Cost utility analysis of intramedullary nailing and skeletal traction treatment for patients with femoral shaft fractures in Malawi.

Background and purpose - In Malawi, both skeletal traction (ST) and intramedullary nailing (IMN) are used in the treatment of femoral shaft fractures, ST being the mainstay treatment. Previous studies have found that IMN has improved outcomes and is less expensive than ST. However, no cost-effectiveness analyses have yet compared IMN and ST in Malawi. We report the results of a cost-utility analysis (CUA) comparing treatment using either IMN or ST.Patients and methods - This was an economic evaluation study, where a CUA was done using a decision-tree model from the government healthcare payer and societal perspectives with an 1-year time horizon. We obtained EQ-5D-3L utility scores and probabilities from a prospective observational study assessing quality of life and function in 187 adult patients with femoral shaft fractures treated with either IMN or ST. The patients were followed up at 6 weeks, and 3, 6, and 12 months post-injury. Quality adjusted life years (QALYs) were calculated from utility scores using the area under the curve method. Direct treatment costs were obtained from a prospective micro costing study. Indirect costs included patient lost productivity, patient transportation, meals, and childcare costs associated with hospital stay and follow-up visits. Multiple sensitivity analyses assessed model uncertainty.Results - Total treatment costs were higher for ST ($1,349) compared with IMN ($1,122). QALYs were lower for ST than IMN, 0.71 (95% confidence interval [CI] 0.66-0.76) and 0.77 (CI 0.71-0.82) respectively. Based on lower cost and higher utility, IMN was the dominant strategy. IMN remained dominant in 94% of simulations. IMN would be less cost-effective than ST at a total procedure cost exceeding $880 from the payer's perspective, or $1,035 from the societal perspective.Interpretation - IMN was cost saving and more effective than ST in the treatment of adult femoral shaft fractures in Malawi, and may be an efficient use of limited healthcare resources.

Inpatient versus outpatient halo-gravity traction in children with severe spinal deformity.

STUDY DESIGN: A retrospective, comparative study. OBJECTIVE: To compare the results, complications, and costs of preoperative halo-gravity traction in in- and outpatient settings. BACKGROUND DATA: Surgical management of severe spinal deformities remains complex and controversial. Preoperative halo-gravity traction results in a decreased need for aggressive surgical techniques, lower incidence of intraoperative neurologic complications, and improvement of nutritional parameters and preoperative cardiopulmonary function. METHODS: Twenty-nine patients younger than 18 years with kyphoscoliosis undergoing preoperative halo-gravity traction were divided into two groups: inpatients (n: 15) and outpatients (n: 14, home care or care at the Foundation). Traction time (weeks), traction weight (kg), radiographic curve correction, complications, and costs were compared. For statistical analysis, t test and odds ratio were calculated with a significance of p < 0.05. RESULTS: Mean traction time was 6 weeks for in- and 4 weeks for outpatients (p = 0.038). Initial traction weight was 6 kg in both groups, while final traction weight was 13 kg for in- and 15 kg for outpatients (p = 0.50). At the end of the traction period, coronal correction was 24° in in- and 28° in outpatients (p = 0.5), while sagittal correction was 27° and 29°, respectively (p = 0.80). Pin loosening was observed in 2 patients in each group, of whom 1 outpatient developed pin-site infection. In each group, one patient developed transient neurologic complications (odds ratio 1.091). Mean treatment cost per patient was 2.8-fold higher in inpatients. CONCLUSIONS: Considering complications and costs, our results show that preoperative halo-gravity traction in an outpatient setting is an option to be taken into account. LEVEL OF EVIDENCE: Grade III.

Comparative Cost-effectiveness of Surgery, Collagenase Clostridium Histolyticum, and Penile Traction Therapy in Men with Peyronie's Disease in an Era of Effective Clinical Treatment.

