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Cost-Utility Analysis of Clinic-Based Hand Therapy versus Home Therapy after Distal Radius Fracture
Lin Lin Gao, MD; Ines Lin, MD
Hospital of the University of Pennyslvania, Philadelphia, PA

Introduction: In recent prospective randomized trial, home based and clinic based therapy have yielded similar improvements in hand function after operatively treated distal radius fractures. Home based therapy is less costly, for both the hospital and for the patient, and challenges the paradigm of starting all patients in clinic based therapy. The aim of the study is to determine if initiating clinic based physical therapy for all patients after distal radius fractures is cost effective, compared to home exercise programs.

Methods: We developed a decision tree model (Fig. 1) using the cost, quality adjusted life years, health state probabilities and incremental cost effectiveness ratio of home exercise program, as compared to clinic based therapy, for patients treated operatively for distal radius fractures. The three health states are clinic therapy, home therapy with good progression and home therapy with poor progression requiring closer monitoring with clinic therapy. The probability for the health care states and the Patient-Rated Wrist Hand Evaluation (PRWHE) are derived from prospective, randomized trial. PRWHE scores were used to estimate quality adjusted life years. We obtained cost from national DRG reimbursement. We tested the robustness of the model using one-way, two-way and threshold sensitivity analysis. We performed Monte Carlo simulation to sample uncertainty distributions.

Results: The total cost of clinic-based therapy is \.43, versus \.09 for home exercise program (Table 1). The incremental cost effectiveness ratio of clinic vs. home therapy is \,642.36/QALY (Fig. 2). We set the willingness-to-pay threshold at \,000, therefore, clinic based therapy is not a cost effective option compared to home exercise program. One-way and two-way sensitivity analysis shows clinic based therapy becomes more cost effective as the cost per therapy session is lowered and the efficacy of home therapy is decreased (Fig. 3). Threshold analysis revealed the cost of each therapy session would have to be as low as \.73 for clinic based therapy to be cost effective, 34% of mean national reimbursement. Monte Carlo microsimulations showed even after adjusting for variations in costs and PRWHE scores, home exercise program is the optimal strategy.

Conclusion: Initiating clinic based hand therapy program for all patients after operatively treated distal radius fracture is not cost effective. Instead, starting patients on home exercise program as first line treatment and transitioning non-progressing patients into clinic-based therapy is a more cost effective alternative and would result in \.34 savings per patient or \,884,000 annually.

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