Is reduction of routine radiograph use in patients with distal radius fractures cost effective? Analysis of data from the multicentre, randomised controlled WARRIOR trial

Abstract

Objective To assess the cost effectiveness of a reduced imaging follow-up protocol of distal radius fractures compared with usual care.Design An economical evaluation conducted alongside a multicentre randomised controlled trial (RCT).Setting Four level-one trauma centres in the Netherlands.Participants 341 patients participated (usual care (n=172), reduced imaging (n=169)).Interventions Patients were randomised to usual care (routine radiography at 1, 2, 6 and 12 weeks) or a reduced imaging strategy (radiographs at 6 and 12 weeks only for a clinical indication).Outcome measures Functional outcome was assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and quality-adjusted life years (QALYs) using the EuroQol-5Dimensions-3 Levels (EQ-5D-3L). Costs were measured using self-reported questionnaires and medical records, and analysed from a societal perspective. Multiple imputation, seemingly unrelated regression analysis and bootstrapping were used to analyse the data.Results Clinical overall outcomes of both groups were comparable. The difference in DASH was −2.03 (95% CI −4.83 to 0.77) and the difference in QALYs was 0.025 (95% CI −0.01 to 0.06). Patients in the reduced imaging group received on average 3.3 radiographs (SD: 1.9) compared with 4.2 (SD: 1.9) in the usual care group. Costs for radiographic imaging were significantly lower in the reduced imaging group than in the usual care group (€−48 per patient, 95% CI −68 to −27). There was no difference in total costs between groups (€−401 per patient, 95% CI −2453 to 1251). The incremental cost-effectiveness ratio (ICER) for QALYs was −15 872; the ICER for the DASH was 198. The probability of reduced imaging being cost effective compared with usual care ranged from 0.8 to 0.9 at a willingness to pay of €20 000/QALY to €80 000/QALY.Conclusions Implementing a reduced imaging strategy in the follow-up of distal radius fractures has a high probability of being cost effective for QALYs, without decreasing functional outcome. We, therefore, recommend imaging only when clinically indicated.Trial registration number The Netherlands trial register (NL4477).