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.

Cost-Effectiveness of Volar Locking Plate Compared with Augmented External Fixation for Displaced Intra-Articular Wrist Fractures.

BACKGROUND: The purpose of the present study was to estimate the cost-effectiveness of treating displaced, intra-articular distal radial fractures with volar locking plate fixation compared with augmented external fixation. METHODS: A cost-utility analysis was conducted alongside a randomized, clinical trial comparing 2 surgical interventions for intra-articular distal radial fractures. One hundred and sixty-six patients were allocated to either volar locking plate fixation (84 patients) or external fixation (82 patients) and were followed for 2 years. Health-related quality of life was assessed with the EuroQol-5 Dimensions and was used to calculate patients' quality-adjusted life-years (QALYs). Resource use was identified prospectively at the patient level at all follow-up intervals. Costs were estimated with use of both a health-care perspective and a societal perspective. Results were expressed in incremental cost-effectiveness ratios, and uncertainty was assessed with use of bootstrapping methods. RESULTS: The average QALY value was equivalent between the groups (1.70463 for the volar locking plate group and 1.70726 for the external fixation group, yielding a nonsignificant difference of -0.00263 QALY). Health-care costs were equal between the groups, with a nonsignificant difference of &OV0556;52 (p = 0.8) in favor of external fixation. However, the external fixation group had a higher loss of productivity due to absence from work (5.5 weeks in the volar locking plate group compared with 9.2 weeks for the external fixation group; p = 0.02). Consequently, the societal costs were higher for the external fixation group compared with the volar locking plate group (&OV0556;18,037 compared with &OV0556;12,567, representing a difference of &OV0556;5,470; p = 0.04) in favor of the volar locking plate group. Uncertainty analyses showed that there is indifference regarding which method to recommend from a health-care perspective, with volar locking plate treatment and external fixation having a 47% and 53% likelihood of being cost-effective, respectively. From the societal perspective, volar locking plate treatment had a 90% likelihood of being cost-effective. CONCLUSIONS: External fixation was less cost-effective than volar locking plate treatment for distal radial fractures from a societal perspective, primarily because patients managed with external fixation had a longer absence from work. LEVEL OF EVIDENCE: Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

The Amsterdam Wrist Rules: how much money can they save?

PURPOSE: To allow physicians to be more selective in their request for a radiograph of the wrist and to potentially reduce costs, the Amsterdam Wrist Rules (AWR) have been developed, externally validated, and recently also implemented. The aim of this study was to conduct an incremental cost analysis and budget impact analysis of the implementation of the AWR at the emergency department (ED) in the Netherlands. METHODS: A cost-minimisation analysis to determine the expected cost savings for implementation of the Amsterdam Wrist Rules. The incremental difference in costs before and after implementation of the AWR was based on the reduction in costs for radiographs, the cost savings due to reduction of ED consultation times and the costs of a re-evaluation appointment by a physician. RESULTS: In the Netherlands, implementation of the AWR could potentially result in 6% cost savings per patient with a wrist injury. In addition, implementation of the AWR resulted in €203,510 cost savings annually nationwide. In the sensitivity analysis, an increase in physician compliance to 100% substantially increased the potential total amount of annual cost savings to €610,248, which is 6% of total costs before implementation. Variation in time spent at the ED, a decrease and increase in costs and patients presenting annually at the ED did not change the cost savings substantially. CONCLUSION: Implementation of the AWR has been shown to reduce direct and indirect costs and can, therefore, result in considerable savings of healthcare consumption and expenditure.

Profile and cost of sport and exercise-related hand and wrist injuries with Emergency Department presentation.

