Calculating Value in Hand and Wrist Care: A Systematic Review on the Current Literature

Abstract

Purpose

Global health care systems are shifting toward value-based care models, with the hand and wrist field presenting a notable opportunity to enhance quality and efficiency because of large patient volumes, a variety of pathologies, and diversity in treatment options. This systematic review aimed to investigate the literature on calculations of value between different treatment options in hand and wrist care.

Methods

Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, two reviewers searched three databases to identify, screen, and evaluate research articles within hand and wrist care comparing the value between treatment groups based on real-world clinical data.

Results

Nineteen of 181 hand and wrist articles screened met our predetermined inclusion criteria. Studies primarily employed the EuroQol 5-Dimension survey for quality metrics with the payer or societal cost perspective. The incremental cost-effectiveness ratio formula was the most used value calculation. The majority of included studies originate from Europe. Studies assessing distal radius fracture care highlighted reduced imaging strategies as more cost effective than traditional methods and bandaging as more cost effective than rigid immobilization. Studies assessing scaphoid fractures identified immediate magnetic resonance imaging intervention to outperform standard care and cast treatment combined with early fixation to be superior to standalone surgery or no treatment.

Conclusions

Global literature on value-based comparative studies in hand and wrist care demonstrates variability in methodology, limiting direct comparisons. Most real-world studies were conducted within single-payer systems, highlighting the potential for further investments in value analysis protocols in multipayer systems.

Clinical relevance

Establishing a standardized methodology for value assessment, will enable better comparisons and improvements in hand and wrist care. As global health care costs continue to rise, conducting research that identifies high-value care across diverse health care systems is essential to ensure sustainable, effective, and patient-centered care for all stakeholders.

Global health care systems are shifting from traditional fee-for-service models toward value-based approaches to improve outcomes and benefit all stakeholders.1, 2, 3 This transition is driven by escalating health care expenditures, which have placed notable financial strain worldwide.⁴ For example, global health spending reached approximately US$9.8 trillion, or 9.9% of global gross domestic product, in 2022, more than doubling since 2000, with many countries experiencing cost growth that outpaces their economic development.^4,5 Countries such as the United States stand as prime candidates for value-based care (VBC) reform, driven by their high health care expenditures.⁶ Although the United States holds a strong position in global health care innovation and patient care, there are opportunities for growth and increased value, with 2022 spending data totaling $4.5 trillion.⁵ Moreover, current expenditure projections indicate a 5.4% annual increase through 2031, outpacing the annual global gross domestic product growth rate of 4.6%.⁷ Value-based care focuses on the health outcomes achieved per dollar spent, requiring simultaneous consideration of both quality and cost.^2,8 Importantly, the consideration of value is not merely a cost-cutting measure.² It is, instead, an approach toward optimizing the benefits for all participants involved in an episode of care, including patients, payers, and health care providers.²

Initial efforts toward value often focused on primary care because of its emphasis on prevention, screening, and chronic disease management.9, 10, 11, 12 In contrast, specialty care has seen slower VBC adoption because of its acute nature and complex interventions.^13,14 Specialty care expenditures often triple those of primary care, providing an opportunity to address inefficiencies and improve outcomes with a focus on calculating and comparing the value of specialty treatments.^13,15, 16, 17 The focus on value is especially apparent within orthopedics and the hand subspeciality in particular, stemming from the high incidence and costs of hand conditions that greatly impact patients’ quality of life.^18,19 One defining condition is carpal tunnel syndrome, with an estimated global prevalence rate that ranges from 11% to 14% of the global population.²⁰ This volume combined with the frequency of nonsurgical treatments such as corticosteroid injections highlights the necessity of establishing clear standards within hand and wrist value comparisons.²¹

