Analysis of factors influencing hospitalization cost of patients with distal radius fractures: an empirical study based on public traditional Chinese medicine hospitals in two cities, China.

BACKGROUND: Distal radius fractures (DRFs) have become a public health problem for all countries, bringing a heavier economic burden of disease globally, with China's disease economic burden being even more acute due to the trend of an aging population. This study aimed to explore the influencing factors of hospitalization cost of patients with DRFs in traditional Chinese medicine (TCMa) hospitals to provide a scientific basis for controlling hospitalization cost. METHODS: With 1306 cases of DRFs patients hospitalized in 15 public TCMa hospitals in two cities of Gansu Province in China from January 2017 to 2022 as the study object, the influencing factors of hospitalization cost were studied in depth gradually through univariate analysis, multiple linear regression, and path model. RESULTS: Hospitalization cost of patients with DRFs is mainly affected by the length of stay, surgery and operation, hospital levels, payment methods of medical insurance, use of TCMa preparations, complications and comorbidities, and clinical pathways. The length of stay is the most critical factor influencing the hospitalization cost, and the longer the length of stay, the higher the hospitalization cost. CONCLUSIONS: TCMa hospitals should actively take advantage of TCMb diagnostic modalities and therapeutic methods to ensure the efficacy of treatment and effectively reduce the length of stay at the same time, to lower hospitalization cost. It is also necessary to further deepen the reform of the medical insurance payment methods and strengthen the construction of the hierarchical diagnosis and treatment system, to make the patients receive reasonable reimbursement for medical expenses, thus effectively alleviating the economic burden of the disease in the patients with DRFs.

Increasing Brace Treatment for Pediatric Distal Radius Buckle Fractures: Using Quality Improvement Methodology to Implement Evidence-based Medicine.

BACKGROUND: Multiple randomized trials have showed equivalent outcomes and improved patient/family satisfaction using a removable brace to treat pediatric distal radius buckle fractures (DRBF). We tested the hypothesis that we could use quality improvement (QI) methodology to increase the proportion of patients with DRBF treated with removable braces at 2 tertiary care orthopaedic clinics from a baseline of 34.8% to 80%. METHODS: Clinic billing records were reviewed monthly to determine treatment (brace vs. cast) of DRBF and tracked using control charts (p-chart). Balance measures including correct application of the diagnostic criteria and algorithm were monitored. Process measures including the number of follow-up visits, radiographs obtained, and total cost of treatment were collected. Baseline data were obtained over a 3-month period, followed by a 12-month period of interventions using Plan-Do-Study-Act cycles targeting both individuals and groups of providers. RESULTS: The proportion of DRBF treated in a brace increased from a combined baseline of 34.8% to a combined 84% at the end of the study period. Following intervention, 83% (15/18) of providers began using braces for a majority of patients (defined as >67%), with only 1 provider continuing to use casts 100% of the time. Patient preference was cited as the most common reason for use of cast treatment. There was a significant decrease in the number of radiographs obtained at 1 of 2 institutions. The charges for brace treatment averaged $630 less per patient than for cast treatment, leading to an estimated medical-cost savings of $205,000 following intervention. CONCLUSIONS: Implementation of brace treatment for pediatric DRBF using QI methodology resulted in a shift toward brace treatment in the majority of patients, leading to substantial medical and nonmedical cost savings. Although patient preference was cited as the most common reason for persistent cast treatment, the data show the use of cast treatment to be more dependent upon individual provider preference. LEVEL OF EVIDENCE: Level II-therapeutic.

A Bundled Payment Model for Pediatric Distal Radius Fractures: Defining an Episode of Care.

