In this Editor’s Choice post, Dr. Matt Schmitz reflects on a new study in the current issue of JBJS.
Functional bracing for humeral shaft fractures was championed by Sarmiento starting in the 1970s. Bracing is still used around the world for management, including in resource-limited settings, but there has been a steady increase in the operative treatment of these fractures.
When contemplating the economic burden of humeral shaft fractures, including the potential for lengthy absences from work and loss of productivity, the question arises: what is the cost-effectiveness of surgery vs. functional bracing? This question was studied in a prespecified economic evaluation conducted alongside the Finnish Shaft of the Humerus (FISH) randomized clinical trial. Suter et al. present their findings in the current issue of The Journal:
The investigators evaluated the relative cost-effectiveness of surgical fixation versus functional bracing for adults with displaced, closed humeral shaft fractures over a 2-year follow-up period.
Eighty-two adult patients (mean age, 48.9 years) were randomized to either surgical fixation (n = 38) or functional bracing (n = 44) at 2 Finnish university hospitals between 2012 and 2018 as part of the FISH clinical trial. Seventy-four patients (90%) completed 2-year follow-up.
The primary outcome was the incremental net monetary benefit (INMB), based on quality-adjusted life years (QALYs) measured using the 15-dimensional (15D) instrument. Cost-effectiveness was analyzed from both societal and health-care perspectives.
From a societal perspective—accounting for both direct medical costs and productivity losses—surgery had lower overall costs. The mean total cost per patient was €23,680 for surgical fixation versus €30,389 for bracing, yielding a positive INMB of €9,423 in favor of surgery. The higher costs in the bracing group were largely driven by patients who required conversion to secondary surgery (32% of the bracing group) and substantially greater work absence (median of 129 days lost versus 90 days in the surgical group). Looking further at cost-effectiveness, surgery was highly likely to be cost-effective at willingness-to-pay thresholds up to €120,000 per QALY when productivity losses were included.
From a health-care perspective—considering only direct medical costs—functional bracing was the more cost-effective option, with a mean medical cost per patient of €4,904 compared with €10,967 for surgery (INMB of −€4,087). Surgery was unlikely to be cost-effective at willingness-to-pay thresholds below €80,000 per QALY and reached a 75% probability of cost-effectiveness only at €120,000 per QALY.
The authors concluded that surgery may be preferable for working-age patients due to faster recovery and reduced productivity losses, while bracing remains a reasonable option for those less affected by time away from work or wishing to avoid surgical risk. They emphasize the importance of shared decision-making that incorporates both economic and individual patient factors.
This study highlights that medical costs can involve more than just the direct costs of treatment. Although that number is what usually ends up on a hospital’s budget sheet, or a practice’s profit-and-loss spreadsheet, it does not take into account other potential costs for the patient. Lost work and wages, mobility issues precluding transport, or impact on activities of daily living may not show up on a billing notice, but are real costs borne by our patients. So shared decision-making is paramount, and each patient’s care should be individualized with that in mind. A 40-year-old patient whose job involves manual labor may have different priorities and needs than a 72-year-old retired patient with a gardening hobby. Our care should be tailored toward our patients, and data from this study may help to inform discussions with patients with the aim of making the best treatment decision possible.
The full study and a related video summary are available at JBJS.org: Cost-Effectiveness of Surgery Versus Functional Bracing for Humeral Shaft Fractures in Adults. A Prespecified Economic Evaluation of the Finnish Shaft of the Humerus (FISH) Trial
Additional perspective on this study is provided in a commentary by Philip A. Band, PhD and Joseph D. Zuckerman, MD: Treatment Alternatives for Displaced Closed Humeral Shaft Fractures. Practical Implications for Shared Decision-Making from a Randomized Pragmatic Trial
Matthew R. Schmitz, MD
JBJS Senior Editor for Pediatrics and Social Media