To address gaps in VBC research, many hand and wrist care studies have used simulation models to evaluate cost effectiveness.22, 23, 24, 25, 26, 27, 28 These models are invaluable for projecting long-term outcomes, conducting comparative analyses, and filling in critical gaps where real-world clinical data may fall short, especially when real-world data are limited.^25,29,30 Clinical data, in contrast, not only capture the real-life variability and ensure practical applicability to clinical decision-making but also require greater resources to capture.30, 31, 32, 33, 34 Both clinical data and simulation models serve complementary roles, addressing unique aspects of health care research and decision making.^25,32

The purpose of this article was to systematically review the existing literature on value comparisons in the hand and wrist care domain, with a specific focus on using real-world clinical data. It aimed to address the following two key objectives: (1) to examine the methodologies currently employed to facilitate effective value comparisons within the context of hand and wrist care and (2) to highlight current recommendations seen in value comparison literature regarding treatments for specific hand conditions.

Materials and Methods

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guideline in addition to the systematic review methodology proposed by Cochrane to systematically search PubMed, Embase, and Web of Science databases for studies indexed between January 1, 2003, and December 6, 2023 (Fig.).^35,36

Figure.

PRISMA diagram depicting the screening, eligibility, inclusion, and exclusion processes with two reviewers. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Studies were included with the following criteria: (1) prospective and retrospective comparative cohort studies or randomized controlled trials concentrated on hand and wrist-related treatments/interventions, (2) used real-world clinical data (simulated models were not included), and (3) compared value in terms of both cost and quality metrics simultaneously in a quantifiable measurement.

Studies were excluded if they were not written in English, were missing full text, did not compare two or more cohorts, or did not specify a value equation that incorporated both cost and the quality of care delivered.

Custom search terms were created for each database (Table 1) to capture all studies that examined health care value based on each individual article’s interpretation of the definition of “value.” These search query words and terms related to VBC (Table 1) were determined and finalized using Boolean operators and wildcards to capture as many relevant articles as possible. To mitigate the risk of overlooking pertinent articles, the initial search query encompassed the entirety of orthopedics, followed by a manual search focusing on articles related to hand and wrist pathology. After conducting searches across databases, duplicates were eliminated initially using Endnote’s deduplication tool followed by further manual deduplication as needed. Two reviewers independently screened each electronic article by title, abstract, and figures for the inclusion criteria. In instances where the reviewers disagreed about inclusion, group discussion with a third reviewer would act as the tiebreaker and determine the final decision on such articles.

Table 1.

