Surgical treatment is not cost-effective compared to nonoperative treatment for displaced distal radius fractures in patients 65 years and over

Abstract

Aims: The purpose was to compare operative treatment with a volar plate and nonoperative treatment of displaced distal radius fractures in patients aged 65 years and over in a cost-effectiveness analysis.

Methods: A cost-utility analysis was performed alongside a randomized controlled trial. A total of 50 patients were randomized to each group. We prospectively collected data on resource use during the first year post-fracture, and estimated costs of initial treatment, further operations, physiotherapy, home nursing, and production loss. Health-related quality of life was based on the Euro-QoL five-dimension, five-level (EQ-5D-5L) utility index, and quality-adjusted life-years (QALYs) were calculated.

Results: The mean QALYs were 0.05 higher in the operative group during the first 12 months (p = 0.260). The healthcare provider costs were €1,533 higher per patient in the operative group: €3,589 in the operative group and 2,056 in the nonoperative group. With a suggested willingness to pay of €27,500 per QALY there was a 45% chance for operative treatment to be cost-effective. For both groups, the main costs were related to the primary treatment. The primary surgery was the main driver of the difference between the groups. The costs related to loss of production were high in both groups, despite high rates of retirement. Retirement rate was unevenly distributed between the groups and was not included in the analysis.

Conclusion: Surgical treatment was not cost-effective in patients aged 65 years and older compared to nonoperative treatment of displaced distal radius fractures in a healthcare perspective. Costs related to loss of production might change this in the future if the retirement age increases. Level of evidence: II Cite this article: Bone Jt Open 2021;2(12):1027-1034.

Keywords: Colle's fracture; Cost-benefit; Distal radius fracture; EQ-5D-5L; Fractures of the distal radius; Health economic evaluation; Nonoperative treatment; Quick-DASH; Surgical treatment; displaced fractures; nonoperative treatment; physiotherapy; primary surgery; randomized controlled trial; volar locking plates.

Fig. 1

Mean EuroQoL five-dimension, five-level index score at follow-up for the two groups, p-values from t-tests.

Fig. 2

The cost-effectiveness scatterplot showing the uncertainty of the incremental cost-effectiveness ratio (ICER) in the base-case analysis. Incremental cost is on the y-axis and incremental effectiveness on the x-axis. Each quadrant represents whether surgery is either more or less effective and more or less costly. The upper right quadrant shows more effective but also more costly treatment, and it is interpreted in relation to willingness to pay (WTP) (€27,500) line: above the line are ICERs that are not cost-effective, while below the line are the ones that are cost-effective. 45% of ICER iterations are above the WTP line, and are hence considered not cost-effective. The rest are inferior or under the WTP threshold.

Fig. 3

Acceptability curve presenting the relative cost-effectiveness as a function willingness to pay (WTP). For each WTP value, the graph determines the percentage that favours each strategy. Operative group is presented in blue and non-surgery in red.

Fig. 4

A Tornado diagram is a set of one-way sensitivity analyses comparing the effect of the different variables on the incremental cost-effectiveness ratio (ICER). Tornado reports the range of ICERs generated for each parameter's uncertainty range (lower and upper range showing their impact on change in ICER). Costs of primary surgery and productivity loss were variables that had the largest impact on the ICER. EV, expected value (of ICER); QALY, quality-adjusted life year; WTP, willingness to pay. VLP, volar locking plate.