A Cost-Utility Analysis of Nonsurgical Management, Total Wrist Arthroplasty, and Total Wrist Arthrodesis in Rheumatoid Arthritis

Purpose Management of end-stage rheumatoid wrist disease remains controversial. Total wrist arthrodesis provides reliable pain relief and stability and is the most commonly applied management strategy. Total wrist arthroplasty is a motion-preserving alternative that is gaining popularity. The purpose of this study was to perform a cost-utility analysis comparing nonsurgical management, total wrist arthroplasty, and total wrist arthrodesis for the rheumatoid wrist. Methods A time trade-off utility survey was developed to investigate patient and physician preferences for the potential outcomes of total wrist arthroplasty and total wrist arthrodesis. The study sample consisted of rheumatoid patients (N = 49) recruited as part of an ongoing prospective study and a national random sample of hand surgeons and rheumatologists (N = 109). A decision tree was created using utility values derived from the survey, and the expected quality-adjusted life-years (QALYs) for each procedure were determined. Using the societal perspective, costs were based on the Medicare fee schedules for the Current Procedural Terminology codes associated with total wrist arthroplasty and total wrist arthrodesis and their potential complications. Costs per QALY were calculated and compared. Results Patients and physicians both showed a preference for surgical management over nonsurgical management. Application of cost data indicated that the incremental cost per additional QALY gained for total wrist arthroplasty over nonsurgical management was $2,281 and the incremental cost per QALY gained with total wrist arthroplasty over total wrist arthrodesis was $2,328, which is substantially less than the national standard of $50,000/QALY deemed acceptable for adoption. Conclusions In the absence of rigorous outcome data, cost-utility analysis is a useful tool to guide treatment decisions. Total wrist arthroplasty and total wrist arthrodesis are both extremely cost-effective procedures. This study incorporated patient and physician utilities to demonstrate that total wrist arthroplasty has only a small incremental cost over the traditional total wrist arthrodesis procedure. Based on this economic model, total wrist arthroplasty may be worthy of further consideration, and cost should not be considered prohibitive. (J Hand Surg 2010;35A:379-391. (C) 2010 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.)