A Cost-Effectiveness Analysis of the Various Treatment Options for Distal Radius Fractures

Abstract

Purpose: To conduct a cost-effectiveness study of nonsurgical and surgical treatment options for distal radius fractures using distinct posttreatment outcome patterns.

Methods: We created a decision tree to model the following treatment modalities for distal radius fractures: nonsurgical management, external fixation, percutaneous pinning, and plate fixation. Each node of the model was associated with specific costs in dollars, a utility adjustment (quality-adjusted life year [QALY]), and a percent likelihood. The nodes of the decision tree included uneventful healing, eventful healing and no further intervention, carpal tunnel syndrome, trigger finger, and tendon rupture as well as associated treatments for each event. The percent probabilities of each transition state, QALY values, and costs of intervention were gleaned from a systematic review. Rollback and incremental cost-effectiveness ratio analyses were conducted to identify optimal treatment strategies. Threshold values of $50,000/QALY and $100,000/QALY were used to distinguish the modalities in the incremental cost-effectiveness ratio analysis.

Results: Both the rollback analysis and the incremental cost-effectiveness ratio analysis revealed nonsurgical management as the predominant strategy when compared with the other operative modalities. Nonsurgical management dominated external fixation and plate fixation, although it was comparable with percutaneous fixation, yielding a $2,242 lesser cost and 0.017 lesser effectiveness.

Conclusions: The cost effectiveness of nonsurgical management is driven by its decreased cost to the health care system. Plate and external fixation have been shown to be both more expensive and less effective than other proposed treatments. Percutaneous pinning has demonstrated more favorable effectiveness in the literature than plate and external fixation and, thus, may be more cost effective in certain circumstances. Future studies may find value in investigating further clinical aspects of distal radius fractures and their association with nonsurgical management versus that with plate fixation.

Type of study/level of evidence: Economic/decision analysis II.

Keywords: Cost effectiveness; Distal radius fracture; Incremental cost-effectiveness ratio; Quality-adjusted life year; Rollback analysis.

Figure 1

Flow diagram of the literature search. PubMed was queried (Appendix 2; available on the Journal’s website at www.jhsgo.org) using general terms to capture the widest range of publications related to the complications of various management strategies for DRFs from 2000 to 2020. This search identified 1,877 abstracts. After input of exclusion criteria, 148 articles that met the criteria for the calculation of outcome probabilities remained.

Figure 2

Tornado diagram of nonsurgical management versus that of percutaneous pinning after DRF. The expected value of percutaneous pinning, relative to that of conservative treatment, resulted in $128,236 incremental dollars per QALY. Bars extending toward the right of the expected value line indicate lesser cost effectiveness of percutaneous pinning relative to alterations in probability reporting of the variables on the y axis. Bars extending toward the left of the expected value line indicate greater cost effectiveness. The willingness to pay was set at a threshold of $100,000. Bars extending through the willingness-to-pay line indicate that percutaneous pinning is more cost effective at the variable probability thresholds listed. Cons, conservative; EV, expected value; PP, percutaneous pinning; WTP, willingness-to-pay.