Search Query Inputs

Database	Query Search (Dates Between January 1, 2003, and December 6, 2023)
PubMed	(‘QALY’ OR ‘DALY’ OR ‘ICER’ OR ‘Cost-Effectiveness’ OR ‘Cost-Effective’ OR ‘Cost-Utility’ OR ‘Cost-Benefit’ OR ‘Cost Effectiveness’ OR ‘Cost Effective’ OR ‘Cost Utility’ OR ‘Cost Benefit’ OR ‘Economic Evaluation’ OR ‘Value-Based’ OR ‘Value-Based Care’ OR ‘VBC’) AND (orthopedics OR orthopaedics OR musculoskeletal OR limb OR appendicular skeleton) With filters for only ‘Books and Documents,’ ‘Classical Article,’ ‘Clinical Study,’ ‘Clinical Trial,’ ‘Clinical Trial, Phase 1,’ ‘Clinical Trial, Phase 2,’ ‘Clinical Trial, Phase 3,’ ‘Clinical Trial, Phase 4,’ ‘Comparative Study,’ ‘Consensus Development Conference, NIH,’ ‘Controlled Clinical Trial,’ ‘Corrected and Republished Article,’ ‘Evaluation Study,’ ‘Government Publication,” ‘Guideline,’ ‘Historical Article,’ ‘Introductory Journal Article,’ ‘Meta-Analysis,’ ‘Multicenter Study,’ ‘Observational study,’ ‘Overall,’ ‘Practice Guidelines,’ ‘Pragmatic Clinical Trials,’ ‘Randomized Controlled Trial,’ ‘Technical Report,’ ‘Validation Study.’
Embase	('qaly' OR 'daly' OR 'icer' OR 'cost-effectiveness' OR 'cost-effective' OR 'cost-utility' OR 'cost-benefit' OR 'cost effectiveness' OR 'cost effective' OR 'cost utility' OR 'cost benefit' OR 'economic evaluation' OR 'Value-Based' OR 'Value-Based Care' OR 'VBC') AND (orthopedics OR orthopaedics OR musculoskeletal OR limb) AND ('clinical article'/de OR 'clinical trial'/de OR 'comparative effectiveness'/de OR 'comparative study'/de OR 'controlled clinical trial'/de OR 'controlled study'/de OR 'major clinical study'/de OR 'multicenter study'/de OR 'prospective study'/de OR 'randomized controlled trial'/de OR 'retrospective study'/de) AND (2003:py OR 2004:py OR 2005:py OR 2006:py OR 2007:py OR 2008:py OR 2009:py OR 2010:py OR 2011:py OR 2012:py OR 2013:py OR 2014:py OR 2015:py OR 2016:py OR 2017:py OR 2018:py OR 2019:py OR 2020:py OR 2021:py OR 2022:py OR 2023:py) AND ('clinical trial'/lnk OR 'clinicaltrials gov'/lnk OR 'disease management'/lnk OR 'rehabilitation'/lnk OR 'surgery'/lnk OR 'therapy'/lnk) AND 'article'/it
Web of Science Core Collection	(economic evaluation OR "Cost-effective analysis" OR "Cost-effectiveness analysis" OR "Cost-utility analysis" OR QALY OR DALY OR ICER OR "Value-Based" OR "Value-Based Care" OR "VBC") AND (orthoped∗ OR orthopaed∗ OR musculoskeletal OR limb OR "appendicular skeleton")

After inclusion based on the screening process, two reviewers independently extracted data from the included articles. The extracted data included year of publication, geographic location of the study, pathology under study, treatments, economic evaluation perspective, costing methodology, outcome metric(s), whether the outcome metric was a subjective or objective assessment and externally or internally validated, and value equation. Additionally, the key outcomes of each included study were tracked with further discussion of the most evaluated pathologies. Please refer to Supplemental 1 and 2 (available online on the Journal’s website at https://www.jhsgo.org), for comprehensive definitions of all data categories under observation.

Costs are categorized and sourced based on the evaluator’s perspective in economic evaluations—mirroring a diverse business landscape where sellers and buyers face distinct costs.37, 38, 39 Each economic evaluation perspective delineates costs in unique ways, albeit under similar economic terminology. To comprehensively grasp this concept, our approach involved initially cataloging cost items collectively and then categorizing further according to the specific perspective of economic evaluation. Based on the economic evaluation literature, we identified three different perspectives through which cost can be considered: hospital/clinic, societal, and payer.37, 38, 39

Our costing categorization framework identified medical costs (direct fixed, direct variable, indirect, and out-of-pocket) and nonmedical/societal costs (nonmedical direct and nonmedical indirect costs). The specific definitions and examples of our cost stratification can be found in Supplemental 2, available online on the Journal’s website at https://www.jhsgo.org. Our aim in developing this extensive framework was to meticulously extract and compare data from diverse cost sources and perspectives such as claims data, patient diaries, and financial departments. In total, we tracked six different cost categories across three different perspectives (Supplemental 3, available online on the Journal’s website at https://www.jhsgo.org).

Within the studies, we sought out the specific quantitative value calculations used to calculate and compare interventions in hand and wrist care. Examples include the cost-effectiveness analysis that uses quality outcomes measured in a natural health unit such as grip strength, blood pressure, pronation, etc.⁴⁰ Within cost-effectiveness analysis is a commonly used subspecialized analysis called the cost-utility analysis, which uses specifically a transformed measure of health status such as a Quality-Adjusted Life Year (QALY), which adds a time component to patient-reported outcomes and allows for comparison across different health care subspecialties.

