Abstract
Purpose
A recent multicentre randomized control trial (RCT) failed to demonstrate superior quality of life at one year following open reduction and internal fixation (ORIF) compared to nonoperative treatment for unstable isolated fibular fractures. We sought to determine the cost-effectiveness of ORIF compared to non-operative management of unstable fibular fractures.
Method
A decision tree was used to model the results of a multicentre trial comparing ORIF versus nonoperative treatment for isolated fibular fractures. A single payer, governmental perspective was used for the analysis. Utilities (a measure of preference for a health state) were obtained from the subjects Short-Form-6D scores and used to calculated Quality Adjusted Life Years (QALYs). Probabilities for each strategy were taken from the one-year trial endpoint. Costs were obtained from the Ontario Case Costing Initiative. Sensitivity analysis was performed for all model variables to determine when ORIF is a cost-effective treatment (incremental cost per QALY gained < $75,000).
Results
Nonoperative management was the preferred treatment during the one-year time-horizon. The nonoperative treatment strategy had an average cost of $2,099 $885 for an average gain of 0.717 0.064 QALYs. ORIF had an average cost of $6,455 $3,589 for an average gain of 0.734 0.051 QALYs. The incremental cost effectiveness ratio for the ORIF treatment was $256,235 per QALY. ORIF becomes the preferred treatment at extreme values for its costs (< $1,450) and its effectiveness (QALY > 0.81).
Conclusion
From a single-payer, governmental perspective open reduction and internal fixation does not appear to be cost-effective; however, if operative fixation decreases the lifetime incidence of post-traumatic ankle arthrosis or a broader societal perspective with a higher willingness to pay threshold is adopted, then the economic attractiveness of ORIF would improve.