OBJECTIVES: Injuries to the hand and wrist from sport and exercise are common and costly. This cost-of-illness analysis was performed to estimate the economic implications of hand and wrist injuries that were sustained as a result of participation during sport or exercise. PERSPECTIVE: Cost estimates were calculated from resource use in the emergency, inpatient and outpatient settings from the perspective of one public healthcare service. SETTING: Alfred Health, a large public health service with two emergency departments located in Victoria, Australia. METHODS: This descriptive epidemiological study used ICD-10 diagnostic codes and electronic billing records to identify 778 potential cases for inclusion. Electronic medical records were screened and reviewed to extract demographic and patient care journey data. RESULTS: 692 individuals, (n=761 individual zone of injuries), were included. Australian Rules Football (ARF) was the largest contributor to injuries (20.2%) followed by riding bicycles (15.9%. The total cost of all injuries was $790,325, with a median cost per case of $278 [IQR $210-$282] in the Emergency Department n=692, $3328 [IQR $2242-$6441] in the inpatient setting n=76 and $630 [IQR $460-$870] in the outpatient setting n=244. CONCLUSIONS: Hand and wrist injuries sustained from sport and exercise contribute to a significant financial burden on the healthcare system. Future research that considers the costs that occur outside of the public healthcare service is required estimate the burden associated with these injuries comprehensively. Injury prevention programs may mitigate the observed injury trends.

Clinical and cost implications of using immediate MRI in the management of patients with a suspected scaphoid fracture and negative radiographs results from the SMaRT trial.

AIMS: The aim of the Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) trial was to evaluate the clinical and cost implications of using immediate MRI in the acute management of patients with a suspected fracture of the scaphoid with negative radiographs. PATIENTS AND METHODS: Patients who presented to the emergency department (ED) with a suspected fracture of the scaphoid and negative radiographs were randomized to a control group, who did not undergo further imaging in the ED, or an intervention group, who had an MRI of the wrist as an additional test during the initial ED attendance. Most participants were male (52% control, 61% intervention), with a mean age of 36.2 years (18 to 73) in the control group and 38.2 years (20 to 71) in the intervention group. The primary outcome was total cost impact at three months post-recruitment. Secondary outcomes included total costs at six months, the assessment of clinical findings, diagnostic accuracy, and the participants' self-reported level of satisfaction. Differences in cost were estimated using generalized linear models with gamma errors. RESULTS: The mean cost up to three months post-recruitment per participant was £542.40 (sd £855.20, n = 65) for the control group and £368.40 (sd £338.60, n = 67) for the intervention group, leading to an estimated cost difference of £174 (95% confidence interval (CI) -£30 to £378; p = 0.094). The cost difference per participant increased to £266 (95% CI £3.30 to £528; p = 0.047) at six months. Overall, 6.2% of participants (4/65, control group) and 10.4% of participants (7/67, intervention group) had sustained a fracture of the scaphoid (p = 0.37). In addition, 7.7% of participants (5/65, control group) and 22.4% of participants (15/67, intervention group) had other fractures diagnosed (p = 0.019). The use of MRI was associated with higher diagnostic accuracy both in the diagnosis of a fracture of the scaphoid (100.0% vs 93.8%) and of any other fracture (98.5% vs 84.6%). CONCLUSION: The use of immediate MRI in the management of participants with a suspected fracture of the scaphoid and negative radiographs led to cost savings while improving the pathway's diagnostic accuracy and patient satisfaction. Cite this article: Bone Joint J 2019;101-B:984-994.

Proximal Row Carpectomy versus Four-Corner Arthrodesis for the Treatment of Scapholunate Advanced Collapse/Scaphoid Nonunion Advanced Collapse Wrist: A Cost-Utility Analysis.

