Evaluating the Cost Effectiveness of the Anterolateral Thigh Free Flap for Lower-Extremity Reconstruction in Rural Africa

PURPOSE: There is a disproportionate incidence of disability secondary to lower limb trauma in Sub-Saharan Africa (SSA) (1). Disability-adjusted life years (DALYs) are the standard unit used by the Global Burden of Disease Study to quantify the morbidity and mortality due to disease (2). The World Health Organization (WHO) recommends that cost-effectiveness of an intervention be measured based the ratio of procedural cost to GDP/capita (3). This study provides the first known assessment of the cost-effectiveness of free flaps for lower extremity reconstruction in SSA. METHODS: We performed a retrospective review on all patients who received an anterolateral thigh (ALT) free flap for lower extremity reconstruction by a single surgeon at an institution in rural Kenya from November 2022 to November 2023. Billing Information for all patients was retrieved. DALYs were calculated based on the database of the Global Health Cost-Effectiveness Analysis Registry using a disability weighting of 0.173 for a long-term untreated amputated lower limb, a discount rate of 0.03 and an age weighting parameter of 0.04. RESULTS: Ten patients (9 male) received ALT free flaps for lower extremity reconstruction. Average age was 43.3-years. The most common indication for flap was traumatic fracture with soft tissue defect. Average cost of hospital admission was $864. The average DALY per lower extremity reconstruction was 7.14. The GDP/capita for Kenya is $2,070. The average cost per DALY averted was $121. CONCLUSIONS: Interventions performed for less than three times the GDP/capital per DALY are considered cost-effective by the WHO. Interventions performed for less than one GDP/capita per DALY are very cost-effective. In our setting, ALT free flaps for lower extremity reconstruction are very cost effective as they can be performed for 5% of the GDP/capita per DALY. Efforts should be made to increase microsurgical capabilities in SSA. REFERENCES: 1. Bach O, Hope MJ, Chaheka CV, Dzimbiri KM. Disability can be avoided after open fractures in Africa-results from Malawi. Injury. 2004;35(9):846-851. doi:10.1016/j.injury.2003.11.014 2. Murray CJL, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet. 2012;380(9859):2197-2223. doi:10.1016/S0140-6736(12)61689-4 3. Hutubessy R, Chisholm D, Edejer TTT. Generalized cost-effectiveness analysis for national-level priority-setting in the health sector. Cost Eff Resour Alloc. 2003;1(1):8. doi:10.1186/1478-7547-1-8