Abstract
BackgroundTo evaluate the cost-effectiveness of a reduction in the number of routine radiographs in the follow-up of patients with ankle fractures.MethodsWe performed an economic evaluation alongside the multicentre, randomised WARRIOR trial. Participants were randomised to a reduced imaging follow-up protocol (i.e. radiographs at week 6 and 12 follow-up obtained on clinical indication) or usual care (i.e. routine radiography at weeks 6 and 12). The Olerud & Molander Ankle Score (OMAS) was used to assess ankle function and the EQ-5D-3L was used to estimate Quality-Adjusted Life Years (QALYs). Costs and resource use were assessed using self-reported questionnaires and medical records, and analysed from a societal perspective. Multiple imputation was used for missing data, and data were analysed using seemingly unrelated regression analysis and bootstrapping.ResultsIn total, 246 patients had data available for analysis (reduced imaging = 118; usual care = 128). Fewer radiographs were obtained in the reduced imaging group (median = 4) compared with the usual-care group (median = 5). Functional outcome was comparable in both groups. The difference in QALYs was − 0.008 (95% CI:-0.06 to 0.04) and the difference in OMAS was 0.73 (95% CI:-5.29 to 6.76). Imaging costs were lower in the reduced imaging group (−€48; 95% CI:- €72 to -€25). All other cost categories did not statistically differ between the groups. The probability of the reduced imaging protocol being cost-effectiveness was 0.45 at a wiliness-to-pay of €20,000 per QALY.ConclusionsReducing the number of routine follow-up radiographs has a low probability of being cost-effective compared with usual care. Functional outcome, health-related quality of life and societal costs were comparable in both groups, whereas imaging costs were marginally lower in the reduced imaging group. Given this, adherence to a reduced imaging follow-up protocol for those with routine ankle fractures can be followed without sacrificing quality of care, and may result in reduced costs.Trial registrationThe trial was registered on 26-05-2014 in the Netherlands Trial Registry, with reference number NL4477 (www.trialregister.nl/trial/4477).
Highlights
To evaluate the cost-effectiveness of a reduction in the number of routine radiographs in the followup of patients with ankle fractures
Both national and international trauma protocols dictate that routine radiographs should be obtained at regular intervals during the follow-up of patients with an ankle fracture, there is little scientific evidence to support this position [4, 13, 14]
A recent retrospective analysis, involving a cohort of 528 patients with an ankle fracture, demonstrated that as few as 1.2% (n = 11/928) of routine radiographs obtained after 3 weeks of follow-up led to a change in treatment strategy [16]. These results suggest that current imaging protocols for the follow-up of ankle fracture patients might not be cost-effective
Summary
To evaluate the cost-effectiveness of a reduction in the number of routine radiographs in the followup of patients with ankle fractures. This has led to an increased interest in the effectiveness of imaging in clinical decision-making [9,10,11,12] Despite increased costs, both national and international trauma protocols dictate that routine radiographs should be obtained at regular intervals during the follow-up of patients with an ankle fracture, there is little scientific evidence to support this position [4, 13, 14]. Both national and international trauma protocols dictate that routine radiographs should be obtained at regular intervals during the follow-up of patients with an ankle fracture, there is little scientific evidence to support this position [4, 13, 14] For both non-operatively and operatively treated patients, it is recommended that four outpatient clinic visits including radiographs, are to be conducted after a follow-up of one, two, six and twelve weeks [13]. The goal of these radiographs are to monitor the position of the fracture fragments, the position of fixation material, the alignment of the joint and the bone-healing process
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