORIQUE: La lumpectomie suivie d'une radiothérapie, ou conservation mammaire (CM), est un traitement chirurgical viable du cancer du sein précoce. Selon les publications, les patients préfèrent toutefois la mastectomie à la CM, probablement en raison du large éventail de possibilités de reconstructions après la mastectomie. Les chercheurs visent à explorer le fardeau objectif d'une vie avec une CM pour la santé, afin d'aider les chirurgiens à mieux comprendre les préférences des patientes en matière de traitement. MÉTHODOLOGIE: Les chercheurs ont utilisé trois outils utilitaires validés sur l'état de santé pour objectiver le fardeau de la vie après une CM : l'échelle visuelle analogique (ÉVA), l'arbitrage temporel (AT) et le pari standard (PS). Ils ont recruté un échantillon prospectif de la population générale et d'étudiants en médecine et ont analysé leurs réponses pour obtenir les scores. RÉSULTATS: Les scores d'utilité d'une vie avec une CM s'établissent comme suit : ÉVA 0,81 ± 0,19, AT 0,93 ± 0,10 et PS 0,92 ± 0,14. L'AT et le PS indiquent respectivement la volonté de perdre 2,5 années de vie et d'accroître le risque de décès de 8 % pendant les interventions de reconstruction pour corriger une anomalie de CM. L'âge, le genre, la race, l'instruction et le revenu n'étaient pas des prédicteurs indépendants statistiquement significatifs des scores d'utilité plus élevés ou plus faibles. CONCLUSION: Les chercheurs ont évalué les répercussions du fardeau de la CM sur la santé au moyen de scores d'utilité numériques validés. Ces indices démontrent la volonté de réduire le nombre d'années de vie pour corriger une anomalie de la CM plutôt qu'une reconstruction après une mastectomie unilatérale. Ils peuvent aider les chirurgiens à mieux comprendre les préférences des patientes pour parvenir à une décision commune en matière de prise en charge du cancer du sein.

A health utility assessment of trapeziectomy with ligament reconstruction and tendon interposition for thumb trapeziometacarpal osteoarthritis.

Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) for trapeziometacarpal joint osteoarthritis may have both postoperative benefits and complications. This study sought to determine the health state utility outcome measures of trapeziectomy with LRTI. Patients who underwent trapeziectomy with LRTI were invited to complete the brief Michigan Hand Questionnaire and utility questionnaires outcomes using a visual analogue scale , time trade-off and standard gamble. Quality-adjusted life years (QALYs) were derived from these utility measures. For this study 32 patients were recruited, with a mean age of 61. Most patients (27/32) perceived the procedure as successful. Utility measures and QALYs serve the purpose of comparing different surgical procedures in terms of their impact on the quality of life of patients as a function of the benefits and complications of each procedure. In this study, the utility of trapeziectomy with LRTI was less than has been described for open palmar fasciectomy but more than for total wrist arthrodesis. Level of evidence: IV.

Nipple-areolar Complex Reconstruction following Postmastectomy Breast Reconstruction: A Comparative Utility Assessment Study.

BACKGROUND: Nipple-areola complex (NAC) reconstruction occurs toward the final stage of breast reconstruction; however, not all women follow through with these procedures. The goal of this study was to determine the impact of the health state burden of living with a reconstructed breast before NAC reconstruction. METHODS: A sample of the population and medical students at McGill University were recruited to establish the utility scores [visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG)] of living with an NAC deformity. Utility scores for monocular and binocular blindness were determined for validation and comparison. Linear regression and Student's t test were used for statistical analysis, and significance was set at P < 0.05. RESULTS: There were 103 prospective volunteers included. Utility scores (VAS, TTO, and SG) for NAC deformity were 0.84 ± 0.18, 0.92 ± 0.11, and 0.92 ± 0.11, respectively. Age, gender, and ethnicity were not statistically significant independent predictors of utility scores. Income thresholds of <$10,000 and >$10,000 revealed a statistically significant difference for VAS (P = 0.049) and SG (P = 0.015). Linear regression analysis showed that medical education was directly proportional to the SG and TTO scores (P < 0.05). CONCLUSIONS: The absence of NAC in a reconstructed breast can be objectively assessed using utility scores (VAS, 0.84 ± 0.18; TTO, 0.92 ± 0.11; SG, 0.92 ± 0.11). In comparison to prior reported conditions, the quality of life in patients choosing to undergo NAC reconstruction is similar to that of persons living with a nasal deformity or an aging neck requiring rejuvenation.