Risk of bias was assessed using two Cochrane Risk of Bias Tools, the ROB2 and ROBINS-I, which have been validated and used frequently to perform systematic reviews. For randomized studies, the ROB2 was used, and for nonrandomized studies, the ROBINS-I tool was used.^41,42 The risk of bias was reviewed independently and was later discussed between two reviewers to reach agreement.

Results

Our literature search identified 6,071 studies; 181 full-text articles were screened, with 19 fulfilling inclusion criteria for review (see Fig.). Of the 19 studies, 13 were in the UK, 4 in the Netherlands, 1 in Spain, and 1 in Norway.

Distal radius fractures (DRFs) (n = 6) and scaphoid fractures (n = 4) were the most commonly evaluated conditions. See Table 2 for additional included study characteristics. Studies used the payer perspective (n = 13) and the societal perspective (n = 12), with several studies employing multiple perspectives (n = 6). None used the hospital/clinic perspective. All 19 studies used public payer cost data as their primary cost source. Seventeen studies also used other sources to identify costs. See Supplemental 3, available online on the Journal’s website at https://www.jhsgo.org, and Table 3 for additional details related to the types of costs used.

Table 2.

Characteristics of Hand and Wrist Value-Based Care Studies (n = 19)

Characteristic	N	%	Characteristic	N	%
Year published			Pathology
2003–2007	1	5.3	CTS	3	15.8
2013–2017	4	21.1	CMC joint	2	10.5
2018–2023 as of 12/06/23	14	73.7	DRF	6	31.6
Geography			Hand osteoarthritis	1	5.3
Americas	0	0	Nonspecific arm pain	1	5.3
Europe			Rheumatoid hand	1	5.3
Netherlands	4	21.1	Scaphoid fracture	4	21.1
Spain	1	5.2	Upper limb prostheses	1	5.3
UK	13	68.4	Type of treatment
Norway	1	5.3	Health care delivery	3	15.8
			Nonsurgical	9	47.4
			Surgical	2	10.5
			Surgical vs nonsurgical	5	26.3

CTS, carpal tunnel syndrome; CMC joint, carpometacarpal joint.

Table 3.

Characteristics of Costing Methods

Characteristic	N	%
Cost perspective	∗n = 25
Hospital/clinic	0	0
Societal	12	48.0
Payer	13	52.0
Type of health care system
Single public payer	19	100.0
Public and private payers	0	0
Source of cost∗
Public payer cost data	19	100.0
Patient diary	16	84.2
Estimation by finance department	1	5.3
Other published study data	1	5.3
Type of cost
Medical costs
Direct fixed	19	100.0
Direct variable	16	84.2
Indirect	1	5.3
Out-of-pocket	0	0
Nonmedical costs
Indirect	14	73.7
Direct	9	47.4

^∗For cost perspectives, there were six studies that used more than one perspective; hence, a total of 25 perspectives were described in the included studies. Similarly, many studies used multiple characteristics for the source and type of cost.

All studies used subjective quality metrics as their primary outcome with all except for one study transforming their quality metric into a QALY, which adds a time component to patient-reported outcomes and allows for comparison across different health care subspecialties.⁴³ The most common primary outcomes were iterations of the EuroQol 5-Dimension (n = 19, 95%). See Table 4 for more details.

Table 4.

