Cost-Effectiveness Analysis of Early Reconstruction Versus Rehabilitation and Delayed Reconstruction for Anterior Cruciate Ligament Tears

Abstract

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.

No economic benefit of early knee reconstruction over optional delayed reconstruction for ACL tears: registry enriched randomised controlled trial data

“…Our results, based on a randomised trial and real-life data, contradict all available cost-effectiveness reports of ACL injury and reconstruction in which ACL reconstruction uniformly was suggested to be more cost-effective than non-surgical and/or delayed surgical treatment strategies 4 5 19–21. There are several potential explanations for the disparity in our findings compared to previous studies including differences in perspectives, prices, applied health utilities, and clinical practices (eg, structure of rehabilitation sessions) across studies.…”

“…The economic impact of ACL tears and the cost-effectiveness of treatments for this group of patients have gained interest and the results of this RCT have been used in at least two recent model-based health economic analyses 4 5. Unfortunately, these reports were based on misinterpreted data from the KANON-trial and relied heavily on expert opinions on the future risk of developing osteoarthritis rather than the actual 5-year radiographic osteoarthritis outcome 3.…”

Comparison of four alternative national universal anterior cruciate ligament injury prevention programme implementation strategies to reduce secondary future medical costs

“…Australian average utility of 0.895 was used as the starting value 30. Utility following ACL injury was taken from Mather et al 201335 drawn from the Multicenter Orthopaedic Outcomes Network database. Arthritis was sourced from Barton et al 32 who presented values for moderate-to-severe arthritis and post-TKR utility was sourced from Losina et al 27…”

The Past, Present And Future Of Ligament Regenerative Engineering

“…In the USA alone, as many as 250,000 ACL injuries occur each year that necessitate surgical intervention, at an annual healthcare cost upward of US$18 billon [2]. Generally, injury to the ACL occurs during sporting activities with pivoting and quick stop and go actions.…”