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Surgical management for displaced pediatric proximal humeral fractures: a cost analysis.

Shore BJ, Hedequist DJ, Miller PE, Waters PM, Bae DS - J Child Orthop (2015)

Bottom Line: A greater percentage of open reduction was seen in the IMN and PPB groups (p = 0.03), while a higher proportion of physeal injury was seen in the PPE group (p = 0.02).The decision analysis revealed that the PPE technique resulted in an average cost saving of $4,502 per patient compared to IMN and $2,066 compared to PPB.This strategy remained cost-effective even when the complication rates with exposed implants approached 55 %.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Hunnewell 221, 300 Longwood Avenue, Boston, MA, 02115, USA, Benjamin.shore@childrens.harvard.edu.

ABSTRACT

Purpose: The purpose of this investigation was to determine which of the following methods of fixation, percutaneous pinning (PP) or intramedullary nailing (IMN), was more cost-effective in the treatment of displaced pediatric proximal humeral fractures (PPHF).

Methods: A retrospective cohort of surgically treated PPHF over a 12-year period at a single institution was performed. A decision analysis model was constructed to compare three surgical strategies: IMN versus percutaneous pinning leaving the pins exposed (PPE) versus leaving the pins buried (PPB). Finally, sensitivity analyses were performed, assessing the cost-effectiveness of each technique when infection rates and cost of deep infections were varied.

Results: A total of 84 patients with displaced PPHF underwent surgical stabilization. A total of 35 cases were treated with IMN, 32 with PPE, and 17 with PPB. The age, sex, and preoperative fracture angulation were similar across all groups. A greater percentage of open reduction was seen in the IMN and PPB groups (p = 0.03), while a higher proportion of physeal injury was seen in the PPE group (p = 0.02). Surgical time and estimated blood loss was higher in the IMN group (p < 0.001 and p = 0.01, respectively). The decision analysis revealed that the PPE technique resulted in an average cost saving of $4,502 per patient compared to IMN and $2,066 compared to PPB. This strategy remained cost-effective even when the complication rates with exposed implants approached 55 %.

Conclusions: Leaving pins exposed after surgical fixation of PPHF is more cost-effective than either burying pins or using intramedullary fixation.

No MeSH data available.


Related in: MedlinePlus

One-way and two-way sensitivity analyses. a One-way sensitivity analysis on cost of deep infection: cost of treating deep infection varied from $4,631 to $40,245. The “Expected Value” refers to the mean treatment cost per patient using a particular strategy. This analysis shows that leaving the pins exposed (squares) consistently results in lower treatment costs than burying the pins (triangles) or intramedullary nailing (circles). b One-way sensitivity analysis on PPE complication rate: the PPE complication rate varied from 0 to 0.8. The “Expected Value” refers to the mean treatment cost per patient using a particular strategy as the PPE complication rate varied. Note that the “Expected Value” for the PPB (triangles) and IMN (circles) strategies does not change but, as the PPE complication rate rises above 0.56, the PPB strategy becomes most cost-effective, and when the PPE complication rate rises above 0.72, the IMN strategy is more cost-effective than the PPE (squares) strategy. c Two-way sensitivity analysis: the proportion of all infections that were superficial (x-axis) varied from 30 to 100 % and the cost of treating deep infection (y-axis) varied from $4,000 to $45,000. Leaving the pins exposed (yellow) results in greater cost savings than leaving them buried (pink), except when the cost of infection rises above $28,600 and the rate of superficial infection is low, between 0.3 and 0.438. Under no circumstances was the IMN strategy cost-effective through the modeled cost and outcome probabilities
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Fig3: One-way and two-way sensitivity analyses. a One-way sensitivity analysis on cost of deep infection: cost of treating deep infection varied from $4,631 to $40,245. The “Expected Value” refers to the mean treatment cost per patient using a particular strategy. This analysis shows that leaving the pins exposed (squares) consistently results in lower treatment costs than burying the pins (triangles) or intramedullary nailing (circles). b One-way sensitivity analysis on PPE complication rate: the PPE complication rate varied from 0 to 0.8. The “Expected Value” refers to the mean treatment cost per patient using a particular strategy as the PPE complication rate varied. Note that the “Expected Value” for the PPB (triangles) and IMN (circles) strategies does not change but, as the PPE complication rate rises above 0.56, the PPB strategy becomes most cost-effective, and when the PPE complication rate rises above 0.72, the IMN strategy is more cost-effective than the PPE (squares) strategy. c Two-way sensitivity analysis: the proportion of all infections that were superficial (x-axis) varied from 30 to 100 % and the cost of treating deep infection (y-axis) varied from $4,000 to $45,000. Leaving the pins exposed (yellow) results in greater cost savings than leaving them buried (pink), except when the cost of infection rises above $28,600 and the rate of superficial infection is low, between 0.3 and 0.438. Under no circumstances was the IMN strategy cost-effective through the modeled cost and outcome probabilities

Mentions: The decision analysis revealed that leaving pins exposed (PPE) after operative fixation of proximal humerus fractures was the most cost-effective strategy. Specifically, a per patient average cost saving of $4,502 was seen compared to the IMN strategy and $2,066 compared to the PPB strategy. The one-way sensitivity analysis demonstrated that PPE was cost-effective through a wide range of costs for treating deep infection (Fig. 3a). This strategy remained cost-effective when the complication rates associated with exposed implants approached 55 % (Fig. 3b). The two-way sensitivity analysis demonstrated that the PPE scenario remained the most cost-effective strategy across a variable rate of superficial infection and cost of deep infection (Fig. 3c).Fig. 3


Surgical management for displaced pediatric proximal humeral fractures: a cost analysis.