BACKGROUND: Traditionally, surgery has been considered the gold standard treatment for Peyronie's disease (PD). Less-invasive alternatives, such as collagenase Clostridium histolyticum (CCH) and traction therapy, have been proposed and proven effective. AIM: To compare cost-effectiveness of management options for PD. METHODS: A Markov analytic model was created to compare the cost-effectiveness of treatment with a novel traction device, RestoreX (RXPTT), vs CCH vs surgery. Outcomes were derived from single-institution, prospective data of 63 men treated with RXPTT, 115 with CCH, and 23 with plication or incision and grafting. Costs were based on 2017 Medicare reimbursement and utility values from the literature. MAIN OUTCOME MEASURES: Model outcomes included complications for each treatment arm, as well as the probability of success, which was defined as ≥20% improvement in curvature. Univariable and multivariable sensitivity analyses were performed to test the robustness of the model. RESULTS: Overall success rates were 96% (surgery), 66% (CCH), and 48% (RXPTT). At 10 years after treatment, RXPTT was the most cost-effective, with mean costs per patient of $883 (RXPTT), $11,419 (surgery), and $33,628 (CCH). CCH and surgery both resulted in a gain of quality adjusted life years (QALYs) relative to RXPTT (9.44 and 9.36 vs 9.27, respectively). Sensitivity analysis demonstrated greater cost-effectiveness for surgery if lower (≤46%) rates of postoperative erectile dysfunction or length loss (≤3%). CCH became more cost-effective at lower costs (≤$16,726) or higher success rates (≥76%). On multivariable sensitivity analysis at a willingness to pay threshold of $100,000/QALY, the most cost-effective strategy was RXPTT in 49%, surgery in 48%, and CCH in 3% of simulations. At a willingness to treat threshold of $150,000/QALY, the most cost-effective treatment option was RXPTT in 33%, surgery in 55%, and CCH in 12% of simulations. CLINICAL IMPLICATIONS: In an era of value-based care, this model can guide cost-effective treatment selection on the basis of provider, patient, and payer characteristics. STRENGTHS & LIMITATIONS: The current study represents the first cost-effectiveness comparison of treatment modalities for PD and is strengthened by prospective data collection, large CCH and traction sample sizes, and robust sensitivity analyses. Consistent with cost-effective models, the model is limited by assumptions and may not apply to all scenarios. CONCLUSIONS: RXPTT represents a more cost-effective method for achieving ≥20% curvature improvement compared with surgery or CCH. Depending on treatment goals, rate of surgical complications, and willingness to pay threshold, surgery and CCH may become more cost-effective in select scenarios. Wymer K, Kohler T, Trost L. Comparative Cost-effectiveness of Surgery, Collagenase Clostridium Histolyticum, and Penile Traction Therapy in Men with Peyronie's Disease in an Era of Effective Clinical Treatment. J Sex Med 2019;16:1421-1432.

The Cost of Intramedullary Nailing Versus Skeletal Traction for Treatment of Femoral Shaft Fractures in Malawi: A Prospective Economic Analysis.

BACKGROUND: In many low- and middle-income countries, non-surgical management of femoral shaft fractures using skeletal traction is common because intramedullary (IM) nailing is perceived to be expensive. This study assessed the cost of IM nailing and skeletal traction for treatment of femoral shaft fractures in Malawi. METHODS: We used micro-costing methods to quantify the costs associated with IM nailing and skeletal traction. Adult patients who sustained an isolated closed femur shaft fracture and managed at Queen Elizabeth Central Hospital in Malawi were followed from admission to discharge. Resource utilization and time data were collected through direct observation. Costs were quantified for procedures and ward personnel, medications, investigations, surgical implants, disposable supplies, procedures instruments and overhead. RESULTS: We followed 38 nailing and 27 traction patients admitted between April 2016 and November 2017. Nailing patient's average length of stay (LOS) was 36.35 days (SD 21.19), compared to 61 (SD 18.16) for traction (p = 0.0003). The total cost per patient was $596.97 ($168.81) for nailing and $678.02 (SD $144.25) for traction (p = 0.02). Major cost drivers were ward personnel and overhead; both are directly proportional to LOS. Converting patients from traction to nailing is cost-saving up to day 23 post-admission. CONCLUSION: Savings from IM nailing as compared with skeletal traction were achieved by shortened LOS. Although this study did not assess the effectiveness of either intervention, the literature suggests that traction carries a higher rate of complications than nailing. Investment in IM nailing capacity may yield substantial net savings to health systems, as well as improved clinical outcomes.

An observational cohort study of the adoption of elastic stable intramedullary nailing for the treatment of pediatric femur fractures in Kumasi, Ghana.