Characteristics of Quality Metrics

Characteristics	N	%
Outcome type	∗n = 23
Subjective	22	95.7
Objective	1	4.2
Validation
External	22	95.7
Internal	1	4.2
Quality metrics used for the value equation	∗n = 23
EQ-5D iterations	19	82.5
EQ-5D unspecified	5	21.7
EQ-5D-3L	4	17.4
EQ-5D-5L	9	39.1
EQ-5D-Y	1	4.3
Hand Pain Severity Score	1	4.3
PUF-ULP	1	4.3
SF-6D	1	4.3
BCTQ	1	4.3
Transformation of quality metrics	∗n = 23
QALY	20	87.0
DALY	0	0
HYE	0	0
WTP	0	0
Did not transform	3	13.0

PUF-ULP, preferred usage features of upper limb prosthesis; EQ-5D, EuroQol-5D; BCTG, Boston Carpal Tunnel Questionnaire; SF-6D, Short Form Six Dimensions.

^∗Some studies used multiple quality metric outcomes.

Economic evaluations included the cost-effectiveness analysis (n = 1), cost-utility analysis (n = 12), cost-utility and cost-effectiveness analyses (n = 2), cost-utility and net monetary benefit (NMB) analyses (n = 4), and cost-utility, cost-effectiveness, and net health benefit analyses (n = 1). From those studies, 11 used an incremental cost-effectiveness ratio (ICER) or incremental cost-utility ratio (ICUR), 3 used ICER and ICUR, 4 used an ICER and NMB, and one used an ICER, ICUR, and net health benefit. Supplemental 4, available online on the Journal’s website at https://www.jhsgo.org, includes descriptions of the value equations.

The studies discussing DRF had key findings highlighting differences in health care delivery and comparing surgical options. Reduced imaging strategies for follow-up were more cost effective than traditional care.⁴⁴ K-wire fixation after manipulation was no more cost effective than molded casting because of increased costs and worse QALYs, and the cost effectiveness of volar-locking plate fixation for DRF equaled percutaneous fixation and K-wire fixation.45, 46, 47, 48 In pediatrics, bandaging was more cost effective than rigid immobilization, characterized by a negative ICER for both payer and societal perspectives.⁴⁹

Within scaphoid fracture care, obtaining an immediate magnetic resonance imaging (MRI) for suspected fractures dominated standard care in terms of cost effectiveness with lower costs and higher QALYs achieved.⁵⁰ One study indicated that a combination of cast treatment and early fixation was more cost effective than surgery only, cast only, or no treatment when both an ICER and NMB were used.⁵¹ Another study reported early cast immobilization with subsequent surgery of nonunions is more cost effective than early surgical fixation because of lower cost and comparable outcomes.⁵² Lastly, pulsed electromagnetic fields in acute fracture treatment were not cost effective compared to standard care because of higher costs and equivocal outcome data.⁵³ The specific value comparison outcomes of all studies can be found in Table 5.44, 45, 46, 47, 48, 49, 50, 51, 52, 53

Table 5.

Characteristics of Hand and Wrist Value-Based Studies Health Care Studies Comparing Value (n = 19)

