Is reduction of routine radiograph use in patients with distal radius fractures cost effective? Analysis of data from the multicentre, randomised controlled WARRIOR trial

WARRIOR Trial Study Group

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OBJECTIVE: To assess the cost effectiveness of a reduced imaging follow-up protocol of distal radius fractures compared with usual care.

DESIGN: An economical evaluation conducted alongside a multicentre randomised controlled trial (RCT).

SETTING: Four level-one trauma centres in the Netherlands.

PARTICIPANTS: 341 patients participated (usual care (n=172), reduced imaging (n=169)).

INTERVENTIONS: Patients were randomised to usual care (routine radiography at 1, 2, 6 and 12 weeks) or a reduced imaging strategy (radiographs at 6 and 12 weeks only for a clinical indication).

OUTCOME MEASURES: Functional outcome was assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and quality-adjusted life years (QALYs) using the EuroQol-5Dimensions-3 Levels (EQ-5D-3L). Costs were measured using self-reported questionnaires and medical records, and analysed from a societal perspective. Multiple imputation, seemingly unrelated regression analysis and bootstrapping were used to analyse the data.

RESULTS: Clinical overall outcomes of both groups were comparable. The difference in DASH was -2.03 (95% CI -4.83 to 0.77) and the difference in QALYs was 0.025 (95% CI -0.01 to 0.06). Patients in the reduced imaging group received on average 3.3 radiographs (SD: 1.9) compared with 4.2 (SD: 1.9) in the usual care group. Costs for radiographic imaging were significantly lower in the reduced imaging group than in the usual care group (€-48 per patient, 95% CI -68 to -27). There was no difference in total costs between groups (€-401 per patient, 95% CI -2453 to 1251). The incremental cost-effectiveness ratio (ICER) for QALYs was -15 872; the ICER for the DASH was 198. The probability of reduced imaging being cost effective compared with usual care ranged from 0.8 to 0.9 at a willingness to pay of €20 000/QALY to €80 000/QALY.

CONCLUSIONS: Implementing a reduced imaging strategy in the follow-up of distal radius fractures has a high probability of being cost effective for QALYs, without decreasing functional outcome. We, therefore, recommend imaging only when clinically indicated.

TRIAL REGISTRATION NUMBER: The Netherlands trial register (NL4477).

Original languageEnglish
Article number035370
Pages (from-to)e035370
JournalBMJ Open
Issue number7
Publication statusPublished - 5 Jul 2020


  • foot & ankle
  • health economics
  • orthopaedic & trauma surgery
  • radiology & imaging

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