BACKGROUND: Distal radius fractures are the most common fracture of childhood, occurring in ∼1 per 100 children annually. Given the high incidence of these fractures, we explored feasibility of a bundled payment model. We determined the total treatment costs for each child and identified components of fracture management that contributed to variations in cost. METHODS: We retrospectively reviewed all hospital and physician costs related to the treatment of closed distal radius fractures at a large academic children's hospital. We included all children age 2 to 15 years treated by an orthopaedic surgeon for an isolated closed distal radius fracture between 2013 and 2015. We compared total treatment costs by fracture management approach. We then estimated the contribution of each component of fracture management to total treatment costs using linear regression. RESULTS: We identified 5640 children meeting the inclusion criteria, of which 4602 (81.6%) received closed treatment without manipulation, 922 (16.3%) underwent closed reduction in the clinic, emergency department, or radiology procedure suite, and 116 (2.1%) underwent treatment in the operating room. The median cost for closed treatment without manipulation was $1390 [interquartile range (IQR) 1029 to 1801], compared with $4263 (IQR, 3740 to 4832) for closed reduction and $9389 (IQR, 8272 to 11,119) for closed reduction and percutaneous pinning (P<0.001). In multivariable regression analysis, fracture management approach and use of the operating room environment were the largest cost drivers (P<0.001, R=0.88). Closed reduction in the clinic or emergency department added $894 (95% confidence interval, 819-969) to treatment costs, while closed reduction in the operating room added $5568 (95% confidence interval, 5224-6297). Location of the initial clinical evaluation, number of radiographic imaging series obtained, and number of orthopaedic clinic visits also contributed to total costs. CONCLUSIONS: Closed pediatric distal radius fractures treated without manipulation show small variations in treatment costs, making them well suited for bundled payment. Bundled payments for these fractures could reduce costs by encouraging adoption of existing evidence-based practices. LEVEL OF EVIDENCE: Level III-therapeutic.

Cost of Surgical Treatment for Distal Radius Fractures and the Implications of Episode-Based Bundled Payments.

PURPOSE: To examine the cost of care of surgical treatment for a distal radius fracture (DRF) and develop episodes that may be used to develop future bundled payment programs. METHODS: Using 2009 to 2015 claims data from the Truven MarketScan Databases, we examined the cost of care for surgical treatment of DRFs among adult patients in the United States. We excluded patients with concurrent fractures, patients who required complex care, and patients in assisted living facilities. We extracted data on cost and type of services provided to eligible patients, tracking patients from 3 days prior to operation to 90 days after operation. From these data, we developed 4 episode-of-care scenarios to develop an estimated bundled payment. We computed the variation in cost between surgery types, time periods, and type of service provided. RESULTS: Our final sample included 23,453 DRF operations, of which 15% were performed on patients 65 years of age or older. The majority (88%) underwent open fixation, the option associated with the highest cost. The average cost of care for a DRF patient ranged from $6,577 to $8,181 depending on the definition of an episode-of-care. Regardless of definition, the variation in cost was high. The cost of surgery itself composed 61% to 91% of the total cost of an episode. Of claims not directly related to the surgery, anesthesia and drugs, imaging, and therapy costs composed the next greatest proportions of the total cost of care. CONCLUSIONS: Many DRF surgical episodes incur substantially higher costs than the average. To maximize cost reduction, bundled payments for DRFs are best designed with a clinically narrow definition that is limited to services related to the fracture and long enough to capture relevant postoperative therapy and imaging costs. CLINICAL RELEVANCE: This study provides insight on spending to lay the foundation for shifting reimbursement strategies.

Evaluation of Factors Driving Cost Variation for Distal Radius Fracture Open Reduction Internal Fixation.

PURPOSE: Distal radius fracture open reduction and internal fixation (ORIF) represents a considerable cost burden to the health care system. We aimed to elucidate demographic-, injury-, and treatment-specific factors influencing surgical encounter costs for distal radius ORIF. METHODS: We retrospectively reviewed adult patients treated with isolated distal radius ORIF between November 2014 and October 2016 at a single tertiary academic medical center. Using our institution's information technology value tools-which allow for comprehensive payment and cost data collection and analysis on an item-level basis-we determined relative costs (RC) for each factor potentially influencing total direct costs (TDC) for distal radius ORIF using univariate and multivariable gamma regression analyses. RESULTS: Of the included 108 patients, implants and facility utilization costs were responsible for 48.3% and 37.9% of TDC, respectively. Factors associated with increased TDC include plate manufacturer (RC 1.52 for the most vs least expensive manufacturer), number of screws (RC 1.03 per screw) and distal radius plates used (RC 1.67 per additional plate), surgery setting (RC 1.32 for main hospital vs ambulatory surgery center), treating service (RC 1.40 for trauma vs hand surgeons), and surgical time (RC 1.04 for every 10 min of additional surgical time). Open fracture was associated with increased costs (RC 1.55 vs closed fracture), whereas other estimates of fracture severity were nonsignificant. In the multivariable model controlling for injury-specific factors, variables including implant manufacturer, and number of distal radius plates and screws used, remained as significant drivers of TDC. CONCLUSIONS: Substantial variations in surgical direct costs for distal radius ORIF exist, and implant choice is the predominant driver. Cost reductions may be expected through judicious use of additional plates and screws, if hospital systems use bargaining power to reduce implant costs, and by efficiently completing surgeries. CLINICAL RELEVANCE: This study identifies modifiable factors that may lead to cost reduction for distal radius ORIF.