A comparison and cost analysis of cranioplasty techniques: autologous bone versus custom computer-generated implants.

BACKGROUND: Cranioplasty can be performed either with gold-standard, autologous bone grafts and osteotomies or alloplastic materials in skeletally mature patients. Recently, custom computer-generated implants (CCGIs) have gained popularity with surgeons because of potential advantages, which include preoperatively planned contour, obviated donor-site morbidity, and operative time savings. A remaining concern is the cost of CCGI production. The purpose of the present study was to objectively compare the operative time and relative cost of cranioplasties performed with autologous versus CCGI techniques at our center. METHODS: A review of all autologous and CCGI cranioplasties performed at our institution over the last 7 years was performed. The following operative variables and associated costs were tabulated: length of operating room, length of ward/intensive care unit (ICU) stay, hardware/implants utilized, and need for transfusion. RESULTS: Total average cost did not differ statistically between the autologous group (n = 15; $25,797.43) and the CCGI cohort (n = 12; $28,560.58). Operative time (P = 0.004), need for ICU admission (P < 0.001), and number of complications (P = 0.008) were all statistically significantly less in the CCGI group. The length of hospital stay and number of cases needing transfusion were fewer in the CCGI group but did not reach statistical significance. CONCLUSION: The results of the present study demonstrated no significant increase in overall treatment cost associated with the use of the CCGI cranioplasty technique. In addition, the latter was associated with a statistically significant decrease in operative time and need for ICU admission when compared with those patients who underwent autologous bone cranioplasty. LEVEL OF EVIDENCE: IV, therapeutic.

Population preferences of undergoing brachioplasty for arm laxity.

BACKGROUND: The number of patients requesting surgical procedures performed for brachioplasty and massive weight loss is increasing. The authors set out to quantify the health state utility outcome assessment of living with arm deformity requiring brachioplasty. METHODS: Utility assessments using the visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG) were used to obtain utilities scores for arm deformity, monocular blindness, and binocular blindness from a sample of the general population and medical students. Linear regression and Student t test were used for statistical analysis. A P value less than 0.05 was deemed statistically significant. RESULTS: All the measures for arm deformity of the 107 volunteers (VAS, 0.80 ± 0.14; TTO, 0.91 ± 0.12; SG, 0.94 ± 0.10) were significantly different (P < 0.001) from the corresponding measures for monocular blindness and binocular blindness. When compared to the sample of the general population, having a medical education demonstrated a statistical significance of being less likely to trade years of life and less likely to gamble risk of death for a procedure such as a brachioplasty. Race and sex were not statistically significant independent predictors of risk acceptance. CONCLUSIONS: We have objectified the health state of living with upper arm deformity requiring brachioplasty. Utility outcome scores (VAS, 0.80 ± 0.14; TTO, 0.91 ± 0.12; SG, 0.94 ± 0.10) were comparable to living with health states such as aging neck needing rejuvenation, excess skin in the thighs necessitating thigh lift, and massive weight loss requiring panniculectomy based on previously reported studies.

Living with a unilateral mastectomy defect: a utility assessment and outcomes study.

BACKGROUND: The gold standard for the treatment of breast cancer includes mastectomy surgery. Our goal was to quantify the health state utility assessment of living with unilateral mastectomy. METHODS: The visual analogue scale (VAS), time trade-off (TTO), and standard gamble (SG) were used to obtain utilities for unilateral mastectomy, monocular blindness and binocular blindness from a prospective sample of the general population and medical students. RESULTS: All measures (VAS, TTO, SG) for unilateral mastectomy (0.75 SD 0.17, 0.87 SD 0.14, and 0.86 SD 0.18, respectively) of the 140 volunteers were significantly different from the corresponding scores for monocular (0.61 SD 0.18, 0.84 SD 0.17, and 0.84 SD 0.18, respectively) and binocular blindness (0.38 SD 0.17, 0.67 SD 0.24, and 0.69 SD 0.23, respectively). Age, gender, race, education, and income were not statistically significant independent predictors of utility scores. CONCLUSION: In a sample of the general population and medical students, utility assessments for living with unilateral mastectomy were comparable with those of living with bilateral mastectomy and severe breast hypertrophy. Our sample population, if faced living with unilateral mastectomy was willing to gamble a theoretical 14% chance of death and willing to trade 4.2 years of existing life-years.