BACKGROUND: In high- and middle-income countries, elastic stable intramedullary nailing (ESIN) is the commonest treatment of femur fractures in children 5-11 years of age. At Komfo Anokye Teaching hospital (KATH) in Kumasi, Ghana, prior to this study all pediatric femur fractures were treated with skin traction to union. This study was designed to report the early results and costs of the adoption of ESIN at KATH to provide data to other low- and middle-income sites considering adoption of this surgical technique. METHODS: An observational cohort study that included 84 pediatric patients ages 3-14 years presenting with closed femur fractures and treated with either skin traction or ESIN. Multivariate logistic regression was used to compare the rate of treatment success between treatment groups. RESULTS: Treatment success (coronal and sagittal angulation less than 10 ° and shortening less than 15 mm at osseous union) was achieved in 92 % of the ESIN group versus 67 % of the skin traction group (odds ratio for ESIN group 9.28 (1.6-54.7); p = 0.0138). Average length of stay was significantly lower in the ESIN group (p = 0.001), but charges to patients were higher in the ESIN group (p < 0.001) because of the high cost of implants. CONCLUSIONS: The initial experience of operative treatment of femoral shaft fractures in children using ESIN was positive, with improved rates of treatment success and no surgical complications. Because of the high cost of implants, direct costs of treatment remained higher with ESIN despite reductions in length of hospital stay.

Time intervals in the treatment of fractured femurs as indicators of the quality of trauma systems.

OBJECTIVE: To investigate the use of time intervals in the treatment of fractured femurs as indicators of the quality of trauma systems. METHODS: Time intervals from injury to admission, admission to surgery and surgery to discharge for patients with isolated femur fractures in four low- and middle-income countries were compared with the corresponding values from one German hospital, an Israeli hospital and the National Trauma Data Bank of the United States of America by means of Student's t-tests. The correlations between the time intervals recorded in a country and that country's expenditure on health and gross domestic product (GDP) were also evaluated using Pearson's product moment correlation coefficient. FINDINGS: Relative to patients from high-income countries, those from low- and middle-income countries were significantly more likely to be male and to have been treated by open femoral nailing, and their intervals from injury to admission, admission to surgery and surgery to discharge were significantly longer. Strong negative correlations were detected between the interval from injury to admission and government expenditure on health, and between the interval from admission to surgery and the per capita values for total expenditure on health, government expenditure on health and GDP. Strong positive correlations were detected between the interval from surgery to discharge and general government expenditure on health. CONCLUSION: The time intervals for the treatment of femur fractures are relatively long in low- and middle-income countries, can easily be measured, and are highly correlated with accessible and quantifiable country data on health and economics.

Cost effectiveness of using surgery versus skeletal traction in management of femoral shaft fractures at Thika level 5 hospital, Kenya.

INTRODUCTION: A prospective quasi experimental study was undertaken at the Thika level 5 hospital. The study aimed to compare the costs of managing femoral shaft fracture by surgery as compared to skeletal traction. METHODS: Sixty nine (46.6%) patients were enrolled in group A and managed surgically by intramedullary nailing while 79 (53.4%) patients were enrolled in group B and managed by skeletal traction. Exclusion criteria included patients with pathological fractures and previous femoral fractures. Data was collected by evaluation of patients in patient bills using a standardized questionnaire. The questionnaire included cost of haematological and radiological tests, bed fees, theatre fees and physiotherapy costs. The data was compiled and analyzed using SPSS version 16. Person's chi square and odds ratios were used to measure associations and risk analysis respectively. RESULTS: A higher proportion of patients (88.4%) in group A were hospitalized for less than one month compared to 20 patients (30.4%) in group B (p, 0.001).Total cost of treatment in group A was significantly lower than in group B. Nineteen (27.9%) patients who underwent surgery paid a total bill of Ksh 5000-7500 compared to 7(10.4%) who were treated by traction. The financial cost benefit of surgery was further complimented by better functional outcomes. CONCLUSION: The data indicates a cost advantage of managing femoral shaft fracture by surgery compared to traction. Furthermore the longer hospital stay in the traction group is associated with more malunion, limb deformity and shortening.

Odebode-Agaja adult cervical traction device.

