Reduction of routine use of radiography in patients with ankle fractures leads to lower costs and has no impact on clinical outcome: an economic evaluation

Abstract

Background To evaluate the cost-effectiveness of a reduction in the number of routine radiographs in the follow-up of patients with ankle fractures. Methods We 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. Results In 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. Conclusions Reducing 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 registration The trial was registered on 26-05-2014 in the Netherlands Trial Registry, with reference number NL4477 (www.trialregister.nl/trial/4477).

Low‐value injury care in the adult orthopaedic trauma population: A systematic review

“…A total of 476/546 studies were excluded after the full‐text review ( n = 34; Supplementary Digital File ). After final screening, we included 70 studies, 22‐91 but no data on primary outcomes were reported in three of these 26,67,91 …”

“…Most studies were based on case series ( n = 33) 22,31,33,34,36,38,41,43‐50,56,57,60‐64,66,68‐72,74,75,77,85,89,90 followed by systematic reviews with or without meta‐analysis ( n = 12), 23‐25,28,29,39,53,59,67,78,83,86,88,91 prospective cohorts ( n = 9), 30,32,35,37,42,51,54,79,87 RCTs ( n = 9) 27,55,65,73,80‐82,84 and retrospective cohorts ( n = 2; Supplemental Digital File ) 52,58 …”

“…However, a few studies conducted in the context of radius shaft or head and/or neck fractures as well as metacarpal fractures observed changes in management for 10%–32% of patients based on such findings 49,64 82 or ankle 84 fracture compared to those with selective approaches.…”

“…We found consistent evidence for routine follow‐up X‐rays and consultations for lower extremity fractures (i.e., hip, femur, tibia, ankle, metatarsal); these practices were not associated with important changes in management or significant differences in complications or functional recovery when compared to selective use. However, apart from one RCT conducted in patients with ankle fractures, 84 these findings were mainly observed in case series. Globally, these results suggest that the number of follow‐up X‐rays should be questioned.…”

“…We identified two systematic reviews of retrospective studies (one with meta-analysis), 78,83 two RCTs, 82,84 three cohort studies (one prospective) 42,52,58 and 32 case series 31,33,34,36,41,[43][44][45][46][47][48][49][50]56,57,[60][61][62][63][64]66,[68][69][70][71][72][74][75][76][77]85,89,90 evaluating routine post-treatment imaging and follow-up consultations.…”