S. #	Author, Year	Journal	Country	Pathology	Type of Treatment	Cost Perspective	Economic Evaluation Type	Major Findings
1	Fernandez et al,54 2019	Journal of Orthopaedic & Sports Physical Therapy	Spain	Carpal tunnel syndrome	Surgical vs nonsurgical	Societal	Cost utility	Manual physical therapy proved to be more cost effective than surgery. ICER: €−137,378 per QALY gained.
2	Ronaldson et al,55 2021	F1000Research	UK	Hand osteoarthritis	Nonsurgical	Societal and payer	Cost utility and cost effectiveness, and NHB	Hydroxychloroquine is unlikely to provide value for hand OA management compared with placebo. ICUR = −2,267 per QALY gained.
3	Rua et al,50 2020	Value in Health	UK	Scaphoid fracture	Health care delivery	Payer	Cost utility	Immediate MRI intervention is more cost effective than standard treatment. ICUR = –£4,687 per QALY gained
4	Hinde et al,52 2021	The Bone & Joint Journal	UK	Scaphoid fracture	Health care delivery	Payer	Cost utility	Initial cast immobilisation is more likely to be cost effective compared to surgical fixation. ICUR between £52,320/QALY and £135,085/QALY across different scenarios due mainly to the cost of surgery.
5	Karantana et al,47 2015	The Bone & Joint Journal	UK	DRF	Surgical	Payer	Cost utility	No evidence that fixation using a volar-locking plate is cost effective over percutaneous fixation for treatment of dorsally displaced radial fracture. ICUR was £40,068 per QALY gained.
6	Png et al,45 2022	The Bone & Joint Journal	UK	DRF	Surgical vs nonsurgical	Societal	Cost utility	Surgical K-wire fixation was more expensive and generated lower QALYs than moulded casting after manipulation of a distal radius fracture, but this difference was not statistically significant.
7	Kerver et al,56 2022	Disability & Rehabilitation	Netherlands	Upper limb prostheses	Nonsurgical	Societal	Cost utility and cost effectiveness	MHPs were not cost effective compared to SHPs. ICUR = €-728,833 per Quality-Adjusted Life Year. ICER = €-187,798 per PUF-ULP point gained
8	Lamb et al,57 2015	Lancet	UK	Rheumatoid hand	Nonsurgical	Payer	Cost utility	Tailored hand exercise programs are a worthwhile intervention as an adjunct to drug regimens. ICUR = £9,549 per QALY gained for the EQ-5D; £7,440 per QALY gained for the SF-6D
9	Hannemann et al,53 2015	BMC Musculoskeletal Disorders	Netherlands	Scaphoid fracture	Nonsurgical	Societal	Cost utility	Pulsed electromagnetic fields (PEMF) are less cost effective than the standard treatment of scaphoid fracture. ICER = €113,559 per QALY gained
10	Tveter et al,58 2023	British Medical Journal	Norway	CMC Joint	Nonsurgical	Societal and payer	Cost utility	Multimodal occupational therapy in addition to usual care was cost effective compared to usual care at 2 years in patients with CMC joint osteoarthritis based on a dominant ICER.
11	van Gerven et al,44 2020	British Medical Journal	Netherlands	DRFs	Nonsurgical	Societal	Cost utility and cost effectiveness	Implementing a reduced imaging strategy when following up on distal radius fractures is cost effective and does not decrease functional outcomes. ICUR = €-15,872 per QALY gained. ICER = €198 per DASH point gained
12	Costa et al,46 2022	Health Technology Assessment	UK	DRFs	Surgical vs nonsurgical	Societal and payer	Cost utility and NMB	K-wire fixation after manipulation of an acute dorsally displaced distal radius fracture had a higher mean cost and similar effectiveness compared to manipulation and use of a moulded cast. The cost effectiveness was <0.5 at cost-effectiveness thresholds of £15,000, £20,000 and £30,000 per QALY
13	Perry et al,49 2022	Health Technology Assessment	UK	DRFs	Nonsurgical	Societal and payer	Cost utility and NMB	The use of a bandage was cost effective was cost effective when compared with rigid immobilisation for pediatric patients. ICER = –£10,680 per QALY, and for the societal perspective, the ICER was –£9,890 per QALY.
14	Korthals-de Bos et al,59 2006	BMC Musculoskeletal Disorders	Netherlands	Carpal tunnel syndrome	Surgical vs nonsurgical	Societal	Cost utility	Surgery is more cost effective than splinting for carpal tunnel syndrome. ICER = €40 per QALY gained.
15	Dias et al,51 2020	Health Technology Assessment	UK	Scaphoid Fracture	Surgical vs nonsurgical	Payer	Cost utility and NMB	Cast treatment and early fixation for scaphoid fractures was the most cost effective option and offered the highest net health benefit (NHB) at a willingness-to-pay (WTP) threshold of £20,000/QALY. This intervention is followed by primary surgery, cast only, and, finally, no treatment.
16	Adams et al,60 2021	British Society of Rheumatology	UK	CMC joint	Nonsurgical	Payer	Cost utility	There was no additional benefit of adding a thumb splint as an adjunct to a therapist-supported self-management program. ICER = 363,640 per QALY gained.
17	Chesterton et al,61 2018	Lancet	UK	Carpal tunnel syndrome	Nonsurgical	Societal and payer	Cost utility and cost effectiveness	Corticosteroid injection was more costly and more effective than night splinting. ICER: £4,193 per QALY gained; resulting in a 76% probability of the corticosteroid injection being cost effective at a WTP threshold of £20,000 per QALY gained
18	Costa et al,48 2015	Health technology assessment	UK	DRF	Surgical	Societal and payer	Cost utility and NMB	Patients with distal radius fractures treated with volar-locking plate fixation are not more cost effective than K-wires. ICUR = £89,322 per QALY gained.
19	Neilson et al,62 2018	Family practice	UK	Nonspecific arm pain	Health care delivery	Payer	Cost utility	Advice to remain active after distal arm pain is more cost effective than advice to rest. ICER = £9,256/QALY. Based on a WTP threshold of £20,000 per QALY gained, advice to remain active had a 71.3% chance of being cost effective. Immediate hand therapy was more cost effective compared to the usual waiting-list hand therapy for distal arm pain with a dominant ICER. Immediate hand therapy proved to be cost effective up to a WTP threshold of £60,000 per QALY gained

