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52 Hyperbaric Oxygenation Therapy KCE Reports 74
4.4.2 Costs
Survival at 3 years was 72% for the foot ulcer patients versus 87% for a group of ageand
sex-matched diabetic patients without foot ulcers (p < 0.001). 117 The mortality
associated with amputation is also high. As mentioned by Wheen et al., 83 in-hospital
mortality was between 11 and 13% in the US 118, 119 and 18% in Denmark. 120 These
mortality rates should be taken into account when gained life years are calculated.
Furthermore, a correct estimation of QoL is necessary to estimate QALYs. According
to Ragnarson-Tennvall et al., 97 QoL significantly reduces in patients with ulcers or after
major amputations. These patients may not be able to take the stairs, drive a car, etc.
Overall, living independently may become very difficult. The consequences of losing a
lower limb and being transferred to a new environment can also be psychologically
devastating. 121 It is, however, not clear for how many patients and how much QoL
improves. As mentioned above, for diabetic foot ulcers, Abidia et al. 80 also measured
QoL including the generic SF-36 and Hospital Anxiety and Depression scale (HAD
scale) and did not find significant improvements in QoL measures with HBOT greater
than those seen in patients in the control group. With respect to HBOT in
osteoradionecrosis, Dempsey et al. 82 suggested that hyperbaric oxygen treated patients
required fewer analgesics after their 10 th treatment and anecdotally also experienced
longer periods of undisturbed sleep. In contrast, conservative treatment patients would
not experience significant reductions in pain and often become dependent on narcotics.
This study, however, did not directly compare HBOT with conservative treatment.
Finally, Pritchard et al. 55 included a measure of QoL (SF-36 health status) following
treatment with HBOT versus air in patients with radiation-induced brachial plexopathy.
They reported the results following 30 sessions. QoL at one week and 52 weeks
appeared to have deteriorated in both groups and any differences between the groups
were not consistently in favour of HBOT. 69 In summary, currently, the extent of both
LYG and QoL gains, and thus QALYs gained, is hard to estimate.
The additional expenses associated with HBOT need to be correctly measured against
health outcomes and cost consequences. The investment costs for the hyperbaric
chamber are high and differ according to the type of chamber (see part on cost
calculation). The monoplace chamber is the less costly option for initial setup and
operation but provides less opportunity for patient interaction while in the chamber. 73
Additional costs for renovations or construction to house the chamber could also be
substantial. 74 Next to these installation costs, the maintenance costs, cost for
consumables and durables, and operational costs of the multidisciplinary team capable of
treating all the recognized indications for HBOT should be taken into account. Other
short- and long-term incremental costs differ according to indication. In the following
paragraphs, we provide an overview of variables which should be taken into account for
an economic evaluation of HBOT and the treatment of diabetic foot ulcers. For other
indications, other variables may be important.
HBOT treatment is suggested to decrease amputation rates. Initially, this will influence
the extra cost of prostheses. Cost differences also exist between infected ulcers being
healed and not requiring amputation versus lower-extremity amputations. In a US study,
this cost was about $17 500 and more than $30 000, respectively. 106 Apelqvist et al. 122
(1995) analyzed the three year follow-up costs for 274 patients with diabetic foot ulcer
from the time of healing. Total costs for patients who achieved primary healing and did
not have critical ischemia were $16 100 per patient compared to $43 100 and $63 100
per patient for patients who had required a minor or major amputation, respectively.
Hospitalisation stay costs may also differ. In the study of Baroni et al. 100 the mean length
of stay for the control group was 81.9 days versus 62.2 days in the HBOT group.
Smaller reductions in hospital stays were noticed in two other studies. The HBOT
group had an average decrease in length of stay of 6.4 days (40.6 versus 47 days) in the
study of Doctor et al. 99 and 7.6 days (43.2 versus 50.8 days) according to Faglia et al. 98
There is, however, a very large variation in length of stay between countries. As
mentioned by Wheen et al., 83 the mean hospital stay for amputations was 29.6 days in
the US. 123 In contrast, in Denmark, this was 81 days for below knee amputations. 120