How Much Will My Child's Operation Cost? Availability of Consumer Prices From US Hospitals for a Common Pediatric Orthopaedic Surgical Procedure.

BACKGROUND: Price transparency allows patients to make value-based health care decisions and is particularly important for individuals who are uninsured or enrolled in high-deductible health care plans. The availability of consumer prices for children undergoing orthopaedic surgery has not been previously investigated. We aimed to determine the availability of price estimates from hospitals in the United States for an archetypal pediatric orthopaedic surgical procedure (closed reduction and percutaneous pinning of a distal radius fracture) and identify variations in price estimates across hospitals. METHODS: This prospective investigation utilized a scripted telephone call to obtain price estimates from 50 "top-ranked hospitals" for pediatric orthopaedics and 1 "non-top-ranked hospital" from each state and the District of Columbia. Price estimates were requested using a standardized script, in which an investigator posed as the mother of a child with a displaced distal radius fracture that needed closed reduction and pinning. Price estimates (complete or partial) were recorded for each hospital. The number of calls and the duration of time required to obtain the pricing information was also recorded. Variation was assessed, and hospitals were compared on the basis of ranking, teaching status, and region. RESULTS: Less than half (44%) of the 101 hospitals provided a complete price estimate. The mean price estimate for top-ranked hospitals ($17,813; range, $2742 to $49,063) was 50% higher than the price estimate for non-top-ranked hospitals ($11,866; range, $3623 to $22,967) (P=0.020). Differences in price estimates were attributable to differences in hospital fees (P=0.003), not surgeon fees. Top-ranked hospitals required more calls than non-top-ranked hospitals (4.4±2.9 vs. 2.8±2.3 calls, P=0.003). A longer duration of time was required to obtain price estimates from top-ranked hospitals than from non-top-ranked hospitals (8.2±9.4 vs. 4.1±5.1 d, P=0.024). CONCLUSIONS: Price estimates for pediatric orthopaedic procedures are difficult to obtain. Top-ranked hospitals are more expensive and less likely to provide price information than non-top-ranked hospitals, with price differences primarily caused by variation in hospital fees, not surgeon fees. LEVEL OF EVIDENCE: Level II-economic and decision analyses.

Intramedullary nails in the treatment of the distal radius fractures.

The distal radius fracture is a common injury in old persons. Its treatment remains a critical challenge because of number of cases, the final cost of the procedure, the level of X-ray irradiation, and the demand of technique of fixation in osteoporotic bone. The entire closed procedure requires a strict percutaneous nailing. This offers advantages in terms of postoperative pain, per-operative irradiation, and cost. The main problem was so far the ability to insure a stable reduction in time. This point is discussed with the introduction of the "Nail-o-Flex®" nail. A continuous series of 83 patients is introduced.

Outcomes and financial implications of intra-articular distal radius fractures: a comparative study of open reduction internal fixation (ORIF) with volar locking plates versus nonoperative management.

BACKGROUND: To evaluate the functional and radiographic outcomes, as well as the treatment costs, of closed displaced intra-articular distal radius fractures treated with either open reduction internal fixation (ORIF) with volar locking plates or nonoperative treatment with plaster cast immobilisation. MATERIALS AND METHODS: A total of 60 patients (32 receiving ORIF, 28 receiving nonoperative treatment) with closed intra-articular distal radius fractures were included. The mean age was 52.1 and 57.4, respectively. Functional and radiographic assessments were carried out at 12 months post-injury. Patients' treatment costs, median salaries and lengths of medical leave were obtained. RESULTS: DASH and MAYO wrist score in the ORIF group did not differ significantly from those in the nonoperative group. Apart from superior ulnar deviation in the ORIF group (p = 0.0096), differences in the range of motion of the injured wrists were not significant. Similarly, there were no significant differences in grip strength and visual analog scale for pain. Volar tilt (p = 0.0399), radial height (p = 0.0087), radial inclination (p = 0.0051) and articular step-off (p = 0.0002) were all significantly superior in the ORIF group. There was a 37-fold difference in mean treatment costs between ORIF (SGD 7951.23) and nonoperative treatment (SGD 230.52). CONCLUSION: Our study shows no difference in overall functional outcomes at 12 months for closed displaced intra-articular distal radius fractures treated with either ORIF with volar locking plates or plaster cast immobilisation, and this is independent of radiographic outcome. A longer follow-up, nevertheless, is needed to determine whether the development of post-traumatic arthritis will have an effect on function. The vast difference in treatment costs should be taken into consideration when deciding on the treatment option. LEVEL OF EVIDENCE: Level 3.

