Economic evaluation of operative versus nonoperative treatment of a humeral shaft fracture: economic analyses alongside a multicenter prospective cohort study (HUMMER)
Authors: Van Bergen Saskia H. , Van Lieshout Esther M. M. , Mahabier Kiran C. , Geraerds Alexandra J. L. M. , Polinder Suzanne , Den Hartog Dennis , Verhofstad Michael H. J. ,   the HUMMER Investigators, Beetz Ivo , Bolhuis Hugo W. , Bos P. Koen , Bronkhorst Maarten W. G. A. , Bruijninckx Milko M. M. , De Haan Jeroen , Deenik Axel R. , Den Hoed P. Ted , Eversdijk Martin G. , Goslings J. Carel , Haverlag Robert , Heetveld Martin J. , Kerver Albertus J. H. , Kolkman Karel A. , Leenhouts Peter A. , Meylaerts Sven A. G. , Onstenk Ron , Poeze Martijn , Poolman Rudolf W. , Punt Bas J. , Ritchie Ewan D. , Roerdink W. Herbert , Roukema Gert R. , Sintenie Jan Bernard , Soesman Nicolaj M. R. , Ten Holder Edgar J. T. , Tuinebreijer Wim E. , Van der Elst Maarten , Van der Heijden Frank H. W. M. , Van der Linden Frits M. , Van der Zwaal Peer , Van Dijk Jan P. , Van Jonbergen Hans-Peter W. , Verleisdonk Egbert J. M. M. , Vroemen Jos P. A. M. , Waleboer Marco , Wittich Philippe , Zuidema Wietse P. , Al Khanim Ahmed , Bousema Jelle E. , Cheng Kevin , Claes Yordy , Cnossen J. Daniël , Dekker Emmelie N. , De Zwart Aron J. M. , Jawahier Priscilla A. , Joling Boudijn S. H. , Notenboom Cornelia A. W. , Schulte Jaap B. , Theyskens Nina , Van Aert Gijs J. J. , Van der Schaaf Boyd C. P. , Van der Torre Tim , Van Veldhuizen Joyce , Verhagen Lois M. M. , Verwer Maarten , Vollbrandt Joris 
Published: December 2022

Abstract
Purpose
Operative treatment of a humeral shaft fracture results in faster recovery than nonoperative treatment. The cost-effectiveness, in terms of costs per Quality-Adjusted Life Year (QALY) gained (Dutch threshold €20,000-€80,000) or minimal important change (MIC) in disability reduced (DASH 6.7), is unknown. The aim of this study was to determine cost-utility and cost-effectiveness of operative versus nonoperative treatment in adults with a humeral shaft fracture type 12A or 12B.

Methods
This study was performed alongside a multicenter prospective cohort study. Costs for health care and lost productivity until one year after trauma were calculated. The incremental cost-utility ratio (ICUR) was reported in costs per QALY (based on the EuroQoL-5D-3L (EQ-5D)) gained. The incremental cost-effectiveness ratio (ICER) was reported in costs per MIC (based on the DASH score at three months) reduced.

Results
Overall, 245 patients were treated operatively and 145 nonoperatively. In the operative group, the mean total costs per patient (€11,925 versus €8793; p < 0.001) and QALYs (0.806 versus 0.778; p < 0.001) were higher. The ICUR of operative treatment was €111,860 per QALY gained (i.e., €3132/0.028). The DASH was 7.3 points (p < 0.001) lower in the operative group. The ICER of operative treatment was €2880 per MIC in disability reduced (i.e., €3132/7.3*6.7).

Conclusion
Due to the limited effect of treatment on quality of life measured with the EQ-5D, the ICUR of operative treatment (€111,860 per QALY gained) exceeds the threshold. However, the incremental costs of €2880 per clinically meaningful difference in DASH are much lower and suggest that operative treatment for a humeral shaft fracture is cost-effective.