BACKGROUND: Two mainstay surgical options for salvage in scapholunate advanced collapse and scaphoid nonunion advanced collapse are proximal row carpectomy and four-corner arthrodesis. This study evaluates the cost-utility of proximal row carpectomy versus three methods of four-corner arthrodesis for the treatment of scapholunate advanced collapse/scaphoid nonunion advanced collapse wrist. METHODS: A cost-utility analysis was performed in accordance with the Second Panel on Cost-Effectiveness in Health and Medicine. A comprehensive literature review was performed to obtain the probability of potential complications. Costs were derived using both societal and health care sector perspectives. A visual analogue scale survey of expert hand surgeons estimated utilities. Overall cost, probabilities, and quality-adjusted life-years were used to complete a decision tree analysis. Both deterministic and probabilistic sensitivity analyses were performed. RESULTS: Forty studies yielding 1730 scapholunate advanced collapse/scaphoid nonunion advanced collapse wrists were identified. Decision tree analysis determined that both four-corner arthrodesis with screw fixation and proximal row carpectomy were cost-effective options, but four-corner arthrodesis with screw was the optimal treatment strategy. Four-corner arthrodesis with Kirschner-wire fixation and four-corner arthrodesis with plate fixation were dominated (inferior) strategies and therefore not cost-effective. One-way sensitivity analysis demonstrated that when the quality-adjusted life-years for a successful four-corner arthrodesis with screw fixation are lower than 26.36, proximal row carpectomy becomes the optimal strategy. However, multivariate probabilistic sensitivity analysis confirmed the results of our model. CONCLUSIONS: Four-corner arthrodesis with screw fixation and proximal row carpectomy are both cost-effective treatment options for scapholunate advanced collapse/scaphoid nonunion advanced collapse wrist because of their lower complication profile and high efficacy, with four-corner arthrodesis with screw as the most cost-effective treatment. Four-corner arthrodesis with plate and Kirschner-wire fixation should be avoided from a cost-effectiveness standpoint.

Description and cost-analysis of emergency department attendances for hand and wrist injuries.

BACKGROUND: Injuries to the hand and wrist are estimated to account for between 10% and 30% of all ED presentations. The economic burden placed on the healthcare system can be extensive and rise sharply with increase in injury severity. OBJECTIVES: This cost-analysis was performed with the aim of estimating the economic implications of ED attendances for hand and wrist injuries from the perspective of one Australian public health network. METHODS: Data from two EDs were retrieved from the electronic billing records of one large health network across two financial year periods (2014-2015 and 2015-2016) using ICD-10 codes. All costs that resulted from the treatment of any acute hand or wrist injury across the 2 year period were calculated and are presented by age, sex, injury type and mechanism of injury. RESULTS: A total of 10 024 individuals presented to the two EDs in the 2 year period, accounting for approximately 5.4% of all presentations. The most common presentations were males (62.2%), people aged 25-34 years (26.9%) and lacerations (31.2%). The total cost in the 2 year study period was $3 959 535.38 ($1 923 852.38 in 2014-2015; $2 035 683.00 in 2015-2016). The mean cost per presentation was $383 (95% CI [$373, $393]) in 2014-2015 and $407 (95% CI [$394, $421]) in 2015-2016. CONCLUSIONS: Acute hand and wrist injuries contribute to a significant volume of ED presentations each year in one Australian public health network leading to significant expenditure and health resources. Further research into how to best utilise resources and reduce avoidable injuries should be priority areas to reduce the cost of these injuries to the healthcare system and society.

Rationale and design of the SMaRT trial: A randomised, prospective, parallel, non-blinded, one-centre trial to evaluate the use of magnetic resonance imaging in acute setting in patients presenting with suspected scaphoid fracture.

Background Wrist injury is a common presentation to the Emergency Department in the United Kingdom. Among these injuries, the scaphoid is the most common fractured carpal bone. However, given the limited ability of conventional radiography to accurately diagnose a suspected scaphoid fracture on presentation, its diagnosis and management remain challenging. Despite the vast clinical evidence supporting the superior accuracy of magnetic resonance imaging, there is little to no evidence around the real-world clinical and economic impact of immediate magnetic resonance imaging in the management of suspected scaphoid fractures. Methods Review of design and implementation challenges associated with the identification and subsequent recruitment of eligible patients, implementation of a novel clinical pathway in an acute setting, rationale behind the primary and secondary outcomes selected and measurement of the primary outcome. Results The Scaphoid Magnetic Resonance Imaging in Trauma trial is a single-site prospective, randomised, non-blinded, parallel design trial that aims to evaluate the use of immediate magnetic resonance imaging in the management of patients presenting to the acute setting with suspected scaphoid fractures. The primary outcome is the total 3-month cost per patient associated with the diagnosis and treatment of suspected scaphoid fractures. It is hypothesised that the immediate use of magnetic resonance imaging, a more accurate but expensive imaging modality, in patients with negative findings in the initial four-view radiography, will reduce the overall National Health Service costs by promoting definitive care and avoiding unnecessary diagnostic and treatment procedures. Other rationale design considerations in the recruitment, randomisation, data acquisition and intervention implementation are also discussed. Several of these challenges derive from real-world operational issues associated with the provision of magnetic resonance imaging in an intrinsically complex acute setting. Staff engagement during the trial's planning phase, combined with an extensive training programme rolled out prior to the trial's launch, were essential to raise staff awareness and engagement. Given the acute nature of the clinical condition, the latter was deemed essential as the eligibility assessment, recruitment, randomisation and treatment allocation processes all need to happen in a very tight time frame. Limitations Findings from the Scaphoid Magnetic Resonance Imaging in Trauma trial might not be generalisable to other National Health Service hospitals, foreign healthcare systems nor patient presentations outside normal magnetic resonance imaging working hours. Conclusion The Scaphoid Magnetic Resonance Imaging in Trauma trial was designed to evaluate the costs, patient satisfaction and clinical outcomes around the management of suspected scaphoid fractures and ultimately provide solid evidence on which to base the United Kingdom and international clinical practice. This article discusses the steps considered in the design of this novel trial, with particular emphasis on the issues and lessons learned during the planning and implementation stages.