The impact of living with severe lower extremity lymphedema: a utility outcomes score assessment.

BACKGROUND: Debilitating lower extremity lymphedema can be either congenital or acquired. Utility scores are an objective measure used in medicine to quantify degrees of impact on an individual's life. Using standardized utility outcome measures, we aimed to quantify the health state of living with severe unilateral lower extremity lymphedema. METHODS: A utility outcomes assessment using visual analog scale, time trade-off, and standard gamble was used for lower extremity lymphedema, monocular blindness, and binocular blindness from a sample of the general population and medical students. Average utility scores were compared using a paired t test. Linear regression was performed using age, race, and education as independent predictors. RESULTS: A total of 144 prospective participants were included. All measures [visual analog scale, time trade-off, and standard gamble; expressed as mean (SD)] for unilateral lower extremity lymphedema (0.50 ± 0.18, 0.76 ± 0.22, and 0.76 ± 0.21, respectively) were significantly different (P < 0.001) from the corresponding scores for monocular blindness (0.64 ± 0.18, 0.84 ± 0.16, and 0.83 ± 0.17, respectively) and binocular blindness (0.35 ± 0.17, 0.61 ± 0.28, and 0.62 ± 0.26, respectively). CONCLUSIONS: We found that a sample of the general population and medical students, if faced with severe lymphedema, is willing to theoretically trade 8.64 life-years and undergo a procedure with a 24% risk of mortality to restore limb appearance and function to normal. These findings provide a frame of reference regarding the meaning of a diagnosis of severe lower extremity lymphedema to a patient and will allow objective comparison with other health states.

Thigh laxity after massive weight loss: a utilities outcomes assessment.

BACKGROUND: The presence of excess skin after massive weight loss, particularly in the thighs, not only contributes to a negative body image but can also lead to functional deficits in mobility. In the present study, we quantified the health state utility of living with excess skin in the thighs in an attempt to objectively establish the burden on the quality of life in patients living with excess thigh skin laxity. METHOD: Using visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG), we compared the utility outcome scores for thigh skin excess with monocular and binocular blindness from a prospective sample of medical students and the general population. Utility scores were compared using paired t test. Linear regression was performed using age, race, and education as independent predictors of each of the utility scores. RESULTS: One hundred thirty-four prospective participants were enrolled during a 6-month period, and 112 participants met our inclusion criteria. The utility outcome scores for thigh lift (VAS, TTO, and SG, 0.77 ± 0.15, 0.90 ± 0.11, and 0.89 ± 0.14, respectively) were statistically different from binocular blindness (VAS, TTO, and SG, 0.37 ± 0.18, 0.70 ± 0.23, and 0.70 ± 0.26; P < 0.001), but other than VAS (0.67 ± 0.15, P < 0.001), similar to monocular blindness (TTO and SG, 0.89 ± 0.13 and 0.81 ± 0.14, respectively; P > 0.05). SG (0.89 ± 0.14 vs 0.97 ± 0.02, P = 0.003) and TTO (0.89 ± 0.11 vs 0.95 ± 0.03, P = 0.038) were different between general population and medical students, respectively, corresponding to 3.96 versus 1.80 potential years willing to be traded (P < 0.05). Additionally, SG was higher in whites versus nonwhites who were willing to take a potential 8% chance of mortality compared to 15%, respectively (P = 0.001), to achieve "perfect" health. CONCLUSIONS: We have objectified the utility of living with thigh deformity after massive weight loss. Our sample population if faced with the condition was willing to sacrifice a potential 3.6 years of life and potentially undergo a procedure with 11% chance of mortality to address excess thigh laxity.

