From the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School; and Health Management and Policy, University of Michigan School of Public Health.
Plast Reconstr Surg. 2021 Feb 1;147(2):240e-252e. doi: 10.1097/PRS.0000000000007528.
This study performs an economic analysis of volar locking plate, external fixation, percutaneous pinning, or casting in elderly patients with closed distal radius fractures.
This is a secondary analysis of the Wrist and Radius Injury Surgical Trial, a randomized, multicenter, international clinical trial with a parallel nonoperative casted group of patients older than 60 years with surgically indicated, extraarticular closed distal radius fractures. Thirty-Six-Item Short-Form Health Survey-converted utilities and total costs from Medicare were used to calculate quality-adjusted life-years and incremental cost-effectiveness ratio.
Casted patients were self-selected and older (p < 0.001) than the randomized surgical cohorts, but otherwise similar in sociodemographic characteristics. Quality-adjusted life-years for percutaneous pinning were highest at 9.17 and external fixation lowest at 8.81. Total costs expended were $16,354 for volar locking plates, $16,012 for external fixation, $11,329 for percutaneous pinning, and $6837 for casting. The incremental cost-effectiveness ratios for volar locking plates and external fixation were dominated by percutaneous pinning and casting. The ratio for percutaneous pinning compared to casting was $28,717. Probabilistic sensitivity analysis revealed a 10, 5, 53, and 32 percent chance of volar locking plate, external fixation, percutaneous pinning, and casting, respectively, being cost-effective at the willingness-to-pay threshold of $100,000 per quality-adjusted life-year.
Casting is the most cost-effective treatment modality in the elderly with closed extraarticular distal radius fractures and should be considered before surgery. In unstable closed fractures, percutaneous pinning, which is the most cost-effective surgical intervention, may be considered before volar locking plates or external fixation.
本研究对掌侧锁定板、外固定、经皮克氏针和石膏固定治疗老年闭合性桡骨远端骨折进行了经济学分析。
这是腕关节和桡骨损伤手术试验（Wrist and Radius Injury Surgical Trial）的二次分析，该试验是一项随机、多中心、国际临床试验，有一个平行的非手术石膏固定组，纳入年龄大于 60 岁、具有手术指征的、关节外闭合性桡骨远端骨折患者。使用 36 项简明健康调查问卷（Short-Form Health Survey）转换效用和 Medicare 总费用来计算质量调整生命年和增量成本效益比。
接受石膏固定的患者是自我选择的，且年龄大于（p<0.001）随机手术组，但其他社会人口学特征相似。经皮克氏针的质量调整生命年最高，为 9.17，外固定最低，为 8.81。掌侧锁定板的总费用为 16354 美元，外固定为 16012 美元，经皮克氏针为 11329 美元，石膏固定为 6837 美元。掌侧锁定板和外固定的增量成本效益比被经皮克氏针和石膏固定所主导。与石膏固定相比，经皮克氏针的比值为 28717 美元。概率敏感性分析显示，掌侧锁定板、外固定、经皮克氏针和石膏固定分别有 10%、5%、53%和 32%的可能性在 10 万美元/QALY 的意愿支付阈值下具有成本效益。
在老年闭合性桡骨远端关节外骨折患者中，石膏固定是最具成本效益的治疗方式，应优先于手术考虑。在不稳定的闭合性骨折中，应优先考虑经皮克氏针，这是最具成本效益的手术干预措施，然后再考虑掌侧锁定板或外固定。
