Slipped capital femoral epiphysis (SCFE) is the most common pediatric hip disorder. The most devastating complication is development of avascular necrosis of the femoral head. In order to reduce the potential for this complication occurring following delayed contralateral SCFE, there has been consideration in the literature of prophylactic pinning of the contralateral hip. The objective of this study was to determine the cost-effectiveness of this treatment strategy.

The outcome probabilities and utilities utilised in a decision analysis of prophylactic pinning of the contralateral hip in SCFE, reported by Kocher et al, were used in this study. Costing data, reported in 2005 Canadian dollars, was obtained from our institution. Using this data, an economic evaluation was performed. The time horizon was four years, so as to follow the adolescents to skeletal maturity. Discounting was performed at 3% per year. Sensitivity analyses were conducted to determine the effect of variation of the outcome probabilities and utilities.

In all analyses, prophylactic pinning resulted in cost savings but lower utility, compared to the currently accepted strategy of observation of the contralateral hip. The results were most sensitive to an increase in the probability of a delayed contralateral SCFE to 27%. Using the base case analysis, the incremental cost-effectiveness ratio was $7856.12 per utility gained. Using the most sensitive probability of a delayed contralateral SCFE of 27%, the incremental cost-effectiveness ratio was $27,252.92 per utility gained.

The results of this study demonstrated overall cost savings with prophylactic treatment, however the utility was lower than the standard treatment of observation. For both the base case and sensitivity analysis, the incremental cost-effectiveness ratio was less than the accepted threshold of $50,000 per quality adjusted life year gained. It should be noted that the use of a four year time horizon excluded consideration of the costs related to total hip arthroplasty for the sequelae of AVN. A prospective, randomised controlled trial, with an accompanying economic evaluation, is required to definitively answer the question of the cost-effectiveness of this treatment. On the basis of this cost-effectiveness analysis, prophylactic pinning of the contralateral hip in SCFE cannot be recommended. A prospective, randomised controlled trial, with an accompanying economic evaluation, is required to definitively answer the question of the cost-effectiveness of this treatment.

To evaluate the cost-effectiveness of operative versus non-operative management of displaced intra-articular calcaneal fractures (DIACFS), a model was constructed based on a randomized clinical trial. Model outputs were costs and quality-adjusted life years (QALYs). When a societal perspective was taken (i.e. productivity losses were included), operative management was less costly and more effective than non-operative care. Sensitivity analysis revealed that cost-effectiveness was highly dependent on the estimates of productivity losses. When productivity losses were excluded, the increase in cost of operative treatment was $2,700 for an incremental gain of .06 QALYs, giving an incremental cost-utility (CU) ratio of $44,000 per QALY gained.

To evaluate the cost-effectiveness of operative versus non-operative management of displaced intra-articular calcaneal fractures (DIACFs).

A decision tree was constructed to model the effect on costs and quality-adjusted life years (QALYs) of operative versus non-operative management for DIACFs. Complication rate, fusion rate, patient survival and utilities, and productivity losses were estimated from a recent prospective randomized control trial. Four-year costs were estimated from the center treating 73% of the patients in the trial. A societal perspective was used. Future costs and benefits were discounted at 5% and reported in 2002 Canadian Dollars. One-way and multi-way sensitivity analysis was performed on all variables using plausible ranges.

When productivity losses were included, operative management was less costly ($13,000 saving) and had a gain of .06 QALYs (based on improvements in health related quality of life), making it the dominant strategy compared to non-operative treatment. The cost-effectiveness was most sensitive to the return to work estimates. When productivity losses were excluded, the increase in cost of operative treatment was $2,700 for a .06 QALY gain, giving an incremental cost-utility (CU) ratio of $44,000 per QALY gained.

The treatment of the DIACF has long a source of uncertainty in orthopedic surgery. A recent prospective, randomized, trial concluded that operative management provided no improvement over non-operative care. The cost-effectiveness of operative management indicates that it is a moderately economically attractive treatment (a CU ratio of < $50,000). Further exploration of the impact of productivity losses is required.

Funding: Dr. Brauer is supported by a grant from Alberta Heritage Foundation

Introduction and Aims: Treatment of the displaced intra-articular calcaneal fracture (DIACF) has long been a source of uncertainty in orthopaedic surgery. To evaluate the cost-effectiveness of operative versus non-operative management of this fracture, a model was constructed based on a randomised clinical trial. Model outputs were costs and quality-adjusted life years (QALYs).

Method: A decision tree was constructed to model the effect on costs and quality-adjusted life years (QALYs) of operative versus non-operative management for DIACFs. Complication rate, fusion rate, survival data, productivity losses and patient utilities were estimated from a recent prospective randomised control trial. Four-year costs were estimated from the centre treating 73% of the patients. A societal perspective was used in the primary analysis. Future costs and benefits were discounted at 5% and reported in 2002 Canadian dollars. One-way sensitivity analysis and a multi-way Monte Carlo simulation were performed incorporating all ranges of values for the utilities, costs and probabilities.

Results: When productivity losses were included, operative management was less costly ($13,000 cost saving) and had an incremental gain of .06 QALYs, based on improvements in health-related quality of life, thus, making it the dominant strategy compared to non-operative treatment. The cost-effectiveness was most sensitive to the estimates of the productivity losses. When productivity losses were excluded, the increase in cost of operative treatment was $2700 for an incremental gain of .06 QALYs, giving an incremental cost-utility (CU) ratio of $44,000 per QALY gained. The outcome of the analysis remained stable with the remainder of the one-way and multi-way sensitivity analysis. Of the 2000 iterations, with Monte Carlo simulation when productivity losses were included, 80% resulted in cost-effectiveness ratios less than $50,000 per QALY gained for operative treatment. When productivity losses were excluded, 53% of the 2000 iterations resulted in cost-effectiveness ratios less than $50,000.

Conclusion: The treatment of the DIACF has long been a source of uncertainty in orthopaedic surgery. The cost-effectiveness of operative management indicates that it is a moderately economically attractive treatment (a CU ratio of < $50,000). Further exploration of the impact of productivity losses is required.