An objective assessment of the perceived quality of life of living with bilateral mastectomy defect.

BACKGROUND: Mastectomy is a common treatment for breast cancer. We set out to quantify the health state utility assessment of living with bilateral mastectomy using previously described validated methods. METHODS: Utility assessments using visual analogue scale (VAS), time trade-off (TTO), and standard gamble (SG) were used to obtain utilities for mastectomy, monocular blindness and binocular blindness from a prospective sample of the general population and medical students. RESULTS: All measures (VAS, TTO, SG) for mastectomy (0.70 ± 0.18, 0.85 ± 0.16, and 0.86 ± 0.17, respectively) of the 120 volunteers were significantly different (p < 0.0001) from the corresponding scores for binocular blindness (0.38 ± 0.17, 0.67 ± 0.24, and 0.69 ± 0.23, respectively). Utility scores for mastectomy were not statistically different (p > 0.05) when compared to those for monocular blindness (0.67 ± 0.13, 0.86 ± 0.15, and 0.86 ± 0.15, respectively). Age, gender, race, and income were not statistically significant independent predictors of utility scores. Medical education was associated with statistically significant higher SG compared to general population (0.90 ± 0.11 versus 0.84 ± 0.19; p < 0.05). CONCLUSION: In a sample of the general population and medical students, utility assessments for living with bilateral mastectomy were comparable with those of living with the loss of sight from one eye. Our sample population, if faced with living with bilateral mastectomy, would consent to undergo a procedure such as breast reconstruction with a theoretical 14 percent chance of mortality and be willing to trade 5.4 years of existing life-years for such a procedure.

The impact of living with a functional and aesthetic nasal deformity after primary rhinoplasty: a utility outcomes score assessment.

BACKGROUND: Revision rhinoplasty for functional deformities can be both an aesthetic and reconstructive surgical challenge. We set out to quantify the health state utility assessment of living with the physical appearance of nasal asymmetry along with having nasal obstruction. The use of utility scores has helped to establish the health burden of living with various medical conditions. We sought to quantify living with a health state of nasal asymmetry with nasal obstruction after primary rhinoplasty using utility outcome scores. METHODS: We used previously validated utility outcome measures to quantify the health burden of this clinical scenario in 128 prospective subjects. These subjects were from a sample of the population and medical students recruited to complete a survey to determine the utility outcome score of revision rhinoplasty using visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG) tests to obtain utility scores for revision rhinoplasty. Linear regression and Student t test were used for statistical analysis. RESULTS: All measures (VAS, TTO, and SG) for functional nasal deformity (0.80±0.13, 0.90±0.12, and 0.91±0.13, respectively) of the 128 prospective subjects participating in this online study were significantly different (P<0.005) from the corresponding scores for monocular blindness (0.63±0.15, 0.85±0.16, and 0.85±0.19, respectively) and binocular blindness (0.38±0.18, 0.66±0.25, and 0.69±0.24, respectively). Being white was inversely related to the VAS utility scores for rhinoplasty (P<0.05). Additionally, female sex was positively correlated to the TTO score. Age, income, and education were not predictors of utility scores. CONCLUSIONS: In a sample of the population and medical students, VAS, TTO, and SG utility scores for revision rhinoplasty were determined and can be compared objectively with other health states and diseases with known utility scores. In a preoperative setting, women were objectively willing to potentially "trade" more years of life to treat a functional nasal deformity. If faced with a deformed nose after primary rhinoplasty, our sample population would consent to undergo a revision rhinoplasty procedure with a theoretical 9% chance of mortality and were willing to trade 3.6 years of their remaining life.

Cleft lip and palate: an objective measure outcome study.