Cost description of clinical examination and MRI in wrist ligament injuries.

OBJECTIVE: The total number and cost of wrist MRIs in the catchment area of the Västra Götaland Region in Sweden (population 1 723 000) during 1 year was analysed, together with the number and content of referrals. METHODS: Six radiology departments reported the numbers and rate of all MRI investigations intended to diagnose wrist ligament injuries (n = 411) and other injuries to the wrist. RESULTS: The additional cost of the difference between MRIs and a clinical examination by a hand surgeon, plus indirect costs for patients with suspected wrist ligament injuries, was calculated as 957 000 euros. CONCLUSIONS: It is recommended that MRI should only be used in patients in whom there are clinical difficulties in terms of diagnosing wrist ligament injuries. It is suggested that patients with suspected wrist ligament injuries should be referred directly to an experienced hand surgeon, capable of performing a standardised wrist examination and, when needed, diagnostic arthroscopy and final treatment. The proposed algorithm for the diagnosis and treatment of suspected wrist ligament injuries presented in the present study could save time for the patient and for the radiology departments, as well as reducing costs. The ability to implement the early and appropriate treatment of acute ligament injuries could be improved at the same time.

Appropriateness of the Use of Magnetic Resonance Imaging in the Diagnosis and Treatment of Wrist Soft Tissue Injury.

BACKGROUND: When diagnosing wrist soft tissue injury, the authors hypothesize that magnetic resonance imaging is used injudiciously and is associated with unnecessary cost. METHODS: A retrospective review was conducted of patients aged 20 to 60 years who underwent magnetic resonance imaging for possible wrist soft tissue injury at a tertiary care center between 2009 and 2014. Treatment recommendation was classified as nonoperative, operative, or equivocal. If the magnetic resonance imaging-directed treatment recommendation differed from the pre-imaging recommendation, it was noted that the imaging influenced patient care (impact study). The cost estimate of an impact study was calculated by dividing the total studies performed by the number of studies that impacted the treatment recommendation and multiplying this value by the institutional wrist magnetic resonance imaging cost ($2246 in 2016). RESULTS: One hundred forty patients were included. Magnetic resonance imaging affected treatment recommendation in 28 percent of patients. Independent predictors of impact on treatment recommendation were "question specific injury" (OR, 9.46; 95 percent CI, 3.18 to 28.16; p < 0.001) and "question scapholunate injury" (OR, 2.88; 95 percent CI, 1.21 to 6.88; p = 0.02). The only independent predictor of surgery was ordering physician (hand surgeon) (OR, 3.69; 95 percent CI, 1.34 to 10.13; p = 0.01). The cost of an impact study ordered by a non-hand surgeon versus a hand surgeon was $13,359 versus $6491, respectively. CONCLUSIONS: The provider must carefully consider the pretest probability of ordering a study that will affect treatment recommendation. Injudicious screening with magnetic resonance imaging ($15,565) incurred a cost nearly seven times the cost of the one imaging scan ($2246) before impacting one treatment recommendation. In the current era of cost containment and bundled payment, diagnostic test probability must be appreciated to guide physician ordering practices.

