Clement R Carter, Lang Pamela J, Pettett Brett J, Overman Robert A, Ostrum Robert F, Tennant Joshua N
*Department of Orthopaedics, University of North Carolina Hospital, Chapel Hill, NC;†Division of Sports Medicine, Boston Childrens Hospital, Boston, MA; and‡UNC Eshelman School of Pharmacy, Chapel Hill, NC.
J Orthop Trauma. 2017 Jun;31(6):299-304. doi: 10.1097/BOT.0000000000000813.
This study compares the cost and cost-effectiveness of treatments options for Sanders II/III displaced intra-articular calcaneus fractures (DIACFs) in laborers.
Literature on Sanders type II and III fractures was reviewed to determine complication rates and utility values for each treatment option. Costs were calculated using Medicare reimbursement and implant prices from our institution. Monte Carlo simulations were used to analyze a decision tree to determine the cost and cost-effectiveness of each treatment from a societal perspective. Sensitivity analysis was performed on all variables.
Minimally invasive open reduction internal fixation (ORIF) (sinus tarsi approach with 4 screws alone) was least expensive ($23,329), followed by nonoperative care ($24,530) and traditional ORIF using extensile lateral approach ($27,963) (P < 0.001); this result was most sensitive to time out of work. Available cost-effectiveness data were limited, but our analysis suggests that minimally invasive ORIF is a dominant strategy, and traditional ORIF is superior to nonoperative care (incremental cost-effectiveness ratio $57,217/quality-adjusted life year).
Our findings suggest that minimally invasive ORIF (sinus tarsi approach) is the least expensive option for managing Sanders II/III displaced intra-articular calcaneus fractures, followed by nonoperative care. Our cost-effectiveness results favor operative management but are highly sensitive to utility values and are weakened by scarce utility data. We therefore cannot currently recommend a treatment course based on value, and our primary conclusion must be that more extensive effectiveness research (ie, health-related quality of life data, not just functional outcomes) is desperately needed to elucidate the value of treatment options in this field.
Economic Level III. See Instructions for Authors for a complete description of levels of evidence.
本研究比较了劳动者Sanders II/III型移位关节内跟骨骨折（DIACF）治疗方案的成本及成本效益。
回顾有关Sanders II型和III型骨折的文献，以确定每种治疗方案的并发症发生率和效用值。使用医疗保险报销费用和本机构的植入物价格计算成本。采用蒙特卡洛模拟分析决策树，从社会角度确定每种治疗方法的成本和成本效益。对所有变量进行敏感性分析。
微创切开复位内固定术（ORIF）（仅采用跗骨窦入路并用4枚螺钉）成本最低（23,329美元），其次是非手术治疗（24,530美元）和采用扩大外侧入路的传统ORIF（27,963美元）（P<0.001）；该结果对误工时间最为敏感。可用的成本效益数据有限，但我们的分析表明，微创ORIF是主要策略，传统ORIF优于非手术治疗（增量成本效益比为57,217美元/质量调整生命年）。
我们的研究结果表明，对于Sanders II/III型移位关节内跟骨骨折，微创ORIF（跗骨窦入路）是成本最低的治疗选择，其次是非手术治疗。我们的成本效益结果支持手术治疗，但对效用值高度敏感，且因效用数据稀缺而受到削弱。因此，我们目前无法基于价值推荐治疗方案，我们的主要结论必须是，迫切需要更广泛的有效性研究（即与健康相关的生活质量数据，而不仅仅是功能结果）来阐明该领域治疗方案的价值。
经济水平III。有关证据水平的完整描述，请参阅作者指南。