BACKGROUND: Cleft lip and/or palate is a debilitating condition if left unrepaired, resulting in significant speech, hearing, swallowing, feeding, and psychosocial impairments. The authors' objective was to determine the potential impact of being born with cleft lip and/or palate by using previously validated health state utility assessment measures. METHODS: A utility assessment using the visual analogue scale, time trade-off, and standard gamble was used to obtain utilities for cleft lip and/or palate, monocular blindness, and binocular blindness from a prospective sample of the general population and medical students. Average utility scores were compared using paired t test. Linear regression was performed using age, race, and education as independent predictors of each of the utility scores. RESULTS: Over a 1-year prospective enrollment period, 110 participants were included in our utility analysis. The utility outcome scores for cleft lip and/or palate (visual analogue scale, time trade-off, and standard gamble, 0.69±0.18, 0.85±016, and 0.84±0.18, respectively) were statistically different from those of binocular blindness (visual analogue scale, time trade-off, and standard gamble: 0.38±0.17, 0.70±0.24, and 0.66±0.25, respectively; p<0.001) but not statistically different from those of monocular blindness (visual analogue scale, time trade-off, and standard gamble, 0.67±0.15, 0.86±0.15, and 0.84±0.18, respectively). There was no statistically significant difference in utility scores between male and female participants. CONCLUSION: The results of the study demonstrate objectively via health state utility scores that the perceived burden of being born with cleft lip and/or palate is comparable to living with monocular blindness.

Utility outcome assessment of the aging neck following massive weight loss.

OBJECTIVE: The authors set out to quantify the health state utility assessment of living with the physical appearance of the aging neck following massive weight loss. Described utility scores may help to establish the health burden of the aging neck in the growing bariatric patient population. STUDY DESIGN: Prospective cohort observational study. SETTING: Tertiary referral medical center. SUBJECTS AND METHODS: Three validated tools were used to determine utility scores for living with an aging neck: visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG). A 5-point Likert scale was used to evaluate the subjects' ease of understanding. A prospective sample of volunteers from the general population and medical students was used for this assessment. RESULTS: In total, 118 prospective volunteers were included in the survey. All measures (VAS, TTO, SG); (0.89 ± 0.07, 0.94 ± 0.08, and 0.95 ± 0.10, respectively) varied (P < .0001) from the corresponding ones for monocular blindness (0.62 ± 0.18, 0.87 ± 0.15, and 0.85 ± 0.20, respectively) and binocular blindness (0.32 ± 0.18, 0.66 ± 0.25, and 0.64 ± 0.28, respectively). CONCLUSION: The authors objectified the health state of living with an aging neck in the massive weight loss patient with utility scores (TTO, 0.94) comparable with those living with obstructive sleep apnea. This sample population, if faced with an aging neck following massive weight loss, would undertake a neck rejuvenation procedure with a theoretical 5% chance of mortality and would be willing to trade 2.1 years of remaining life-years to attain this procedure.

Ageing midface: The impact of surgeon's experience on the consistency in the assessment and proposed management.

An individual's face undergoes numerous changes throughout life. Since mid-face aesthetic units are key areas for rejuvenation procedures, their comprehensive assessment is essential for the development of any aesthetic management plan. Despite the availability of many evaluation criteria for treatment of mid-face ageing, there are discrepancies existing in both assessment and management approaches. The goal of this study was to determine if there are any identifiable profiles of clinical judgements and approaches related to the level of surgeon's experience. Forty seven standardised non-digital and not altered natural size photographic images of patients' faces (front and profile) were presented to eight senior board certified plastic surgeons, eight junior non-board certified plastic surgeons and eight plastic surgery residents from an independent program. Surveyed physicians were 'blinded' from each other and asked to assess five different major features characterising ageing mid-face. An interclass correlation data analysis was performed and the Cronbach coefficient alpha values were computed for each category. Responses obtained from senior plastic surgeons were consistently characterised by higher Cronbach coefficient alpha values indicating higher concordance. The highest agreement levels were obtained for the assessment of rhytids and jowls across all groups and the lowest agreement levels were obtained for the assessment and recommendation of upper lip management. This study illustrated that discrepancies in clinical assessments and surgical management exist among surgeons involved in the aesthetic surgery of the mid-face ageing. It appears that the level of surgeon's experience significantly impacts the inter-rater reliability and consensus in assessment and treatment of mid-face ageing. The most senior plastic surgeons' assessment and recommendations had the highest level of concordance while the junior non-board certified plastic surgeons and the residents group produced variations with less consistency.