Direct, indirect and intangible costs of acute hand and wrist injuries: A systematic review.

BACKGROUND: Injuries sustained to the hand and wrist are common, accounting for 20% of all emergency presentations. The economic burden of these injuries, comprised of direct (medical expenses incurred), indirect (value of lost productivity) and intangible costs, can be extensive and rise sharply with the increase of severity. OBJECTIVE: This paper systematically reviews cost-of-illness studies and health economic evaluations of acute hand and wrist injuries with a particular focus on direct, indirect and intangible costs. It aims to provide economic cost estimates of burden and discuss the cost components used in international literature. MATERIALS AND METHODS: A search of cost-of-illness studies and health economic evaluations of acute hand and wrist injuries in various databases was conducted. Data extracted for each included study were: design, population, intervention, and estimates and measurement methodologies of direct, indirect and intangible costs. Reported costs were converted into US-dollars using historical exchange rates and then adjusted into 2015 US-dollars using an inflation calculator RESULTS: The search yielded 764 studies, of which 21 met the inclusion criteria. Twelve studies were cost-of-illness studies, and seven were health economic evaluations. The methodology used to derive direct, indirect and intangible costs differed markedly across all studies. Indirect costs represented a large portion of total cost in both cost-of-illness studies [64.5% (IQR 50.75-88.25)] and health economic evaluations [68% (IQR 49.25-73.5)]. The median total cost per case of all injury types was US$6951 (IQR $3357-$22,274) for cost-of-illness studies and US$8297 (IQR $3858-$33,939) for health economic evaluations. Few studies reported intangible cost data associated with acute hand and wrist injuries. CONCLUSIONS: Several studies have attempted to estimate the direct, indirect and intangible costs associated with acute hand and wrist injuries in various countries using heterogeneous methodologies. Estimates of the economic costs of different acute hand and wrist injuries varied greatly depending on the study methodology, however, by any standards, these injuries should be considered a substantial burden on the individual and society. Further research using standardised methodologies could provide guidance to relevant policy makers on how to best distribute limited resources by identifying the major disorders and exposures resulting in the largest burden.

Healthcare costs and productivity costs of hand and wrist injuries by external cause: A population-based study in working-age adults in the period 2008-2012.

BACKGROUND: Hand and wrist injuries are very common at the Emergency Departments (ED), and among the most costly injury types in the working population. The purpose of this study was to explore the causes of non-trivial hand and wrist injuries (i.e., hand fractures, wrist fractures and complex soft-tissue injuries) in working-age adults in order to identify target areas for prevention. METHODS: Data were extracted from the Dutch Injury Surveillance System, from the National Hospital Discharge Registry and from a patient follow-up survey in working-age adults (aged 20-64 years) in the period 2008-2012. An incidence-based cost model was used to estimate healthcare costs, and an absenteeism model for estimating the productivity costs. Total costs were calculated by external cause, subdivided in their main categories (home, sports, work, traffic and violence) and their most important subclasses. RESULTS: Total costs of these injuries in The Netherlands were US $410 million per year, of which 75% (US $307 million) productivity costs. Males represented 66% (US $271 million) of the total costs. Within the male group, the group 35-49 years had the highest contribution to total costs (US $112 million), as well as the highest costs per case (US $10,675). Work-related injuries showed the highest costs per case (US $11,797), however, only 25% of the total costs were work-related. The top five causes in terms of total costs were: accidents at home (falls 23%, contact with an object 17%), traffic (cycling 9%) and work (industrial work 4%, and construction work 4%). CONCLUSION: Hand and wrist injuries are a major cause of healthcare and productivity costs in working-age adults. To reduce the costs to society, prevention initiatives should be targeted at major contributing causes, that are mainly related to activities at home (falls, contact with an object) and accidents at the road (cycling).

Diagnosis of Occult Scaphoid Fractures: A Cost-Effectiveness Analysis.

