An interesting article titled “Is Surgical Repair With Nerve Allograft More Cost-Effective Than Non-Surgical Management for Persistent Trigeminal Neuropathy? Initial Assessment With Q1 Markov Model,” written by Benjamin Palla and et. al. appears in the Journal of Oral an Maxillofacial Surgery published online February 17, 2023. The article explores if surgical repair with allogeneic nerve graft a more cost-effective
treatment option than no surgery.
The article explores patients who suffer from trigeminal nerve injuries and how in some patients that show no signs of improvement after 3 months they are considered to have persistent trigeminal neuropathy (PTN). This condition can result as a complication of wisdom teeth removal. This condition can affect aspects of daily life including tooth brushing, flossing, talking, eating, drinking, chewing, smiling, kissing, and sleeping. A total of 36% of patients with trigeminal neuropathy have depression and many expeirence job loss and reduced quality of life.
In the article the authors used a computer-based Markov model developed with TreeAge Pro Healthcare 2022 to estimate lifetime costs to patients with PTN treated with either surgical nerve allograft treatment or nonsurgical treatment. The model ran for 40 years with one-year cycles on a 40-year-old “model” patient was healthy except for having persistent inferior alveolar or lingual nerve injury at three months after nerve injury without signs of improvement and without dysesthesia or neuropathic pain.
Nerve injuries were assessed and graded using the MRCS scale developed by Seddon. Using the 2022 Medicare Physician Fee Schedule, the authors etimate costs involved with surgery. To assesss nonsurgical treatment direct costs, including specialist referral, medications, and imaging, and indirect costs, like quality of life (QoL) and loss of employment, the authors used historical data and research. Direct surgical costs for allograft repair were found to be $13,291. While state-specific direct costs for hypoesthesia/anesthesia were $2,127 per year, and neuropathic pain were $3,168.24 per year respectivley.
The authors found that surgical treatment with nerve allograft had a cost-effectiveness ratio of 10,751.94 indicating surgerical treatment was more effective and had a lower long-term cost for patients with PTN. Further the authors calculated the net monetary benefits of surgical treatment of $1,158,339 compared to $830,654 for non-surgical treatment. For the first five years after surgery the total cost of surgical treatment was greater than non-surgical treatment while at this point the cost of non-surgical treatmentncreases continuously and remains higher than the surgical treatment. The authors state:
“The Markov model performed here was the first, to our knowledge, to analyze the direct and indirect costs of nerve allograft, as well as the first to combine the direct and indirect costs of non-surgical treatment, with the expected treatment outcomes. Despite the high initial costs associated with nerve allograft, surgical treatment achieved cost-equivalency at year 5, and it was the most cost-effective option by around year 4 due lower indirect costs and the benefit to the patient’s QoL”
The authors mention limitations of the study which includes the theoretical modeling was based primarily on current literature and evidence. They mention that various terminology and diagnostic criteria related to trigeminal nerve injuries is not in agreement and this could have adversly impacted their model.