Person:

Rajan, Prashant Vaidnath

Background: There is no consensus on the optimal fixation method for patients who require surgical management for distal radius fractures. We used a cost-effectiveness analysis to determine which of three modalities: closed reduction and percutaneous pinning (CRPP), external fixation (EF), or open reduction internal fixation (ORIF), offers the best value. Methods: We developed a state-transition computerized Markov model that simulates cohorts of patients undergoing surgery for distal radius fracture, projecting short- and long-term health outcomes and costs. Simulations began at age 50 and were run over lifetime. The model inputs were transition probabilities, quality of life values, and costs. Transition probabilities incorporated postsurgical complication rates derived from the literature, which were categorized as postsurgical minor (e.g. infection), major non- operative (e.g. neuropathy), and major operative (e.g. tendon rupture) complications and loss of reduction. Quality of life values incorporated clinical outcomes, also derived from the literature. Costs incorporated Medicare reimbursement schedules in 2016 U.S. dollars. The simulation was conducted from two cost reference perspectives: health care payer, which accounts for health-related costs, and societal, which accounts for indirect costs such as lost productivity. The model outputs were total costs and quality- adjusted life-years (QALYs), discounted at 3% per year. We then calculated an incremental cost- effectiveness ratio (ICER) by dividing the differences in costs by the difference in QALYs between two comparators to determine the value of a given procedure. ICERs were evaluated against willingness-to- pay thresholds (WTP) of $50,000 and $100,000 per QALY. If the ICER for a procedure was less than the WTP, then it could be considered a cost-effective alternative to its comparator. We conducted deterministic and probabilistic sensitivity analyses to evaluate the impact of data uncertainty on the results. Results: The total QALYs were 13.99, 13.98, and 13.89 for CRPP, ORIF, and EF, respectively. From the health care payer perspective, total costs were $8,735 (CRPP), $11,125 (ORIF), and $11,759 (EF). CRPP dominated (i.e. produced greater QALYs at lower costs than) ORIF and EF. From the societal perspective, total costs were $19,214 (ORIF), $19,435 (CRPP), and $22,295 (EF). The ICER for CRPP compared to ORIF was $21,058 per QALY and EF remained dominated. In probabilistic sensitivity analysis, ORIF was cost- effective roughly 50% of the time compared to roughly 45% for CRPP. Conclusions: CRPP is the cost-effective method at the base case from both health care payer and societal perspectives. When considering data uncertainty in sensitivity analysis, ORIF appears to be more cost- effective; however, there is only a 5 to 10% difference in the frequency of probability combinations in favor of ORIF. The current degree of uncertainty in the data produces difficulty in distinguishing either CRPP or ORIF as being more cost-effective overall and thus may be left to surgeon and patient shared decision-making.