Reducing Cost and Radiation Exposure During the Treatment of Pediatric Greenstick Fractures of the Forearm.

BACKGROUND: We hypothesize that after successful closed reduction of pediatric greenstick fractures of the forearm, there is a low rate of lost reduction requiring intervention. By reducing the frequency of clinical and radiographic follow-up, we can reduce costs and radiation exposure. METHODS: A retrospective analysis was performed on patients aged 2 to 16 years treated with closed reduction and cast immobilization for greenstick fractures of the forearm at our institution between 2003 and 2013. The primary endpoint was a healed fracture with acceptable alignment at the final radiographic evaluation. Time-derived activity-based costing was used for cost analysis. We estimated radiation exposure in consultation with our hospital's radiation safety office. RESULTS: One hundred and nine patients with an average age of 6.9 years (range, 2 to 15 y) met the inclusion criteria. The initial maximal fracture angulation of the affected radius and/or ulna averaged 19.3 (SD=±8.7) degrees (range, 2 to 55 degrees). Patients were followed for an average of 60 days (range, 19 to 635 d). On average, patients received 3.6 follow-up clinical visits and 3.5 sets of radiographs following immediate emergency department care. Ninety-four percent of patients met criteria for acceptable radiographic alignment. Only 1 patient (0.9%; 95% confidence interval, 0.2%-5.0%) underwent rereduction, as determined by the treating physician. If clinical follow-up were limited to 2 visits and 3 sets of radiographs total, there would be a 14.3% reduction in total cost of fracture care and a 41% reduction in radiation exposure. CONCLUSIONS: This retrospective study suggests that pediatric greenstick fractures of the forearm rarely require intervention after initial closed reduction. We propose that 2 clinical follow-up visits and 3 sets of radiographs would reduce overall care costs and radiation exposure without compromising clinical results. LEVEL OF EVIDENCE: Level IV-economic and decision analyses.

Economic and social impact of upper extremity fragility fractures in elderly patients.

BACKGROUND: Fragility fractures of the proximal humerus and distal radius can have a significant impact on the elderly population, both economically and physically. Limited data are available to demonstrate the functional and economic impact of upper extremity fragility fractures. AIMS: To investigate the economic and social impact that proximal humerus fragility fractures may have on an older population. METHODS: A retrospective chart review for patients ≥50 years old treated as an inpatient at a local hospital between 2006 and 2012 for a proximal humerus or a distal radius fracture was done. Patients were divided into two groups to show age impact; Group 1 = 50-79 years old and Group 2 = 80 years and older. Eighty-six charts were reviewed, 38 for Group 1 and 48 for Group 2. Demographic, admission, inpatient, and discharge data were compared between groups. RESULTS: A third of patients in each group had a previous fragility fracture. Inpatient length of stay was comparable between groups. Surgical treatment was used at a higher rate in the younger cohort (p = 0.06). Approximate average hospital charges for an inpatient surgical treatment were about twice those of the non-surgically treated patients. DISCUSSION: Our results illustrate the significant burden of upper extremity fractures in terms of loss of independence, inpatient hospitalizations and prolonged nursing home or rehabilitation needs, which account for considerable health care costs. CONCLUSION: Fractures of the humerus, forearm and wrist account for one-third of the total incidence of fractures and can be a significant burden to individuals and the community.

Using softcast to treat torus fractures in a paediatric emergency department.

Wrist torus fractures in children are a frequent reason for Emergency Department (ED) visits. Torus fractures traditionally were treated with a backslab cast in the Children's ED and then referred to the Fracture Clinic. Guidelines were developed in order to standardise the care for children who attended the ED with a torus fracture. All patients who were seen & treated by the Advanced Nurse Practitioner (ANP) over a one year period with a diagnosis of a torus fracture were treated with immobilisation in a softcast. 119 patients met the criteria for inclusion. There were no adverse events recorded and no patient required subsequent visits to the Fracture Clinic. There was a cost savings of €18,596 as compared with the normal referral pathway to the Fracture Clinic.

