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An Economic Evaluation of Operative Compared with Nonoperative Management of Displaced Intra-Articular Calcaneal Fractures
Carmen A. Brauer, MD, MSc, FRCSC1; Braden J. Manns, MD, MSc, FRCPC2; Michael Ko, MD3; Cam Donaldson, PhD4; Richard Buckley, MD, FRCSC5
1 Harvard Center for Risk Analysis, Harvard School of Public Health, 718 Huntington Avenue, Boston, MA 02115. E-mail address: cbrauer@hsph.harvard.edu
2 Departments of Community Health Sciences and Medicine, University of Calgary, 1403 29th Street N.W., Calgary, AB T2N 2T9, Canada
3 Queen's University School of Medicine, 68 Barrie Street, Queen's University, Kingston, ON K7L 3N6, Canada
4 Centre for Health Services Research, University of Newcastle upon Tyne, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA, United Kingdom
5 Division of Orthopaedic Surgery, University of Calgary, 3330 Hospital Drive N.W., Calgary, AB T2N 4N1, Canada
View Disclosures and Other Information
In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Al-berta Heritage Foundation for Medical Research. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at Harvard Center for Risk Analysis, Harvard School of Public Health, Boston, Massachusetts

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Dec 01;87(12):2741-2749. doi: 10.2106/JBJS.E.00166
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Abstract

Background: The choice of therapy for a displaced intra-articular calcaneal fracture has long been a source of uncertainty in orthopaedic surgery, both in terms of the impact of the therapy on clinical outcomes and on health-care and non-health-care costs. We performed an economic evaluation, based on the results of a randomized clinical trial, to evaluate the economic implications of operative compared with nonoperative management of this fracture.

Methods: An economic evaluation was performed, with use of a four-year time horizon, to determine the effect on costs and health benefits of operative compared with nonoperative management for a group of patients with displaced intra-articular fractures of the calcaneus. The complication rate, arthrodesis rate, survival data, and health-outcome data were estimated prospectively from a recent randomized clinical trial. Direct health-care costs and indirect costs (the cost of time lost from work) were estimated retrospectively from the center treating the majority of the patients.

Results: Operative management resulted in a lower rate of subtalar arthrodesis and a shorter time off from work compared with nonoperative treatment. When indirect costs, such as the time lost from work, were included in the analysis, operative management was less costly (an average savings of Can$19,000 per patient) and more effective, thus making it the preferred strategy. The result was most sensitive to the estimates of the costs of time lost from work. When these costs were excluded, operative treatment remained more effective, but with an increased average cost of Can$2800 per patient.

Conclusions: Calcaneal fractures have been recognized as having relatively poor clinical outcomes and a major socioeconomic impact with regard to time lost from work and recreation. Our analysis suggests that operative management of displaced intra-articular fractures is economically attractive. However, further exploration of the impact and valuation of time lost from work and patient outcomes is required.

Level of Evidence: Economic and decision analysis, Level II. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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