BACKGROUND: Scaphoid fractures are common but may be missed on initial radiographs. Advanced imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) have improved diagnostic accuracy, but at an increased initial cost. The purpose of this study was to evaluate the cost-effectiveness of immediate advanced imaging for suspected occult scaphoid fractures. METHODS: A decision analysis model was created to evaluate three diagnostic strategies for patients with concerning history and examination but negative radiographs: (1) empiric cast immobilization with orthopaedic follow-up and repeat radiography at two weeks post-injury, (2) immediate CT scanning, or (3) immediate MRI. Prevalence of occult scaphoid fracture, sensitivity and specificity of CT and MRI, and risks and outcomes of a missed fracture were derived from published clinical trials. Costs of imaging, lost worker productivity, and surgical costs of nonunion surgery were estimated on the basis of the literature. RESULTS: Advanced imaging was dominant over empiric cast immobilization; advanced imaging had lower costs and its health outcomes were projected to be better than those of empiric cast immobilization. MRI was slightly more cost-effective than CT on the basis of the mean published diagnostic performance, but was highly sensitive to test performance characteristics. Advanced imaging would have to increase in cost to more than $2000 or decrease in sensitivity to <25% for CT or <32% for MRI for empiric cast immobilization to be cost-effective. CONCLUSIONS: Given its relatively low cost and high diagnostic accuracy, advanced imaging for suspected scaphoid fractures in the setting of negative radiographs represents a cost-effective strategy for reducing both costs and morbidity. The decision to use CT compared with MRI is a function of individual institutional costs and local test performance characteristics.

WARRIOR-trial - is routine radiography following the 2-week initial follow-up in trauma patients with wrist and ankle fractures necessary: study protocol for a randomized controlled trial.

BACKGROUND: Extremity fractures such as wrist and ankle fractures are a common and costly healthcare problem. The management of these fractures depends on fracture type and loss of congruity of the joint, resulting in cast immobilization or operative treatment. Loss of congruity or displacement leading to uneven joint loading, osteoarthritis and an increased probability of a poor functional outcome should be identified within the first 2 weeks post-trauma, based upon radiographs to determine optimal treatment. After this period, routine radiographs are scheduled for monitoring the bone-healing process. Current protocols describe imaging at 1, 2, 6 and 12 weeks post-trauma. However, it is questionable whether routine radiography following the initial follow-up ( 2-weeks post-trauma) is cost effective. The aim of this study is to determine whether a modification of the radiographic follow-up protocol can be conducted with no worse outcome and less cost than the current standard of care for patients with a wrist or ankle fracture. METHODS/DESIGN: In a multicenter randomized controlled trial, 697 patients aged 18 years or older will be included: 385 wrist fracture- and 312 ankle fracture patients. Patients will be randomized into two groups: Group 1 receives usual care, consisting of radiographs 1, 2, 6 and 12 weeks post-trauma; Group 2 receives radiographs beyond the initial follow-up only when clinically indicated. The primary outcome is the overall extremity-specific function. For wrist fractures, this includes the Disabilities of the Arm, Shoulder and Hand Score; for the ankle fractures, this includes the Olerud and Molander ankle score. Secondary outcomes include: healthcare cost, the specific function measured with the Patient Rated Wrist and Hand Evaluation for wrist fractures and American Academy of Orthopaedic Surgeons foot and ankle questionnaire for ankle fractures, pain-intensity, health-related quality of life, self-perceived recovery, and complications. Both groups will be monitored at 1, 2, and 6 weeks and 3, 6, and 12 months. DISCUSSION: This study will provide data on (cost) effectiveness of routine radiography in the follow-up of wrist and ankle fractures, and could pave the way for a change in (inter)national protocols. TRIAL REGISTRATION: Netherlands Trial Register NTR4610 , registration date 22 June 2014.

Costs analysis and comparison of usefulness of acute MRI and 2 weeks of cast immobilization for clinically suspected scaphoid fractures.