Malpractice in distal radius fracture management: an analysis of closed claims.

PURPOSE: Distal radius fractures comprise the majority of hand- and wrist-related malpractice claims. We hypothesized that a majority of lawsuits would be for malunions resulting from nonsurgical treatment. Additional goals of this study were to quantify costs associated with claims, determine independent risk factors for making an indemnity payment, and illustrate trends over time. METHODS: Seventy closed malpractice claims filed for alleged negligent treatment of distal radius fractures by orthopedic surgeons insured by the largest medical professional liability insurer in New York State (NYS) from 1981 to 2005 were reviewed. We separately reviewed defendants' personal closed malpractice claim histories from 1975 to 2011. Overall incidence of malpractice claims among distal radius fractures treated in NYS was calculated using the NYS Statewide Planning and Research Cooperative System database and the 2008 American Academy of Orthopedic Surgeons census data. RESULTS: The overall incidence of malpractice claims for distal radius fracture management was low. Malunion was the most common complaint across claims regardless of treatment type. Claims for surgically treated fractures increased over time. A majority of claims documented poor doctor-patient relationships. Male plaintiffs in this group were significantly older than males treated for distal radius fractures in NYS. Most defendants had a history of multiple malpractice suits, all were male, and only a small percentage were fellowship-trained in hand surgery. Defendants lacking American Board of Orthopedic Surgery certification were significantly more likely to make indemnity payments. Thirty-eight of 70 cases resulted in an indemnity payment. CONCLUSIONS: Malunion and poor doctor-patient relationships are the major features of malpractice litigation involving distal radius fracture management. Older defendant age and lack of American Board of Orthopedic Surgery certification increase the likelihood of making an indemnity payment. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and decision analyses II.

Cost-effectiveness analysis of soft bandage and immediate discharge versus rigid immobilization in children with distal radius torus fractures.

Aims: The aim of this trial was to assess the cost-effectiveness of a soft bandage and immediate discharge, compared with rigid immobilization, in children aged four to 15 years with a torus fracture of the distal radius. Methods: A within-trial economic evaluation was conducted from the UK NHS and personal social services (PSS) perspective, as well as a broader societal point of view. Health resources and quality of life (the youth version of the EuroQol five-dimension questionnaire (EQ-5D-Y)) data were collected, as part of the Forearm Recovery in Children Evaluation (FORCE) multicentre randomized controlled trial over a six-week period, using trial case report forms and patient-completed questionnaires. Costs and health gains (quality-adjusted life years (QALYs)) were estimated for the two trial treatment groups. Regression was used to estimate the probability of the new treatment being cost-effective at a range of 'willingness-to-pay' thresholds, which reflect a range of costs per QALY at which governments are typically prepared to reimburse for treatment. Results: The offer of a soft bandage significantly reduced cost per patient (saving £12.55 (95% confidence interval (CI) -£5.30 to £19.80)) while QALYs were similar (QALY difference between groups: 0.0013 (95% CI -0.0004 to 0.003)). The high probability (95%) that offering a bandage is a cost-effective option was consistent when examining the data in a range of sensitivity analyses. Conclusion: In addition to the known clinical equivalence, this study found that the offer of a bandage reduced cost compared with rigid immobilization among children with a torus fracture of the distal radius. While the cost saving was small for each patient, the high frequency of these injuries indicates a significant saving across the healthcare system.

Current and future national costs to medicare for the treatment of distal radius fracture in the elderly.

PURPOSE: Distal radius fractures (DRFs) are the second most common fracture experienced by elderly individuals. In 2005, 16% of DRFs in the Medicare population were being treated with internal fixation, up from 3% in 1997. This shift in treatment strategy can have substantial financial impact on Medicare and the health care system in general. The specific aims of this project were to quantify the current and future Medicare expenditures attributable to DRF and to compare Medicare payments for the 4 treatment options for elderly DRF. METHODS: We analyzed the 100% 2007 Medicare dataset for annual DRF-attributable spending. Payments were obtained for claims that were identified as attributable to DRF by International Classification of Diseases, 9th Revision, Clinical Modification codes for DRF in conjunction with a Current Procedural Technology code for relevant treatment or service. We projected annual payments based on increasing internal fixation treatment. All payments are reported in 2007 U.S. dollars. RESULTS: In 2007, Medicare made $170 million in DRF-attributable payments. If the usage of internal fixation were to reach 50%, DRF-attributable payments could be nearly $240 million. The mean attributable payment made for each patient in 2007 was $1,983. Most of this is due to facility and staffing cost for the treatment procedure. CONCLUSIONS: This analysis provides an accurate quantification of Medicare DRF-attributable expenditure. Use of 100% Medicare data allows for the summation of actual patient experience rather than modeling or estimation. The burden of DRF is going to grow as the U.S. population ages and as internal fixation becomes more widely used. The Medicare payment data can help in allocating resources nationally to address the increasing disease burden of DRF.