This technical note describes a new simple, cheap and affordable adult cervical traction device that is especially suitable for use in resource-poor third world countries because of its cost-effectiveness. While the widely used imported Gardner-Wells tongs cost over N250,000 (Nigerian) naira (approximately $1630 USD), the new equally effective, durable and locally readily available Odebode-Agaja traction device sells for N35,000 naira (approximately $220 USD). The device does not require scalp incision or skull drilling. It is designed for bedside application in patients with cervical spine injuries, including subluxation and fracture-dislocation of the cervical spine from the atlanto-occipital joint to T1.

Traction removal of percutaneous endoscopic gastrostomy devices in children.

BACKGROUND: There are few published data on non-endoscopic removal of percutaneous endoscopic gastrostomy devices in children. AIMS: To describe prospective data acquired for traction removal of percutaneous endoscopic gastrostomy devices at a single pediatric center over a 5-year period. METHODS: Data were obtained from endoscopy records, computerized hospital patient information systems and case note analysis. The device that could be removed by traction was the Corflo (Merck) 12-Fr percutaneous endoscopic gastrostomy tube with a collapsible internal retention dome. All procedures were performed under general anesthesia. RESULTS: Between 2002-2006, 220 children underwent percutaneous endoscopic gastrostomy removals (166 by traction, 51 endoscopically and 3 Foley catheter to button conversions). The median duration between percutaneous endoscopic gastrostomy insertion and low profile button device substitution was 0.83 years (0.12-3.86). Complications from traction removal included internal retention dome separation in two cases (allowed to pass per rectum, uneventfully), failure to a insert a low profile button device needing percutaneous endoscopic gastrostomy reinsertion, enterocutaneous fistula requiring surgical closure in one patient and laparoscopy for suspected low profile button device misplacement in one instance. The material cost of endoscope disinfection (£10) and disposable usage (£80) avoided by traction removal was calculated at £90 per procedure. CONCLUSION: No mortality occurred as a result of the traction removal of percutaneous endoscopic gastrostomy tubes. Laparoscopy for suspected low profile button device misplacement was needed in one case (0.60%). Traction removal of percutaneous endoscopic gastrostomy tubes was generally safe and a cost-saving procedure in our experience.

Cost-effectiveness of replacing skeletal traction by interlocked intramedullary nailing for femoral shaft fractures in a provincial trauma hospital in Cambodia.

In this article the costs and effectiveness of introducing the SIGN nailing system for femoral shaft fractures in a provincial trauma hospital in Cambodia are compared to those of Perkin's traction treatment. At an average cost per patient of $1,107 in the traction group and $888 in the nail group (p < 0.01), and with better clinical outcomes in the nail group, internal fixation is more cost-effective than conservative treatment.

Termination of second and early third trimester pregnancy: comparison of 3 methods.

The efficacy and safety of 3 methods used in legal termination of pregnancy in the second and early third trimester was assessed in 258 women in Jordan randomly assigned to receive Foley catheter (with and without traction) or prostaglandin E2 vaginal tablets. The failure rate of termination and the total insertion-to-termination time was higher with Foley catheter without traction (16.5%, 16.5 hours) than with traction (10.0%, 14.2 hours) or prostaglandin (8.0%, 11.5 hours). However, Foley catheter as a method of termination of pregnancy in second and early third trimester is safe and inexpensive, and its efficacy can be enhanced with the use of traction to give similar results to prostaglandin E2.

A cost analysis of three methods of treating femoral shaft fractures in children: a comparison of traction in hospital, traction in hospital/home and external fixation.

INTRODUCTION: There is no consensus as to which is best treatment of femoral fractures in children. PATIENTS AND METHODS: We performed a cost analysis comparing three treatments of femoral shaft fractures in children aged 3-15 years at 3 hospitals during the same period (1993-2000). The analysis included total medical costs and costs for the care provider and were calculated from the time of injury up to 1 year. RESULTS: At hospital 1, treatment consisted of external fixation and early mobilization. At hospital 2, the treatment was skin or skeletal traction in hospital for 1-2 weeks, followed by home traction. At hospital 3, treatment was skin or skeletal traction in hospital until the fracture healed. RESULTS: The average total costs per patient were EUR 10,000 at hospital 1, EUR 23,000 at hospital 2, and EUR 38,000 at hospital 3. INTERPRETATION: The main factor for determining the cost of treatment was the number of days in hospital, which was lower in children treated with external fixation.

