title: Is surgery for displaced, midshaft clavicle fractures in adults cost-effective? Results based on a multicenter randomized, controlled trial.
abstract: OBJECTIVE
  To determine the cost-effectiveness of open reduction internal fixation (ORIF) of displaced, midshaft clavicle fractures in adults.
  
  
  METHODS
  Formal cost-effectiveness analysis based on a prospective, randomized, controlled trial.
  
  
  METHODS
  Eight hospitals in Canada (seven university-affiliated and one community hospital).
  
  
  METHODS
  One hundred thirty-two adults with acute, completely displaced, midshaft clavicle fractures.
  
  
  METHODS
  Clavicle ORIF versus nonoperative treatment.
  
  
  METHODS
  Utilities derived from SF-6D.
  
  
  RESULTS
  The base case cost per quality-adjusted life-year (QALY) gained for ORIF was $65,000. Cost-effectiveness improved to $28,150/QALY gained when the functional benefit from ORIF was assumed to be permanent with cost per QALY gained falling below $50,000 when the functional advantage persisted for 9.3 years or more. In other sensitivity analyses, the cost per QALY gained for ORIF fell below $50,000 when ORIF cost less than $10,465 (base case cost $13,668) or the long-term utility difference between nonoperative treatment and ORIF was greater than 0.034 (base case difference 0.014). Short-term disutility associated with fracture healing also affected cost-effectiveness with the cost per QALY gained for ORIF falling below $50,000 when the utility of a fracture treated nonoperatively before union was less than 0.617 (base case utility 0.706) or when nonoperative treatment increased the time to union by 20 weeks (base case difference 12 weeks).
  
  
  CONCLUSIONS
  The cost-effectiveness of ORIF after acute clavicle fracture depended on the durability of functional advantage for ORIF compared with nonoperative treatment. When functional benefits persisted for more than 9 years, ORIF had a favorable value compared with many accepted health interventions.
authors.affiliation: Dartmouth-Hitchcock Medical Center, Lebanon, NH 03755, USA. adam.pearson@hitchcock.org
authors.forename: Adam M
authors.initials: AM
authors.lastname: Pearson
authors.forename: Anna N A
authors.initials: AN
authors.lastname: Tosteson
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Koval
authors.forename: Michael D
authors.initials: MD
authors.lastname: McKee
authors.forename: Robert V
authors.initials: RV
authors.lastname: Cantu
authors.forename: John E
authors.initials: JE
authors.lastname: Bell
authors.forename: Milena
authors.initials: M
authors.lastname: Vicente
mesh_terms: D000328:Adult; D002968:Clavicle / Q000293:injuries* / Q000601:surgery; D003362:Cost-Benefit Analysis; D005593:Fracture Fixation, Internal / Q000191:economics*; D006304:Health Status; D006801:Humans; D009984:Orthopedic Fixation Devices / Q000191:economics*; D017063:Outcome Assessment, Health Care; D011446:Prospective Studies; D019057:Quality-Adjusted Life Years; D012680:Sensitivity and Specificity; D012784:Shoulder Fractures / Q000601:surgery*