Cost-Effectiveness of Treatments after Closed Extraarticular Distal Radius Fractures in Older Adults from the WRIST Clinical Trial

Abstract

Background: This study performs an economic analysis of volar locking plate, external fixation, percutaneous pinning, or casting in elderly patients with closed distal radius fractures.

Methods: This is a secondary analysis of the Wrist and Radius Injury Surgical Trial, a randomized, multicenter, international clinical trial with a parallel nonoperative casted group of patients older than 60 years with surgically indicated, extraarticular closed distal radius fractures. Thirty-Six-Item Short-Form Health Survey-converted utilities and total costs from Medicare were used to calculate quality-adjusted life-years and incremental cost-effectiveness ratio.

Results: Casted patients were self-selected and older (p < 0.001) than the randomized surgical cohorts, but otherwise similar in sociodemographic characteristics. Quality-adjusted life-years for percutaneous pinning were highest at 9.17 and external fixation lowest at 8.81. Total costs expended were $16,354 for volar locking plates, $16,012 for external fixation, $11,329 for percutaneous pinning, and $6837 for casting. The incremental cost-effectiveness ratios for volar locking plates and external fixation were dominated by percutaneous pinning and casting. The ratio for percutaneous pinning compared to casting was $28,717. Probabilistic sensitivity analysis revealed a 10, 5, 53, and 32 percent chance of volar locking plate, external fixation, percutaneous pinning, and casting, respectively, being cost-effective at the willingness-to-pay threshold of $100,000 per quality-adjusted life-year.

Conclusions: Casting is the most cost-effective treatment modality in the elderly with closed extraarticular distal radius fractures and should be considered before surgery. In unstable closed fractures, percutaneous pinning, which is the most cost-effective surgical intervention, may be considered before volar locking plates or external fixation.

Figure 1:

Tornado diagram illustrating one-way sensitivity analyses of ICER between closed reduction percutaneous pinning (CRPP) and casting. The 12-month utilities and age at time of injury were the most important factors that affect cost-effectiveness.

Figure 2:

Two-way sensitivity analysis between age at time of injury and difference in utility between closed reduction percutaneous pinning (CRPP) and casting. If the patient is below the age of 83, even a 0.01 utility gain of CRPP over casting makes CRPP a cost-effective intervention.

Figure 3:

Probabilistic sensitivity analysis with 10,000 iterations by treatment type. At a willingness-to-pay threshold of $100,000/QALY, there is a 10%, 5%, 53%, and 32% chance of volar locking plate (VLP), external fixation (ex-fix), closed reduction percutaneous pinning (CRPP), and casting being cost-effective respectively.