Interventions:
The choice of interventions was appropriate, in that they were common options, for distal radial fractures, in the authors' setting. It was unclear whether other relevant treatment options could have been considered.
Effectiveness/benefits:
The clinical data were from a systematic review, which was not described, making it difficult to determine if the most up-to-date and relevant data were used. The methods of the studies that supplied the effectiveness data were not reported, making it difficult to comment on their validity. QALYs were an appropriate outcome measure, capturing the impact of the interventions on quality of life and allowing comparisons with other diseases and interventions. The instrument and methods used to elicit the utility weights were reported. The authors did not explicitly state the time horizon, but it appears to have been lifetime (the elderly patients' remaining years).
Costs:
The perspective was not explicitly stated, so it is unclear whether all the relevant costs were included. The source for the cost estimates was appropriate for the authors' setting, but the costs were reported as category totals, rather than unit costs, reducing the transparency of the analysis. Discounting of costs was not performed, and as a time horizon was not reported, it is unclear whether it was necessary or not.
Analysis and results:
The results were clearly presented and an incremental approach was used to identify the preferred strategy. A partial sensitivity analysis was performed, by varying the rates of complications, but no other model inputs. The authors discussed a number of limitations to their analysis, including the assumptions that were required for the decision tree. The results of the study are unlikely to be generalisable to other settings.
Concluding remarks:
There were some limitations to the reporting of the methods, but the authors’ conclusions seem appropriate, as they emphasise the uncertainty in the clinical evidence.