[Long-term results after conservative treatment of pediatric femoral shaft fractures]. / Konservative Behandlung der isolierten Oberschenkelfraktur im Kindesalter. Langzeitergebnisse.

The principles of treatment for fractures of the femoral shaft in children include conservative and operative management. Traditionally, these fractures have been treated conservatively with skeletal traction. More frequent consideration is being given to the psychological and economical outcome. At what age of the patient surgery can be performed is still open to debate. From 1988 to 1999, 52 children with closed femoral shaft fractures were treated conservatively in the Klinik für Unfallchirurgie, Plastische und Wiederherstellungschirurgie der Universität Göttingen (until 1994 Klinik für Allgemeinchirurgie). Overhead traction was applied in 27 children with a mean age of 19.9 months (group I), and a 90-90 skeletal traction was performed in 25 children with a mean age of 47 months (group II). This treatment was followed by spica casting on an outpatient basis. At a mean follow-up of 6 11/12 years (2 4/12-12 5/12) in 33 children all fractures were healed and no malalignment with clinical relevance could be observed. In four patients the limb overgrowth was 15-20 mm. The assessment of psychological and somatic aspects revealed disturbances in the family environment. The average length of hospitalization was much shorter in group I (mean: 17.4 days) than in group II (mean: 23.7 days). Our study confirms the good long-term results after conservative treatment of femoral shaft fractures in children up to 6 years. Social and psychological problems due to the prolonged period of hospitalization as well as the high costs of skeletal traction favor surgical treatment for children older than 3-4 years.

Femoral shaft fractures in children: traction and casting versus elastic stable intramedullary nailing.

BACKGROUND: Treatment of pediatric femoral fractures by 90/90 traction and spica casting (TXN/CST) has begun to be replaced by elastic stable intramedullary nailing (ESIN). The purpose of our study was to perform a cost analysis of TXN/CST versus ESIN in addition to comparing clinical/functional parameters. METHODS: We reviewed all children admitted with femoral shaft fractures between January 1995 and April 1998. Overall cost and clinical/radiographic outcome measures were analyzed, and 60% of patients' parents completed a follow-up telephone interview. Sixty-eight patients representing 71 femoral shaft fractures that had complete data and 1-year follow-up were included. RESULTS: No difference existed between the two groups for standard clinical/functional criteria. ESIN was associated with a lower overall cost than TXN/CST. ESIN also resulted in better scar acceptance, and higher overall parent satisfaction. CONCLUSION: Less cost and comparable clinical outcome make ESIN a better option than traditional TXN/CST for femoral fracture care in the skeletally immature patient.

The treatment of femoral shaft fractures in children: a systematic overview and critical appraisal of the literature.

OBJECTIVE: Through a critical systematic overview of the literature on the treatment of pediatric femoral shaft fractures to determine if any method of treatment can be recommended over others. DATA SOURCES: A MEDLINE search was performed for all cohort and randomized clinical trials for the years 1966 to 1996. STUDY SELECTION: Of 1217 identified articles, 15 cohort studies (where 2 or more treatments were compared in the same study) reported the treatment of children with femoral fractures. DATA EXTRACTION: Information was abstracted and articles rated for quality blind to author, institution and journal. DATA SYNTHESIS: Children having early application of a hip spica cast had an average hospital stay of 11 days (range from 5 to 29 days), average charges of $5784 (range from $590 to $11,800), average rates of limb-length discrepancy (greater than 2 cm) of 3% (range from 0 to 25%), angulatory malunion rates (greater than 10 degrees) of 8% (range from 0 to 19%), and rotational malunion rates (greater than 10 degrees) of 13% (range from 0 to 5%). The costs and malunion rates of early application of a hip spica cast were lower than for traction. Internal fixation (including intramedullary nails) had low angulatory malunion rates compared with early application of a hip spica cast but higher over-lengthening rates (greater than 2 cm) of 25% (range from 5% to 100%) and mean rotational malunion rates (greater than 10 degrees) of 25% (range from 11% to 32%). CONCLUSION: Early application of a hip spica cast had lower costs and malunion rates than traction.

Skeletal traction versus external fixation for pediatric femoral shaft fractures: a comparison of hospital costs and charges.

