Proefschrift

PWB insurgically treated trauma patients with peri- and/or intra-articular fractures of the lower extremities is cost effective 115 Discussion The main goal of this prospective comparative multicenter cohort study was to determine whether permissive weight bearing in surgically treated trauma patients with peri- and/or intra-articular fractures of the lower extremities is preferable in terms of costs, effects and utilities, from a societal perspective, compared to the restricted weight bearing protocol. The patients’ self-perceived outcome levels (activities of daily living (ADL), quality of life, pain), weight bearing and postoperative complications have been compared between groups following a PWB regimen and restricted weight bearing (RWB) regimen over a period of 26-weeks post-surgery. The novel permissive weight bearing (PWB) regimen led to the patients being able to bear full weight on their affected leg much sooner with a better ADL and quality of life, as compared to those that followed the usual RWB regimen. Furthermore, no differences were found in either postoperative complication rates or pain levels between both treatment regimes. Total costs were lower in the PWB group than in the RWB group. In terms of cost per improvement in LEFS, the PWB group showed higher effects and lower costs, resulting in an ICER of €1,945 per improvement on the LEFS. However, in the absence of a willingness-to-pay threshold for such a clinical measure, no statements regarding its cost-effectiveness can be made. Looking at the quality of life, the PWB group had comparable QALYs to the RWB group with lower costs, resulting in a dominated ICER and ICUR. This indicates that PWB is cost-effective. In the base-case analysis, regression correction was used for the baseline costs and QALYs. Although utilities did not differ significantly among the groups of patients, it is likely that the patient’s baseline utility is highly correlated with the QALY outcome. As shown by the sensitivity analyses, the study results were not heavily affected by specific assumptions, perspectives or inclusion criteria. However, there may be several reasons which could be of influence in the differential effect of PWB. The ADL and quality of life were both significantly increased in the PWB group compared to the RWB group over a period of 26-weeks post-surgery. The median length of stay in the PWB group was 2 days longer compared to the RWB group, which can be related to the slightly higher mean Charlson score in the PWB group. Despite the longer length of stay the patients in the PWB were fully bearing weight 9 weeks faster compared to the RWB group. Also, the outpatient physiotherapy duration was significantly less than in the RWB group. Furthermore, this study found that there was no significant difference in postoperative complications between the PWB group compared to the RWB group. According to recent literature, a composite postoperative complications rate of up to 27.0% has been reported in surgically treated trauma patients with peri- and/or intra-articular fractures of the lower extremities.31-38 Comparing our complication rates with data published in recent literature, we found lower rates of postoperative complications in

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