An economic analysis of outcomes and complications of treating distal radius fractures in the elderly.

PURPOSE: There is a lack of scientific data regarding which treatment provides the best outcome for distal radius fractures (DRFs) in the elderly. Currently, casting is used to treat the majority of these fractures, although open reduction and internal fixation (ORIF) has been used increasingly in recent years. Given the recent emphasis on the wise use of medical resources, we conducted a cost-utility analysis to assess which of 4 common DRF treatments (casting, wire fixation, external fixation, or ORIF) optimizes the cost-to-patient preference ratio. METHODS: We created a decision tree to model the process of choosing a DRF treatment and experiencing a final outcome. Fifty adults aged 65 and older were surveyed in a time trade-off, one-on-one interview to obtain utilities for DRF treatments and possible complications. We gathered Medicare reimbursement rates and calculated the incremental cost-utility ratio for each treatment. RESULTS: Participants rated DRF treatment relatively high, assigning utility values close to perfect health to all treatments. The ORIF was the most preferred treatment (utility, 0.96), followed by casting (utility, 0.94), wire fixation (utility, 0.94), and external fixation (utility, 0.93). The ORIF was the most expensive treatment (reimbursement, $3,516), whereas casting was the least expensive (reimbursement, $564). The incremental cost-utility ratio for ORIF, when compared to casting, was $15,330 per quality-adjusted life years, which is less than $50,000 per quality-adjusted life year, thereby indicating that, from the societal perspective, ORIF is considered a worthwhile alternative to casting. CONCLUSIONS: There is a slight preference for the faster return to minimally restricted activity provided by ORIF. Overall, patients show little preference for one DRF treatment over another. Because Medicare patients pay similar out-of-pocket costs regardless of procedure, they are not particularly concerned with procedure costs. Considering the similar long-term outcomes, this study adds to the uncertainty surrounding the choice of DRF treatment in the elderly, further indicating the need for a high-powered, randomized trial.

Effect of facility on the operative costs of distal radius fractures.

PURPOSE: The purpose of this study was to investigate whether ambulatory surgery centers can deliver lower-cost care and to identify sources of those cost savings. METHODS: We performed a cost identification analysis of outpatient volar plating for closed distal radius fractures at a single academic medical center. Multiple costs and time measures were taken from an internal database of 130 consecutive patients and were compared by venue of treatment, either an inpatient facility or an ambulatory, stand-alone surgery facility. The relationships between total cost and operative time and multiple variables, including fracture severity, patient age, gender, comorbidities, use of bone graft, concurrent carpal tunnel release, and surgeon experience, were examined, using multivariate analysis and regression modeling to identify other cost drivers or explanatory variables. RESULTS: The mean operative cost was considerably greater at the inpatient facility ($7,640) than at the outpatient facility ($5,220). Cost drivers of this difference were anesthesia services, post-anesthesia care unit, and operating room costs. Total surgical time, nursing time, set-up, and operative times were 33%, 109%, 105%, and 35% longer, respectively, at the inpatient facility. There was no significant difference between facilities for the additional variables, and none of those variables independently affected cost or operative time. CONCLUSIONS: The only predictor of cost and time was facility type. This study supports the use of ambulatory stand-alone surgical facilities to achieve efficient resource utilization in the operative treatment of distal radius fractures. We also identified several specific costs and time measurements that differed between facilities, which can serve as potential targets for tertiary facilities to improve utilization. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decisional Analysis III.

Cost Analysis of Volar Plate Fixation Versus Plaster Cast Immobilization for Intra-Articular Distal Radial Fractures.