CMC, carpometacarpal; DASH, Disabilities of the Arm, Shoulder and Hand; EQ-5D, EuroQol 5-Dimensions; MHP, Mental Health Professional; NHB, net health benefit; NMB, net monetary benefit; OA, osteoarthritis; PEMF, pulsed electromagnetic fields; SF-6D, short form-6 dimensions; SHP, secondary health professional; WTP, willingness-to-pay.

Discussion

This systematic review analyzed value comparison literature in hand and wrist care over the past 20 years, identifying the use of quality metrics, such as the EuroQol 5-Dimension (EQ-5D) surveys, and varying costing methodologies. Although our search revealed global interest in VBC, there are relatively few studies comparing treatment value using real-world clinical data outside of Europe. Most studies focused exclusively on societal and payer perspectives, with perspectives from health care providers notably absent. Although the societal and payer perspectives consider a more general economic effect, the hospital/clinic perspective focuses on clinical outcomes and resource allocation that more closely align with daily operational realities.^39,63 The emphasis on societal and payer perspectives likely reflects the predominance of public-funded, single-payer health care systems in Europe. These countries are laying the foundation on which countries with more heterogeneous health care systems can build upon, by incorporating a hospital/clinic approach that can provide a more granular cost measurement from multiple sources.

The EQ-5D survey and its iterations were the predominant tools reported in our review. Although the EQ-5D-5L offers advantages such as its ability to describe 243 unique health states, translation into more than 150 languages, and its adoption by national agencies for economic evaluations, it lacks the specificity required to effectively capture aspects of health relevant to specialty medicine.64, 65, 66, 67 This underscores the growing need for alternative approaches that complement QALYs, adding additional dimensions to make studies more translatable and universally applicable to VBC frameworks. Fortunately, the following concerns are remedied by numerous subspeciality-specific patient-reported outcome measures that exist.⁶⁸ Specialty-specific patient-reported outcome measures are tailored to subspecialties, providing more precise insights without the need to be translated into QALYs and offering flexibility in environments where QALYs are not used.^43,69,70 The integration of QALY-driven metrics with specialty-specific outcomes provides a complementary framework that enhances the translatability of findings into clinical practice by capturing both broad health impact and discipline-specific nuances.

