Cost-effectiveness of Treatments after Closed Extra-Articular Distal Radius Fractures in Older Adults from the WRIST Clinical Trial.

BACKGROUND Distal radius fractures (DRF) in the elderly are treated with volar locking plates (VLP), external fixation (ex-fix), percutaneous pinning (CRPP), or casting. This study performs an economic analysis of these treatments in elderly patients with closed DRFs. METHODS This is a secondary analysis of the Wrist and Radius Injury Surgical Trial (WRIST), a randomized multicenter international clinical trial with a parallel nonoperative casted group of patients over the age of 60 with surgically indicated, extra-articular closed DRFs. SF-36-converted utilities and total costs from Medicare were used to calculate quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER). RESULTS Casted patients were self-selected and older (p<0.001) than the randomized surgical cohorts, but otherwise similar in comorbidities and sociodemographic characteristics. QALYs for CRPP were highest at 9.17 and ex-fix lowest at 8.81. Total cost expended were $16,354 for VLP, $16,012 for ex-fix, $11,329 for CRPP, and $6,837 for casting. The ICER for VLP and ex-fix were dominated by CRPP and casting. The ICER for CRPP compared to casting was $28,717 and VLP compared to ex-fix was $2,117. One-way sensitivity analysis demonstrated robustness of the results. Probabilistic sensitivity analysis revealed a 10%, 5%, 53%, and 32% chance of VLP, ex-fix, CRPP, and casting being cost-effective at the willingness-to-pay threshold of $100,000/QALY. CONCLUSIONS Casting is the most cost-effective treatment modality in the elderly with closed extra-articular DRFs and should be considered before operative intervention. In unstable closed fractures, CRPP, which is the most cost-effective surgical intervention, may be considered before VLP or ex-fix.