Is surgery for displaced, midshaft clavicle fractures in adults cost-effective? Results based on a multicenter randomized, controlled trial

Abstract

Objectives: To determine the cost-effectiveness of open reduction internal fixation (ORIF) of displaced, midshaft clavicle fractures in adults.

Design: Formal cost-effectiveness analysis based on a prospective, randomized, controlled trial.

Setting: Eight hospitals in Canada (seven university-affiliated and one community hospital).

Patients/participants: One hundred thirty-two adults with acute, completely displaced, midshaft clavicle fractures.

Intervention: Clavicle ORIF versus nonoperative treatment.

Main outcome measurements: Utilities derived from SF-6D.

Results: The base case cost per quality-adjusted life-year (QALY) gained for ORIF was $65,000. Cost-effectiveness improved to $28,150/QALY gained when the functional benefit from ORIF was assumed to be permanent with cost per QALY gained falling below $50,000 when the functional advantage persisted for 9.3 years or more. In other sensitivity analyses, the cost per QALY gained for ORIF fell below $50,000 when ORIF cost less than $10,465 (base case cost $13,668) or the long-term utility difference between nonoperative treatment and ORIF was greater than 0.034 (base case difference 0.014). Short-term disutility associated with fracture healing also affected cost-effectiveness with the cost per QALY gained for ORIF falling below $50,000 when the utility of a fracture treated nonoperatively before union was less than 0.617 (base case utility 0.706) or when nonoperative treatment increased the time to union by 20 weeks (base case difference 12 weeks).

Conclusions: The cost-effectiveness of ORIF after acute clavicle fracture depended on the durability of functional advantage for ORIF compared with nonoperative treatment. When functional benefits persisted for more than 9 years, ORIF had a favorable value compared with many accepted health interventions.

Figure 1

Model indicating complications and outcomes following ORIF or nonoperative treatment. The broken lines indicate collapsed branches of the tree when a patient is assigned to surgery for a complication, and these branches have similar patterns to those shown for ORIF. p indicates the probability of an event, q indicates quality adjusted life years associated with a long-term outcome, and # indicates a probability of 1-probability of the alternative outcome.

Figure 2

Two way sensitivity analysis for the long-term utility of ORIF (y-axis) and the duration of functional benefit following ORIF (x-axis). This plot allows one to evaluate the ICER for various combinations of these two variables. The blue shaded area indicates the combinations of these two variables that yield an ICER of below $50,000/QALY, while the green area includes combinations with an ICER of above $50,000/QALY. The black circle indicates the base case.

Figure 3

Two way sensitivity analysis for the utility of nonoperative treatment prior to union (y-axis) and the time (years) to union with nonoperative treatment (x-axis). This plot allows one to evaluate the ICER for various combinations of these two variables. The blue shaded area indicates the combinations of these two variables that yield an ICER of below $50,000/QALY, while the green area includes combinations with an ICER of above $50,000/QALY. The black circle indicates the base case.