Routine Chest X-Ray is Not Cost-Effective After Clavicle ORIF: A Cost Effectiveness Analysis with National Estimations

Abstract

Clavicular fractures can be managed surgically or via a non-operative approach. In those electing for surgical fixation, post-operative CXR may be routine practice in the post-anesthesia care unit (PACU) for a rare complication of pneumothorax (PTX), thus driving up the cost for managing these fractures. The value and associated cost of this routine CXR in PACU following open reduction internal fixation (ORIF) of clavicles has not been thoroughly assessed. In this study we investigate the cost effectiveness of obtaining CXR after operative treatment of clavicle fracture. Study was designed as a healthcare two-way dichotomous model with decision trees built in where a CXR was either obtained or not. Literature review was performed to determine the cost estimates of CXR, the cost of ORIF, and associated hospital stay expenses. Annual volume of clavicle ORIF’s performed were derived from the PearlDiver database, queried for CPT-23515 (Clavicle ORIF). Estimation of CXR rates were performed from 3% to 98% of patients undergoing clavicle ORIF. Net monetary analysis with associated sensitivity analysis of 10,000 repetitions was performed. The strategy without CXR proved to be the most cost-effective strategy with a net monetary benefit (NMB) of $32,022.50. At $50,000 willingness to pay (WTP), the no CXR strategy was the preferred option. This strategy was found to be optimal 76% of the time followed by routine CXR 23% of the time and less than 1% being indifferent. The national annual costs of routine CXR after clavicle ORIFs was estimated to range from $7,100 to $349,860, which over 10 years represents anywhere from $81,540 to $2,663,640 in additional expenses. The provided study demonstrates that routine CXR after clavicle ORIF is not cost effective. Due to the exceedingly low incidence of PTX as a post-operative complication in clavicle ORIF, we recommend that hospitals and surgeons refrain from ordering radiographs in post-operative patients, with the exception of those displaying concerning clinical signs for PTX or those with known pre-operative pulmonary injury. Adopting this strategy will limit unnecessary healthcare costs accrued by patients and may be the more clinically appropriate management.