The burden of health-care costs on society continues to grow. U. S. health-care expenditures reached 4. 9 trillion in 2023, accounting for 17. 6% of the U. S. gross domestic product1. In a world of limited resources, alternative treatment options need to be evaluated for their cost-effectiveness in addition to their comparative safety and effectiveness. The article by Suter et al. provides a useful cost-effectiveness analysis of the 2 alternative treatments for displaced, closed humeral shaft fractures, with practical implications for shared decision-making at the individual patient level. The practicing traumatologist must consider 2 reasonable options when treating displaced, closed humeral shaft fractures: (1) nonoperative treatment with functional bracing and (2) open reduction with internal fixation (ORIF). Nonoperative management of closed humeral shaft fractures was the established norm during the 20th century, especially after functional bracing was introduced by Sarmiento in 19772. ORIF, developed to decrease the period of immobilization and to quicken the return to function, has since become the predominant treatment modality in the U. S. , with utilization increasing from 47. 2% of humeral shaft fractures in 2002 to 60. 3% of humeral shaft fractures in 20113. A recently published analysis found that patients who were on Medicare or Medicaid or who were self-paying were significantly less likely to undergo operative treatment for humeral shaft fractures4. Outside the U. S. , functional bracing remains recommended as the first treatment of choice. Clearly, economic resource limitations continue to drive ongoing disparities in the treatment of displaced, closed humeral fractures. The prespecified economic analysis by Suter et al. compares ORIF and functional bracing in the Finnish health-care system with use of prospectively collected economic and outcome data from a pragmatic randomized clinical trial (RCT) for which 1-, 2-, and 5-year clinical results have already been published5–7. These published reports found significantly improved DASH (Disabilities of the Arm, Shoulder and Hand) and Constant-Murley shoulder function scores for the surgery group compared with the bracing group at 6 weeks and 3 months of follow-up but no significant differences at 1 year (the primary outcome measure) or at 2 and 5 years, suggesting that the ultimate trajectory of recovery was similar regardless of the allocated treatment group. In their comparison of societal versus health-care perspectives, Suter et al. identified patient-specific factors that influenced the cost-effectiveness of these 2 treatment alternatives. The base-case analysis, prespecified as the societal perspective, found that ORIF was more effective than functional bracing and yielded a cost-saving incremental net monetary benefit (INMB) of €9, 423. Surgery was also clinically favored for health-related quality of life measured using the 15D utility instrument. This result was considered a cost-effectiveness win-win for society, with all bootstrapped estimates overwhelmingly found in the lower right (win-win) quadrant of the standard cost-effectiveness plane. This societal cost-saving was primarily driven by the inclusion of the indirect cost of time away from work for employed patients. Conversely, when the analysis considered only direct health-care costs, ORIF became markedly more expensive than functional bracing, with an INMB of +€4, 087. Despite the solid evidence of the cost-effectiveness of ORIF from the societal perspective and the finding that 32% of patients who were randomized to functional bracing still required surgery, policy-makers might still tend to favor functional bracing because of health-care resource limitations. Simply put, humeral fracture is just 1 of many “buckets” of societal costs related to injury or degenerative conditions. Policy-makers must allocate available funds among buckets corresponding to multiple disease states and treatments. Randomized health economic trials are the gold-standard tool for guiding the allocation of funds among disease and/or treatment-specific health-care buckets at the societal level. Suter et al. also provide pragmatic evidence to inform treatment decisions for individual patients. This report should be of interest to both practicing clinicians and health economists. Cost-effectiveness was primarily calculated as an INMB in simple € terms that are easy for clinicians to understand. The incremental cost-effectiveness ratio (ICER) favored by health economists was included in the Appendix to facilitate comparison across multiple disease states and treatments. The societal cost-effectiveness of ORIF also has relevant implications for shared decision-making at the individual patient level, establishing a useful framework for patient-physician discussions. This analysis highlights the importance of taking multiple clinical and socioeconomic factors into consideration when making patient-specific decisions. Moreover, it suggests the need for patient-specific flexibility in health-care policy, rather than the typically rigid reliance on treatment guidelines imposed by payers who are forced to deal with group-level effects and resource limitations.
Band et al. (Mon,) studied this question.