Cement augmentation may yield cost savings, QALY gains in unstable trochanteric fractures
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Published results showed fixation with the use of cement augmentation may lead to cost savings and quality-adjusted life-year gains in patients with unstable trochanteric fractures compared with fixation without augmentation.
To assess the cost-effectiveness of injectable bone cement augmentation (Traumacem V+, DePuy Synthes) vs. no augmentation for the fixation of unstable trochanteric fractures, Christian Kammerlander, MD, and colleagues used a previous randomized-controlled trial, the current literature and administrative claims data to create a cost-effectiveness model comprised of a decision tree simulating clinical events, costs and utilities during the first year after the index procedure and a Markov model extrapolating clinical events, costs and utilities during the patient’s lifetime. Researchers included incremental costs in 2020 euros, incremental QALY and incremental cost-effectiveness ratios (ICER) as outcome measures. Researchers assessed model uncertainty with deterministic and probabilistic sensitivity analyses.
Results showed fixation with cement augmentation had an association with cost savings and QALY gains. Researchers found the utility of revision, rates of revision surgery within the first year after fixation surgery, and costs of augmentation and revision surgery were major influential parameters for the ICER. Fixation with augmentation had lower costs in 66.4% of the 10,000 simulations and increased QALYs in 52.7%, according to probabilistic sensitivity analyses. Researchers noted the probability of fixation with cement augmentation being cost-effective vs. no augmentation remained above 50% for a range of willingness-to-pay thresholds from 0 euros to 50,000 euros.
“Additional cement augmentation in intramedullary fixation of unstable hip fractures leads to overall lower reoperation rates,” Kammerlander told Healio. “Although there is an initial higher cost for the use of cement during the initial operation, our model showed that this procedure is cost-saving for the health care system from a socioeconomic perspective and leads to QALY gains for patients. In respecting this and other clinical research for this procedure, we should consider [implementing] additional cement augmentations as standard treatment for fixation of unstable hip fractures.”
Perspective
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For this study, it is important to note that this is a follow-up cost analysis of a randomized trial conducted by lead author Christian Kammerlander, MD, and colleagues. Published in Injury in 2018, the randomized trial showed no difference in outcomes between the augmented and nonaugmented cohorts. Interestingly enough, none of the patients in the augmentation group required revision, while six patients did in the nonaugmented cohort.
While there was a small percentage of patients, this current 2022 cost-effectiveness study exhibits a further developed result of when the subset analyses were performed, indicating that augmentation to yield zero failures is superiorly cost-effective vs. no augmentation with one failure. Does this mean we should augment everyone? I don’t think so. I think the study is important in stating that an overall failure is indeed extremely costly, which highlights the importance of “getting it right” the first time. In this case, for those rare cases where the bone quality is truly severely poor and the helical blade is your implant of choice, augmenting the blade may yield some clinical benefit, and avoiding failure can help avoid a big cost hit.
With the specifics related to this implant, one should keep this one mind: Regardless of company usage, for the fractures, augmentation is another technique we can add to our armamentarium but does not mean that every unstable intertrochanteric hip fracture requires it.
Reference:
Kammerlander C, et al. Injury. 2018;doi:10.1016/j.injury.2018.04.022.
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