OBJECTIVES: To compare the hospital costs, charges, and reimbursement for treatment of pediatric femur fractures by two treatment methods: external fixation and 90-90 traction with spica casting. DESIGN: Retrospective clinical review. SETTING: Department of Orthopaedic Surgery, Children's Hospital Oakland, regional pediatric trauma center. PATIENTS: Twenty-nine consecutive patients between the ages of five and ten with a fracture of the femoral shaft were treated by one of two methods: external fixation (sixteen patients) or 90-90 skeletal traction followed by spica casting (thirteen patients). INTERVENTION: External fixation or 90-90 traction followed by spica casting. MAIN OUTCOME MEASURE: Hospital billing data including costs, charges, reimbursement for the initial inpatient hospitalization, and outpatient financial data until fracture union and cessation of treatment. RESULTS: There was no difference in age, total treatment time, mechanism of injury, or number of associated injuries between the two groups. The average charge for treatment with skeletal traction and spica casting was $32,094 per patient versus $21,439 for external fixation (p < 0.001). The average cost for treatment with traction and spica casting was $22,396 per patient versus $11,520 for external fixation (p < 0.001); reimbursement was $30,846 and $7,490, respectively (p < 0.001). The number of days in the hospital was larger for the traction group than for the external fixation group (22.3 days versus 4.7 days, p < 0.0001). CONCLUSIONS: External fixation of pediatric femoral shaft fractures results in decreased hospital costs and length of hospitalization, but produces significantly less income for the hospital when compared with skeletal traction followed by spica casting.

Isolated closed diaphyseal fractures of the femur in children: comparison of effectiveness and cost of several treatment methods.

The effectiveness of several treatment modalities for isolated closed femur fractures in children ages 4 through 16 years is compared based on outcome (clinical results, morbidity, and parents' satisfaction) and cost. Between 1986 and 1993, 30 patients were treated. Treatment methods included immediate hip spica cast application, distal femoral skeletal traction pin to align the fracture followed by early hip spica cast incorporating the pin (6th day), in-hospital traction, primary external fixation, and primary intramedullary nailing. Average follow up was 4.1 years. Overall results were excellent with minimal morbidity for all treatment methods. Early application of hip spica cast with or without incorporation of the distal femoral traction pin required the fewest hospital days, the shortest time to union, and had the lowest overall cost. Complications, mainly malunion and femoral length discrepancy, however, were greater. Skeletal traction resulted in the longest hospital stay and was equal in cost to external fixation and intramedullary nailing. Primary external fixation appears most applicable in patients who are unlikely to tolerate early casting and who are at increased risk of avascular necrosis with femoral nailing. Patients treated with an intramedullary nail had the fewest complications. Age, size, and gender of patient, location and type of fracture, as well as social circumstances are all significant factors in choosing the optimal method of treatment.

Financial aspects of femoral shaft fracture treatment in children and adolescents.

The billing records of 58 children and adolescents with femoral shaft fractures treated during 1990 were analyzed. The treatment groups included early spica casting, skin traction, skeletal traction, home traction, and intramedullary rodding. The medical charges included both the hospital and physician (orthopedist, radiologist, and anesthesiologist) components. The total charges were lowest for the early spica group ($5,494) and highest for the skeletal traction and intramedullary rodding groups ($21,093 and $21,359, respectively). Both skin traction and home Neufeld traction were associated with significant savings over in-hospital skeletal traction and intramedullary rodding. With the continually rising cost of health care, it is the responsibility of the physician to know the charges for various treatment options.

Comparison of inpatient and outpatient traction in developmental dislocation of the hip.

We studied 83 hips in 72 children being treated for developmental hip dislocation to assess the influence of home traction upon the incidence and severity of avascular necrosis (AVN). We compared two types of traction prior to closed or open reduction: inpatient Bryant's skin traction (40 hips), and outpatient (home) Bryant's skin traction (43 hips). No routine in-traction radiographs were taken in either group. After traction, a stable closed reduction was achieved in 55 hips (66%). Open reduction was performed on 28 hips (34%). The rate of severe AVN involving growth disturbance and resultant deformity (Bucholz types II, III, and IV) was low in both traction groups (inpatient, three out of 40, outpatient, one out of 43). These results demonstrate that an outpatient traction program without attention to radiographic hip station is as safe as identically instituted inpatient programs, as well as those that emphasize achievement of a traction reduction or a predetermined hip station.