Most effective ORIF clavicle fracture treatments are also the most economical

ORIF cost-effectiveness depends on post-surgery function, complication rates and if union occurs.

Fixing adults’ mid-shaft clavicle fracture with open reduction internal fixation may be more cost-effective than nonoperative treatment if the treatment effect is long-lasting, according to findings from a multi-centered study.

“We found as utility and duration of benefit of open reduction internal fixation (ORIF) increases, ORIF becomes more cost-effective,” Robert V. Cantu, MD, an investigator, said in describing results of his group’s analysis of how long-term variables affected costs and outcomes.

The study Cantu and colleagues conducted showed cost-effectiveness of ORIF treatment greatly depended on whether surgery led to improved function and fewer complications, as well as when and if union occurred. Their abstract said ORIF is a reasonable option; however treatments should be individually selected for patients.

Cantu presented these results at the 24th Annual Meeting of the Orthopaedic Trauma Association (OTA).

Modeling, sensitivity analysis

Investigators used patient-specific and 1-year follow-up data from patients in a Canadian multicenter study comparing ORIF and nonoperative treatment for their analysis. ORIF-treated patients in that study had significantly better DASH and Constant scores at 1 year and all other time points, Cantu said.

For their analysis Cantu and colleagues modeled each potential complication with both clavicle fracture treatments, using a decision tree to track complications and benefits. Their final decision-tree question for both treatments related to whether union occurred or if surgery was required.

“We ran a sensitivity analysis for each complication to see what the effects would be,” which helped determine each procedure’s efficacy, Cantu explained.

Investigators defined utility for each health state, from infection to restricted function, running a sensitivity analysis for each state. They ultimately selected a 33-year-old individual as their base-case model.

Cost containment effect

To assess cost-effectiveness, investigators derived ORIF costs from Medicare reimbursements, hospital diagnostic-related groups, physician current procedural terminology (CPT) codes and anesthesiologist billing. Nonoperative costs were derived from CPT codes. According to Cantu, they multiplied Medicare reimbursement by 2.6 to estimate private care reimbursement in the study population.

Through the sensitivity analyses, investigators arrived at a $50,000 per quality-adjusted life year (QALY) threshold, which they used for subsequent cost comparisons.

For the base-case ORIF cost was $65,000/QALY, but in instances when surgical benefits were permanent, cost-effectiveness improved by $28,150/QALY. Investigators found cost/QALY improved when utility — how complications impacted outcomes — improved and when that persisted about 9 years.

Frequently, costs for fracture treatments included in the study were below the $50,000/QALY threshold, Cantu said. “Cost-effectiveness of clavicle fracture ORIF is comparable to many other procedures that are currently done, although in this model it was above the $50,000/QALY threshold,” he noted. “Cost-effectiveness appears to be most dependent on duration and magnitude of benefit of surgery. Disutility of nonoperative treatment prior to union and increased time to union of nonoperative treatments were also important factors in the randomized analysis.”

For more information:
Robert V. Cantu, MD, can be reached at the Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756; 603-650-7590; e-mail: Robert.V.Cantu@hitchcock.org. The study was funded by an OTA grant.

Reference:
Pearson AM, Tosteson A, Koval KJ, et al. Is surgery for displaced, midshaft clavicle fractures in adults cost-effective? Results from a multicenter randomized controlled trial. # 67. Presented at the 24th Annual Meeting of the Orthopaedic Trauma Association. Oct. 15-18, 2008. Denver.