The ICER/ICUR equation emerged as the most common value calculation seen in our review. The ICUR, specifically, incorporates length of effectiveness alongside a utility of health metric (ie, QALY), enhancing its versatility in comparing diverse treatment options. Although some studies employed the incremental net monetary benefit equation to assess cost effectiveness against a willingness-to-pay threshold, this method is limited as a standalone measure because of challenges in establishing a consistent willingness-to-pay threshold for nations with complex health care environments.⁷¹ Rather, an incremental net monetary benefit can help enhance the investigation when used in conjunction with an ICER or an ICUR. It is noteworthy that the ICER/ICUR framework has been effectively used in orthopedic subspecialties beyond hand and wrist care, solidifying its status as the most effective and comprehensible approach for value comparison.72, 73, 74

The findings from these value comparison studies challenge several widely accepted practices in hand and wrist fracture management, highlighting the need to re-evaluate treatment strategies from both a cost-effectiveness and clinical outcome perspective. Nonsurgical interventions, such as molded casting, were frequently found to be as cost effective—or even superior—to surgical approaches such as K-wire fixation and volar-locking plate fixation for DRFs.45, 46, 47, 48^,52,54 Imaging strategies favoring early MRI for suspected fractures and reduced imaging overall proved to be more cost effective than traditional diagnostic pathways.^44,50 Additionally, innovative methods such as pulsed electromagnetic fields were demonstrated not to be more cost effective compared with standard care.⁵³ Despite these findings, current clinical practice often diverges from these cost-effectiveness recommendations. For instance, volar-locking plate fixation remains a predominant choice depending on the functional demands of the patients with DRFs, despite comparable cost effectiveness to less invasive methods.⁷⁵ Similarly, early MRI, although highly sensitive and specific for diagnosing scaphoid fractures, is not routinely performed because of institutional constraints and financial considerations.^76,77 Furthermore, emerging technologies such as pulsed electromagnetic field therapy, despite their increasing presence in hand and wrist care, have not demonstrated sufficient cost effectiveness to justify widespread adoption.^53,77,78

These discrepancies between evidence-based value analyses and prevailing treatment patterns highlight the complex interplay of factors influencing surgical decision making. Although cost effectiveness is a crucial consideration, it is often weighed against perceived clinical efficacy, surgeon familiarity with specific procedures, and patient expectations for more aggressive interventions.⁷⁹ In some cases, higher cost interventions may be preferred because of their ability to accelerate functional recovery, even when conservative management offers similar long-term outcomes at a lower cost.^80,81 This misalignment between economic efficiency and clinical practice underscores the need for further research to determine which interventions provide the best value, not only in terms of cost but also in optimizing patient outcomes and resource allocation. Determining approaches that deliver the best value will aid in developing sustainable, high-quality care that benefits all stakeholders including patients, physicians, and health care systems.

The first key limitation of this study is the consolidation of diverse study characteristics to facilitate comparison, which may obscure important nuances in costing methodology and outcome tracking. Second, although we aimed to explore value calculations and comparisons, we cannot offer a universally applicable value methodology because of the heterogeneity of health systems globally. Our review predominantly focused on the general field of hand and wrist care, and we recognize the need for future research to evaluate cost and quality for individual diagnoses. Furthermore, our search query, despite its design to be thorough, may have inadvertently excluded relevant studies because of the specificity of search terms, an established time frame from 2003 to 2023, and the exclusion of non-English studies. Finally, we intentionally excluded studies using simulated scenarios, such as the Markov model, focusing instead on real-world clinical data to meet our research objectives.

This systematic review highlights a need for further research to determine what approaches deliver the best value in hand and wrist care, particularly given the discrepancies between value study findings and how hand and wrist care is clinically delivered. Establishing standardized value methodologies that integrate relevant hand-specific quality metrics and cost considerations is crucial to bridging this gap. Globally, reconciling cost-effectiveness studies with practical clinical practice can ensure that VBC meets health care realities and stakeholder needs. Expanding value comparison studies with rigorous, evidence-based approaches can guide clinicians and policymakers in optimizing hand and wrist care across diverse health care systems.

Conflicts of Interest

No benefits in any form have been received or will be received related directly to this article.