BACKGROUND AND PURPOSE: Fractures of the scaphoid are often not detected on initial plain radiographs. Conventional management of clinically suspected scaphoid fractures is cast immobilization for 2 weeks and then reassessment. Early MRI is a diagnostic alternative. We compared the cost and usefulness of the early MRI diagnostic strategy with that of conventional management. PATIENTS AND METHODS: This prospective pseudo-randomized study included patients between 18 and 49 years of age who attended Bergen Accident and Emergency Department, Bergen, Norway during 1 year in 2009-2010, after sustaining an acute wrist trauma in the previous week and with a clinically suspected scaphoid fracture. 61 patients were investigated with acute MRI, while 63 patients received standard treatment as a control group. We used cost-minimization analysis to estimate the cost of the 2 patient groups. RESULTS: Concerning cost, there were no statistically significant differences in the total direct medical costs or in indirect costs between the groups. Concerning usefulness, patients in the MRI group without a fracture (n = 35) used a cast for fewer days (mean 1 day) than patients in the control group with no fractures (n = 52) (mean 14 days; p < 0.001). They had less than half the number of days on sick leave than patients in the control group (mean 7 days vs. 15 days; p = 0.002). INTERPRETATION: In a Norwegian setting, an early MRI was of value in patients with clinically suspected scaphoid fracture and normal plain radiographs.

The economic burden of fracture patients with osteoporosis in western China.

UNLABELLED: To study the cost of osteoporotic fracture in China, we performed a prospective study and compared the costs of the disease in referral patients with fractures in three of the most common sites. Our results indicated that the economic burden of osteoporotic fracture to both Chinese patients and the nation is heavy. INTRODUCTION: This paper aims to study the cost of osteoporotic fracture in China and thus to provide essential information about the burden of this disease to individuals and society. METHODS: This prospective observational data collection study assessed the cost related to hip, vertebral, and wrist fracture 1 year after the fracture based on a patient sample consisting of 938 men and women. Information was collected using patient records, registry sources, and patient interviews. Both direct medical, direct non-medical, and indirect non-medical costs were considered. RESULTS: The annual total costs were highest in hip fracture patients (renminbi, RMB 27,283 or USD 4,330, with confidence interval (RMB 25715, 28851)), followed by patients with vertebral fracture (RMB 21,474 or USD 3,409, with confidence interval (RMB 20082, 22866)) and wrist fracture (RMB 8,828 or USD 1,401, with confidence interval (RMB 7829, 9827)). The direct medical care costs averaged approximately RMB 17,007 per year per patient, of which inpatient costs, drugs, and investigations accounted for the majority of the costs. Nonmedical direct costs were much less compared to direct healthcare costs and averaged approximately RMB 1,846. CONCLUSION: These results indicate that the economic burden of osteoporotic fracture to both Chinese patients and China was heavy, and the proportion of the costs in China demonstrated many similar features and some significant differences compared to other countries.

Trends in incidence and costs of injuries to the shoulder, arm and wrist in The Netherlands between 1986 and 2008.

BACKGROUND: Upper extremity injuries account for a large proportion of attendances to the Emergency Department. The aim of this study was to assess population-based trends in the incidence of upper extremity injuries in the Dutch population between 1986 and 2008, and to give a detailed overview of the associated health care costs. METHODS: Age-standardized incidence rates of upper extremity injuries were calculated for each year between 1986 and 2008. The average number of people in each of the 5-year age classes for each year of the study was calculated and used as the standard (reference) population. Injury cases were extracted from the National Injury Surveillance System (non-hospitalized patients) and the National Medical Registration (hospitalized patients). An incidence-based cost model was applied in order to estimate associated direct health care costs in 2007. RESULTS: The overall age-adjusted incidence of upper extremity injuries increased from 970 to 1,098 per 100,000 persons (13%). The highest incidence was seen in young persons and elderly women. Total annual costs for all injuries were 290 million euro, of which 190 million euro were paid for injuries sustained by women. Wrist fractures were the most expensive injuries (83 million euro) due to high incidence, whereas upper arm fractures were the most expensive injuries per case (4,440 euro). Major cost peaks were observed for fractures in elderly women due to high incidence and costs per patient. CONCLUSIONS: The overall incidence of upper extremity injury in the Netherlands increased by 13% in the period 1986-2008. Females with upper extremity fractures and especially elderly women with wrist fractures accounted for a substantial share of total costs.