Shore BJ, Hedequist DJ, Miller PE, Waters PM, Bae DS - J Child Orthop (2015)

One-way and two-way sensitivity analyses. a One-way sensitivity analysis on cost of deep infection: cost of treating deep infection varied from $4,631 to $40,245. The “Expected Value” refers to the mean treatment cost per patient using a particular strategy. This analysis shows that leaving the pins exposed (squares) consistently results in lower treatment costs than burying the pins (triangles) or intramedullary nailing (circles). b One-way sensitivity analysis on PPE complication rate: the PPE complication rate varied from 0 to 0.8. The “Expected Value” refers to the mean treatment cost per patient using a particular strategy as the PPE complication rate varied. Note that the “Expected Value” for the PPB (triangles) and IMN (circles) strategies does not change but, as the PPE complication rate rises above 0.56, the PPB strategy becomes most cost-effective, and when the PPE complication rate rises above 0.72, the IMN strategy is more cost-effective than the PPE (squares) strategy. c Two-way sensitivity analysis: the proportion of all infections that were superficial (x-axis) varied from 30 to 100 % and the cost of treating deep infection (y-axis) varied from $4,000 to $45,000. Leaving the pins exposed (yellow) results in greater cost savings than leaving them buried (pink), except when the cost of infection rises above $28,600 and the rate of superficial infection is low, between 0.3 and 0.438. Under no circumstances was the IMN strategy cost-effective through the modeled cost and outcome probabilities
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

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Fig3: One-way and two-way sensitivity analyses. a One-way sensitivity analysis on cost of deep infection: cost of treating deep infection varied from $4,631 to $40,245. The “Expected Value” refers to the mean treatment cost per patient using a particular strategy. This analysis shows that leaving the pins exposed (squares) consistently results in lower treatment costs than burying the pins (triangles) or intramedullary nailing (circles). b One-way sensitivity analysis on PPE complication rate: the PPE complication rate varied from 0 to 0.8. The “Expected Value” refers to the mean treatment cost per patient using a particular strategy as the PPE complication rate varied. Note that the “Expected Value” for the PPB (triangles) and IMN (circles) strategies does not change but, as the PPE complication rate rises above 0.56, the PPB strategy becomes most cost-effective, and when the PPE complication rate rises above 0.72, the IMN strategy is more cost-effective than the PPE (squares) strategy. c Two-way sensitivity analysis: the proportion of all infections that were superficial (x-axis) varied from 30 to 100 % and the cost of treating deep infection (y-axis) varied from $4,000 to $45,000. Leaving the pins exposed (yellow) results in greater cost savings than leaving them buried (pink), except when the cost of infection rises above $28,600 and the rate of superficial infection is low, between 0.3 and 0.438. Under no circumstances was the IMN strategy cost-effective through the modeled cost and outcome probabilities
Mentions: The decision analysis revealed that leaving pins exposed (PPE) after operative fixation of proximal humerus fractures was the most cost-effective strategy. Specifically, a per patient average cost saving of $4,502 was seen compared to the IMN strategy and $2,066 compared to the PPB strategy. The one-way sensitivity analysis demonstrated that PPE was cost-effective through a wide range of costs for treating deep infection (Fig. 3a). This strategy remained cost-effective when the complication rates associated with exposed implants approached 55 % (Fig. 3b). The two-way sensitivity analysis demonstrated that the PPE scenario remained the most cost-effective strategy across a variable rate of superficial infection and cost of deep infection (Fig. 3c).Fig. 3

Bottom Line: A greater percentage of open reduction was seen in the IMN and PPB groups (p = 0.03), while a higher proportion of physeal injury was seen in the PPE group (p = 0.02).The decision analysis revealed that the PPE technique resulted in an average cost saving of $4,502 per patient compared to IMN and $2,066 compared to PPB.This strategy remained cost-effective even when the complication rates with exposed implants approached 55 %.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Hunnewell 221, 300 Longwood Avenue, Boston, MA, 02115, USA, Benjamin.shore@childrens.harvard.edu.

ABSTRACT

Purpose: The purpose of this investigation was to determine which of the following methods of fixation, percutaneous pinning (PP) or intramedullary nailing (IMN), was more cost-effective in the treatment of displaced pediatric proximal humeral fractures (PPHF).

Methods: A retrospective cohort of surgically treated PPHF over a 12-year period at a single institution was performed. A decision analysis model was constructed to compare three surgical strategies: IMN versus percutaneous pinning leaving the pins exposed (PPE) versus leaving the pins buried (PPB). Finally, sensitivity analyses were performed, assessing the cost-effectiveness of each technique when infection rates and cost of deep infections were varied.

Results: A total of 84 patients with displaced PPHF underwent surgical stabilization. A total of 35 cases were treated with IMN, 32 with PPE, and 17 with PPB. The age, sex, and preoperative fracture angulation were similar across all groups. A greater percentage of open reduction was seen in the IMN and PPB groups (p = 0.03), while a higher proportion of physeal injury was seen in the PPE group (p = 0.02). Surgical time and estimated blood loss was higher in the IMN group (p < 0.001 and p = 0.01, respectively). The decision analysis revealed that the PPE technique resulted in an average cost saving of $4,502 per patient compared to IMN and $2,066 compared to PPB. This strategy remained cost-effective even when the complication rates with exposed implants approached 55 %.

Conclusions: Leaving pins exposed after surgical fixation of PPHF is more cost-effective than either burying pins or using intramedullary fixation.

No MeSH data available.


Related in: MedlinePlus