Cost-Effectiveness Analysis of Humeral Shaft Fracture Management: A Comparison Between the United States and Denmark

Purpose: We aim to compare the cost-effectiveness of operative versus nonoperative management of humeral shaft fracture in the US and Denmark, which employ notably distinct health-care payment models.

Methods: We developed a decision tree for all treatment options (Figure 1: US costs). US costs included ambulatory surgical fee, physician fee, anesthesia fee, and lost wages during recovery. We used CPT codes to determine physician fees via the US Centers for Medicare & Medicaid Services database. We calculated the anesthesia fee using the national conversion factor and average operative time for included procedures. We obtained data on average wages and weeks missed from the US Bureau of Labor. Danish costs were determined via Diagnosis-Related Groups for each treatment option, translated to USD for analysis. We reported functional data via Disabilities of the Arm, Shoulder and Hand (DASH) scores obtained from existing literature. We used rollback analysis and Monte Carlo simulations, presenting cost-effectiveness as dollars per meaningful change in DASH. We utilized a $50,000 willingness-to-pay (WTP) threshold.

Results: At 6-month follow-up, the cost per meaningful change in DASH for operative treatment was $12,499.28 in the US and $3105.91 in Denmark. At 1-year follow-up, the cost per meaningful change in DASH for operative treatment was $17,548.81 and $4153.57, respectively. When excluding lost wages as a component of cost (thus only considering direct costs of treatment), operative treatment at 1 year remained cost effective at 6 months and 1 year in both the US ($18,857.97 and $25,756.36, respectively) and in Denmark ($7031.89 and $8880.55, respectively). Interestingly, we found that nonoperative management would be favored from a cost-effectiveness perspective only with a successful completion rate of 97.55% in Denmark or 84.17% in the US, both notable improvements from the current rate of about 72%, and only at 1-year follow-up.

Conclusion: In both the US and Denmark, operative management is cost-effective at both 6 months and 1 year, compared to nonoperative treatment. Notably, the magnitude of cost-effectiveness, or the distance below the WTP threshold, of operative treatment is significantly larger in Denmark than in the US. This is likely due to several factors, most impactful of which are the distinct differences in health-care payment systems in these regions.

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