Abstract
BACKGROUND: Open tibial fractures are a cause of substantial orthopaedic morbidity in low- and middle-income countries. These injuries represent a substantial cost burden to both individual patients and society because of their high propensity for complications, such as infection, nonunion, and malunion. External fixation and intramedullary (IM) nailing are both utilized for definitive treatment of open tibial fractures, but given the differences in cost and lack of clear superiority of intramedullary nailing, cost-effectiveness becomes important to consider in low- and middle-income countries. The present study aimed to examine the cost-effectiveness of IM nailing versus external fixation within Tanzania. METHODS: This study utilized data from a randomized controlled trial conducted at a single tertiary hospital in Dar es Salaam, Tanzania. Direct cost data were collected via an internal audit of operating costs and hospital staff time. Indirect costs data were collected from patients in a long-term follow-up study assessing total lost work. A Markov model was utilized to run the cost-effectiveness simulations. The primary outcome was the incremental cost-effectiveness ratio (ICER) over a lifetime time horizon. Both the payer and societal perspectives were considered. To account for uncertainty, both 1-way and probabilistic sensitivity analyses were performed. RESULTS: From the payer perspective, the cost of external fixation ($396 USD) was lower than that of IM nailing ($529), primarily because of shorter operative times. However, IM nailing was associated with more quality-adjusted life-years (QALYs). From the payer perspective, the ICER was $499 per QALY with a donated nail and $701 per QALY with a purchased locally available nail. From the societal perspective, the ICER was lower among patients undergoing IM nailing, at $70 per QALY, largely because of shorter recovery times. CONCLUSIONS: From both the payer and the societal perspective, IM nailing is considered highly cost-effective on the basis of the World Health Organization willingness-to-pay thresholds. This finding was consistent whether the IM nail was donated or purchased from local suppliers. These results are likely generalizable to other tertiary referral centers in low- and middle-income countries. LEVEL OF EVIDENCE: Economic Level II. See Instructions for Authors for a complete description of levels of evidence.