Page 19 - REV T-I JOURNAL INTERIOR ISSUU 18 2-3

TRANSTIBIAL ECONOMIC EVALUATIONS 95

differences among the alternatives. Therefore, accord- It is rated as fair quality according to the QHES. This
ing to the included studies (25,26), there is no cost evidentiary support provides moderate confidence in
reduction or clinical performance difference between the clinical outcomes and fair confidence in the eco-
the interventions. Although the PTB sockets have a nomic analysis. Again, further studies are needed to
lower initial cost, the additional clinic visits, which strengthen confidence in EES 5. Additionally, authors
require increased time commitments and travel costs were unable to locate data to support widespread
as well as the risk of potential complications, ulti- adoption of direct manufacturing techniques for TTA
mately increase latent costs. Conversely, provision socket provision.
of the more costly (initial cost) total-contact alter- A second purpose of this scoping review was to
native sockets results in fewer of these additional determine if further review and analysis is indicated
expenses and visits. Thus, the interventions appear based on the current state of the economic science
to be economically equivalent when viewed from all relative to care for the patient with TTA. It seems that
stakeholder perspectives in the short term. This fourth further analysis of economic comparison studies is
EES is supported by two studies, both with moderate less of an issue compared with the need for further
internal validity and high external validity (25,26). primary economic comparison research, input, and
Both are rated as fair quality studies according to the guidance from the profession relative to a strategy to
QHES. This evidentiary support provides moderate further develop this area of research. Additionally,
confidence in the clinical outcomes and fair confi- multiple manuscripts were excluded from this analysis
dence in the economic analysis. In contrast to these of economic comparisons that alternatively provide
studies, a recent systematic review suggests that use of descriptive economic information relative to care
gel-lined sockets, as opposed to traditional PTB sock- for persons with TTA. These excluded narrative eco-
ets, results in numerous clinical benefits, including nomic papers merit further review and analysis and
decreased walk aid dependence, improved suspen- are currently being evaluated by the authors.
sion options, improved load distribution, decreased
pain, and increased comfort (35). This systematic Limitations
review of clinical studies suggests gel-lined sockets
offer clinical improvements relative to PTB sockets Many subjects in this report were patients of limb
and is supported by Level 1 evidence. Thus, if clini- salvage procedures selected for comparison to TTA
cal outcomes are improved with total-contact sockets, cases. Unfortunately, many individual aspects of tran-
users may realize greater value through their use rel- stibial prosthetic intervention are not represented or
ative to PTB alternatives. This particular topic and are under-represented in the health care economic lit-
EES also point out the importance of considering all erature. Currently, economic evaluations in any area
perspectives in an economic analysis. A limitation of of transtibial patient care are limited. There were no
this EES is the time horizon. It is unclear if there are cost-benefit, cost-effectiveness, or cost-utility analyses
potential functional or cost differences over the long identified in this search, as all available studies were
term between specific weight-bearing and total-con- cost-identification or cost-consequence studies. No
tact socket alternatives. economic modeling was identified. Further, described
The second statement (EES 5) within the Prosthetic services and interventions were not quantifiably
Socket topic addresses traditional plaster casting connected directly to health measures. Therefore,
fabrication with direct manufacturing methods of more sophisticated and comprehensive economic
providing prosthetic sockets for patients with TTA. evaluations are needed with regard to transtibial inter-
Direct fabrication methods of socket delivery report- ventions to better understand the potential value of
edly have 32% higher initial provision costs but are certain interventions for the patient with TTA. One
delivered to patients up to 58% faster and in fewer possible solution is to incorporate outcomes condu-
visits. This EES is supported by a single study with cive to economic analysis and modeling as part of
moderate internal validity and high external validity. prosthetic oriented clinical trials (35). While total