Background An initial anterior cruciate ligament (ACL) tear can be treated with surgical reconstruction or focused rehabilitation. The KANON (Knee Anterior cruciate ligament, NON-surgical versus surgical treatment) randomized control trial compared rehabilitation plus early ACL reconstruction (ACLR) to rehabilitation plus optional delayed ACLR and found no difference at two years by intention to treat analysis of total KOOS scores. The purpose of this study was to compare the cost-effectiveness of early versus delayed ACLR. Methods A Markov decision model was constructed for a cost-utility analysis of early reconstruction (ER) versus rehabilitation plus optional delayed reconstruction (DR). Outcome probabilities and effectiveness were derived from two sources: the KANON Study and the Multicenter Orthopaedic Outcomes Network (MOON) database. Collectively, these two sources provided data from 928 ACL patients. Utilities were measured by the SF-6D. Costs were estimated from the societal perspective in 2012 U.S. dollars. Costs and utilities were discounted in accordance with the United States Panel on Cost-Effectiveness in Health and Medicine. Effectiveness was expressed in quality-adjusted life years gained (QALYs). Principal outcome measures were average incremental costs, incremental effectiveness (as measured by QALYs), and net health benefits. Willingness-to-pay was set at $50,000, the currently accepted standard in the U.S. Results In the base case, the ER group resulted in an incremental gain of 0.28 QALYs over the DR group with a corresponding lower overall cost to society of $1572. Effectiveness gains were driven by the low utility of an unstable knee and the lower utility for the DR group. The cost of rehabilitation and the rate of additional surgery drove the increased cost of the DR group. The most sensitive variable was the rate of knee instability after initial rehabilitation. When the rate of instability falls to 51.5%, rehabilitation plus optional delayed ACLR is less costly and when it falls below 18% it becomes the preferred cost-effective strategy. Conclusions An economic analysis of the timing of ACLR using data exclusively from the KANON trial, MOON cohort, and national average reimbursement revealed that early ACLR was more effective (improved QALYs) at a lower cost than rehabilitation plus optional delayed ACLR. Therefore, early ACLR should be the preferred treatment strategy from a societal health system perspective.

Background Osteoarthritis (OA) is a highly prevalent condition associated with substantial clinical and economic burden. Value-based payment reform requires detailed understanding of care utilization. However, previous analyses of OA care have limitations, such as constraining analysis to a single year or to surgical patients. We aimed to more comprehensively characterize health services utilization and payment for hip and knee OA through a 3-year longitudinal analysis, including both operative and non-operative services, using Medicare claims data. Methods We utilized Medicare Standard Analytic Files available from PearlDiver, Inc. The target population for analysis was patients with osteoarthritis in the hip, knee, or both, identified by ICD-9 diagnosis codes. Patients were limited to those whose 1) first instance of hip or knee OA diagnosis in the payer dataset occurred between 2008 and 2011 and 2) who were continuously active in the payer dataset for one year prior to and three years following diagnosis. Results Payments for relevant hip and knee OA services were highest during the first year after diagnosis, representing 55.6%, 65.3%, and 51.2% of total payments for patients with knee, hip, or knee and hip OA, respectively. Payments and utilization of services in the second and third treatment years were lower, and similar to the year prior to OA diagnosis. Service-level analysis revealed that total payments were driven by utilization of high-intensity services like surgery, which accounted for 57.7%, 60.6%, and 63.6% of payments in the first year for knee, hip, and knee and hip OA patients, respectively. High utilization of Medical Services like physician-administered medications, arthrocentesis, and physical therapy drove high payments as well, especially later in treatment. Conclusion Hip and knee OA treatment intensity is highest in the year immediately following a new diagnosis and decreases considerably in the second- and third-years following diagnosis across all relevant service categories. This analysis supports the identification of specific, time-sensitive opportunities to transform hip and knee OA care and payment models to optimize patient-centered outcomes while controlling costs across the episode of care.