Cost effectiveness analysis of early reconstruction versus rehabilitation and the lead reconstruction for anterior cruciate ligament tears
Mather RC, Hettrich CM, Dunn WR, Cole BJ, Bach BR, Hustun LJ, Reinke EK and Spindler KP. Am J Sports Med. 2014, [Epub Ahead of Print].
Take Home Message: An early ACL reconstruction may lead to lower cost than individuals with an optional delayed ACL reconstruction. While this may help clinicians counsel patients, caution should be exercised as little is understood about long-term effects of each option and these results represent societal cost and may not always be applicable to a specific patient.
Although both early anterior cruciate ligament (ACL) reconstruction (ACLR) and rehabilitation with the option of delayed ACLR are legitimate treatment options for an ACL injury, only a few studies have directly compared the two treatment strategies. However, no one has done a direct comparison of the cost-effectiveness of each treatment option. A better understanding of the financial impact of these two options may help clinicians identify a preferred treatment strategy. Therefore, Mather and colleagues completed an economic analysis to compare cost-effectiveness of early ACLR with rehabilitation plus optional delayed ACLR. Researchers built a decision model using records from the KANON study and MOON database (928 individuals with an ACL rupture). All patients in the early ACLR group were assumed to have stable knees at the end of 1 year. Patients in the delayed reconstruction group could undergo other surgeries without ACLR for the treatment of meniscus injuries. The quality of life was measured using the Short Form-36. Cost was estimated by using the average Medicare reimbursement for knee surgeries in 2012. Overall, undergoing an early ACLR was shown to cost $1572 less than the cost of rehabilitation with the potential of ACLR later. These findings were primarily driven by the rate of knee instability among patients. The authors estimated that early ACLR was the “preferred cost-effective strategy for 78% of patients, while rehabilitation plus optional delayed ACLR was preferred for 22% of patients.
The results of this study should be of interest to clinicians because it compares the two treatment strategies not based on patient-reported outcomes but by societal costs of these treatment options. Perhaps the decreased cost associated with an early ACLR could lead to early reconstruction continuing to remain the standard of care; however, these results must be interpreted with caution. While early ACLR may lead to lower overall cost this study does not address the long-term health of the joint. The current study focused on the first 6 years after an injury and did not account for the long-term health of the patients. This is undoubtedly something that clinicians must have a better understanding of prior to identifying 1 treatment option as the standard. Therefore, more research must be completed to identify any detrimental long-term effects after either treatment strategy. Furthermore, we must not lose sight of the patient in front of us. If we can find strategies to identify individuals who may be successful without an early ACLR then this could improve the cost saving aspect of an optional delayed ACLR. In the meantime, clinicians should still counsel patients with ACL ruptures based on their preinjury level of activity, anticipated activity level post-injury, as well as their ability to stabilize the knee joint when ACL-deficient.
Questions for Discussion: What factors do you use to counsel patients who have sustained an ACL rupture? Have you experienced patients who worried about prohibitive cost of undergoing ACLR?
Written by: Kyle Harris
Reviewed by: Jeffrey Driban