An Economic Analysis of the Timing of Microsurgical Reconstruction in Brachial Plexus Birth Palsy

The role and timing of microsurgical reconstruction of the brachial plexus in infants who have no signs of biceps recovery within the first 6 months of life is controversial. Microsurgicala reconstruction at 3 or 6 months of age is commonly practiced. The purpose of this study was to create an economic model to compare the costs in relation to effectiveness of surgical treatment at 3 vs. 6 months in brachial plexus birth palsy patients with no return of the biceps at 3 months.

A decision analysis tree was constructed. Natural history, success and failure rate, tendon transfer, and osteotomy rate were estimated from the literature. Costs were estimated from cost-generating events for brachial plexus patients and unit costs from a single center.

In the model, for brachial plexus birth palsy patients with absent biceps, microsurgical intervention at 3 months costs approximately 200% more than intervention at 6 months. The literature for non-avulsion patients supports a biceps return rate during months 4 to 6 of 80%. Using this value, microsurgical intervention at 3 months could not generate a high enough success rate to produce overall cost saving. Sensitivity analysis revealed equal treatment costs if the probability of biceps returning was half the currently published value and surgery at 3 months had a nine times higher success rate than surgery at 6 months. The literature does not support these values. Preliminary outcome results using the Pediatric Outcomes Data Collection Instrument revealed that if similar outcomes scores for successful microsurgery are expected at 3 and 6 months (scores as high as natural history patients), then microsurgical intervention at 3 months remains more expensive but provides on average a 3 point higher global function score.

It is unlikely that microsurgical intervention at 3 months for rupture neurologic injuries will have a high enough success rate to produce overall cost savings. While the analysis should not be used to dictate policy decisions, it is reasonable to consider economic factors and quality of life outcomes in brachial plexus birth palsy management strategies. The study highlights that the outcome data in this area need improvement before it is possible to recommend which treatment will make the most efficient use of resources.