BACKGROUND: The aim of this study was to compare the cost-effectiveness and cost-utility between plaster cast immobilization and volar plate fixation for acceptably reduced intra-articular distal radial fractures. METHODS: A cost-effectiveness analysis was conducted as part of a randomized controlled trial comparing operative (volar plate fixation) with nonoperative (plaster cast immobilization) treatment in patients between 18 and 75 years old with an acceptably reduced intra-articular distal radial fracture. Health-care utilization and use of resources per patient were documented prospectively and included direct medical costs, direct non-medical costs, and indirect costs. All analyses were performed according to the intention-to-treat principle. RESULTS: The mean total cost per patient was $291 (95% bias-corrected and accelerated confidence interval [bcaCI] = -$1,286 to $1,572) higher in the operative group compared with the nonoperative group. The mean total number of quality-adjusted life-years (QALYs) gained at 12 months was significantly higher in the operative group than in the nonoperative group (mean difference = 0.15; 95% bcaCI = 0.056 to 0.243). The difference in the cost per QALY (incremental cost-effectiveness ratio [ICER]) was $2,008 (95% bcaCI = -$9,608 to $18,222) for the operative group compared with the nonoperative group, which means that operative treatment is more effective but also more expensive. Subgroup analysis including only patients with a paid job showed that the ICER was -$3,500 per QALY for the operative group with a paid job compared with the nonoperative group with a paid job, meaning that operative treatment is more effective and less expensive for patients with a paid job. CONCLUSIONS: The difference in QALYs gained for the operatively treated group was equivalent to an additional 55 days of perfect health per year. In adult patients with an acceptably reduced intra-articular distal radial fracture, operative treatment is a cost-effective intervention, especially in patients with paid employment. Operative treatment is slightly more expensive than nonoperative treatment but provides better functional results and a better quality of life. LEVEL OF EVIDENCE: Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

Cost-Effectiveness of Treatments after Closed Extraarticular Distal Radius Fractures in Older Adults from the WRIST Clinical Trial.

BACKGROUND: This study performs an economic analysis of volar locking plate, external fixation, percutaneous pinning, or casting in elderly patients with closed distal radius fractures. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Bone morphogenetic protein (BMP) for fracture healing in adults.

BACKGROUND: Delay in fracture healing is a complex clinical and economic issue for patients and health services. OBJECTIVES: To assess the incremental effectiveness and costs of bone morphogenetic protein (BMP) on fracture healing in acute fractures and nonunions compared with standards of care. SEARCH STRATEGY: We searched The Cochrane Library (2008, Issue 4), MEDLINE, and other major health and health economics databases (to October 2008). SELECTION CRITERIA: Randomised controlled trials (RCTs) and full or partial economic evaluations of BMP for fracture healing in skeletally mature adults. DATA COLLECTION AND ANALYSIS: All clinical and economic data were extracted by one author and checked by another. MAIN RESULTS: Eleven RCTs, all at high risk of bias, and four economic evaluations were included. Apart from one study, the times to fracture healing were comparable between the BMP and control groups. There was some evidence for increased healing rates, without requiring a secondary procedure, of BMP compared with usual care control in acute, mainly open, tibial fractures (risk ratio (RR) 1.19, 95% CI 0.99 to 1.43). The pooled RR for achieving union for nonunited fractures was 1.02 (95% CI 0.90 to 1.15). One study found no difference in union for patients who had corrective osteotomy for radial malunions. Data from three RCTs indicated that fewer secondary procedures were required for acute fracture patients treated with BMP versus controls (RR 0.65, 95% CI 0.50 to 0.83). Adverse events experienced were infection, hardware failure, pain, donor site morbidity, heterotopic bone formation and immunogenic reactions. The evidence on costs for BMP-2 for acute open tibia fractures is from one large RCT. This indicates that the direct medical costs associated with BMP would generally be higher than treatment with standard care, but this cost difference may decrease as fracture severity increases. Limited evidence suggests that the direct medical costs associated with BMP could be offset by faster healing and reduced time off work for patients with the most severe open tibia fractures. AUTHORS' CONCLUSIONS: This review highlights a paucity of data on the use of BMP in fracture healing as well as considerable industry involvement in currently available evidence. There is limited evidence to suggest that BMP may be more effective than controls for acute tibial fracture healing, however, the use of BMP for treating nonunion remains unclear. The limited available economic evidence indicates that BMP treatment for acute open tibial fractures may be more favourable economically when used in patients with the most severe fractures.