Cost-effectiveness of early surgical fixation versus cast immobilization for adults with a scaphoid waist fracture:five-year follow-up of the Scaphoid Waist Internal Fixation for Fractures Trial

AIMS: The conclusion of the one-year analysis of the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) was that initial cast immobilization with surgical fixation for nonunion was the optimal treatment for patients with a fracture of the waist of the scaphoid. However, there remained significant uncertainty about the medium-term outcomes and how these could influence the patient's health-related quality of life (HRQoL), care requirements, and costs. The aim of this study was to explore how additional data from the five-year follow-up influenced the cost-effectiveness of the treatment of these fractures. METHODS: The analysis presents the patient-reported HRQoL, measured with the EuroQol five-dimension three-level health questionnaire, and the use of healthcare resources at five years after randomization, and considers which factors influenced the results. The original analytical model, in which the implications of the different forms of treatment throughout the patient's life were estimated, was also updated. RESULTS: Five years after randomization, most patients in both groups returned to the HRQoL level which is consistent with age-adjusted norms and did not require further healthcare. In contrast, those who continued to have clinically relevant adverse events at five years reported significantly worse HRQoL scores and greater care needs. It was also confirmed in the updated model that initial cast immobilization was the most cost-effective strategy, with a mean cost to the health system of £1,606 less per eligible patient compared with those who initially underwent surgery, an annual saving of £7.5 million. CONCLUSION: Most patients had no long-term impact from the injury regardless of the form of treatment. However, the few who had clinically defined adverse events at five years had poor HRQoL and greater care needs. The limited difference in these clinical outcomes between the two groups informed the findings of the decision model that, over the patient's lifetime, the small quality-adjusted life year gains for those who underwent surgery initially were not sufficient to justify the higher costs. These findings confirm that initial immobilization in a cast with fixation for nonunion is the optimal form of treatment for these patients.