Screw fixation more cost effective for scaphoid fracture

A cost-utility analysis found a large societal savings for screw fixation over casting.

Issue: November 2004

ASSH 2004 New York [icon] Researchers at the University of Michigan in Ann Arbor found that screw fixation is a more cost-effective method of treatment than casting for acute, nondisplaced mid-waist scaphoid fractures.

“An important point to make is that cost-utility analysis is a simulated economic modeling to address questions of national importance,” said study coauthor Kevin C. Chung, MD, of the University of Michigan. “Each hand surgeon and each patient must make treatment decisions that they are comfortable with. But from a national standpoint, screw fixation for scaphoid fracture that is done correctly is the best strategy from the economic analysis perspective.”

The investigators performed a cost-utility analysis to compare the cost-effectiveness as well as quality of life outcomes for open reduction and internal fixation (ORIF) vs. cast immobilization for scaphoid fractures, the most common fractures of carpal bones, according to the abstract. This included a literature search of scaphoid fracture treatment outcomes, from which the probability of potential complications for each treatment method was determined. Results were presented during the American Society for Surgery of the Hand 59th Annual Meeting.

Societal preferences

Medicare costs were also analyzed for each treatment, as was the cost of the average time off work based on data from the Bureau of Labor Statistics. Finally, a Web-based time trade-off questionnaire was sent randomly to 50 medical students to assess societal preference for different health states. These states included ORIF, cast immobilization, nonunion/bone graft, malplaced screw/hardware removal, arthritis, chronic pain and surgical wound infection. The time trade off values and the expected duration of each outcome were then used to eventually determine quality-adjusted life years (QALYs).

“From a national standpoint, screw fixation for scaphoid fracture that is done correctly is the best strategy from the economic analysis perspective.”
— Kevin C. Chung

Researchers found that QALYs were higher for ORIF than cast immobilization for every age group. With ORIF treatment, the 25- to 34-year-old age group was found to have 0.21 additional QALYs (10 weeks) vs. casting. The societal costs were less for ORIF as well; total cost in the 25 to 55 age group was $13,851 for casting and $7940 for ORIF, saving $5911 for each patient. This translates to a societal savings of $1.9 billion annually if ORIF were used exclusively over casting. It was noted in the abstract that initial treatment costs are higher for ORIF but the ability to return to work faster makes the screw fixation treatment more cost effective.

Barry P. Simmons, MD, of Brigham and Women’s Hospital in Boston, said that the study is important, but the complication rate for the procedure must be considered when interpreting the results. “This is a study based on cost effectiveness, which is of course an extremely important part of the way we address the issues in medicine,” said Simmons, section editor of the Hand and Upper Extremity Section of the Orthopedics Today Editorial Advisory Board. “However, the complication rate may be low, but if one in X number die from this, you can’t dismiss it entirely.

“I think it’s a fantastic paper from the point of view of the cost to society, but it has to be considered in that realm; you still have to individualize it,” Simmons said. “In a way it falls at a very good time, because there are an increasing number of people who feel that aggressive surgical treatment is the best way to treat a scaphoid fracture, but I’m not entirely convinced yet.”

For more information:
Davis EN, Kotsis SV, Lau FH, et al. Cost-utility analysis of open reduction and internal fixation versus cast immobilization for acute nondisplaced mid-waist scaphoid fractures. #25A. Presented at the American Society for Surgery of the Hand 59th Annual Meeting. Sept. 9-11, 2004. New York.