Disclosure(s): No financial relationships to disclose
Disclosure(s):
Peter Filtes, MD: No financial relationships to disclose
Objectives: To perform a Markov model-based cost-utility analysis comparing ACLR+LET with isolated ACLR in patients with an ACL tear. Methods: A systematic review of the current literature was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, to identify level 1 randomized-control trials (RCTs) comparing outcomes after ACLR+LET with those after isolated ACLR (Table I). This provided the outcome probabilities and patient-reported outcomes (PROs), which were utilized to calculate health state utilities, and quality adjusted life years (QALYs), for patients undergoing each procedure (Table II). Next, overall costs for the episode of care after each procedure were calculated using current CMS reimbursement rates. A conversion factor was applied to estimate private payer reimbursements for direct costs associated with each potential outcome; This produced the fiscal burden from a healthcare sector perspective. These direct costs were combined with indirect costs, such as time off from work, to show the fiscal burden for each procedure from a societal perspective. Finally, a Markov model incorporating the aforementioned outcome probabilities, health state utilities, PROs, QALYs, and costs was developed (Figure 1). With this, the accumulated costs and QALYs over a span of 2 years, for two distinct cohorts of patients with ACL tears - those undergoing ACLR+LET and those undergoing isolated ACLR - were calculated. Results: A total of 6 RCTs comparing patients with ACL tears undergoing primary ACLR+LET with ACLR for first-time ACL tear were identified through literature search (Table I). For the baseline case of a 21-year-old patient, under the healthcare sector perspective (direct costs) for private payer reimbursements, an isolated ACLR led to $15,787 in accumulated costs, while providing 0.83 QALYs, compared to an ACLR+LET, which led to $18,471, and 0.85 QALYs, yielding an incremental cost-effectiveness ratio (ICER) of $2,684 for ACLR+LET. Therefore, under a willingness-to-pay (WTP) threshold of $50,000, ACLR is more cost-effective, per QALY due to lower cost, and comparable effectiveness. However, ACLR+LET was undominated meaning, although it is more expensive, it delivers better health outcomes. Under the societal perspective (direct and indirect costs) utilizing private payer reimbursements for the same baseline case, an isolated ACLR led to $42,452 in accumulated costs, while providing 0.83 QALYs, compared to an ACLR+LET, which led to $41,943, and 0.85 QALYs; yielding an ICER of $509 for ACLR. Under the societal perspective, ACLR+LET is more cost effective and ACLR is strictly dominated, meaning ACLR should not be considered a preferred option at any WTP threshold (Table III). Conclusions: Based on this analysis, an ACL reconstruction with a lateral extra-articular tenodesis provides better health outcomes than an isolated ACL reconstruction in the primary management of an ACL tear. Although isolated ACLR was found to be more cost-effective when utilizing the healthcare perspective (direct costs), this may be misleading. Applying the more holistic societal perspective model (direct and indirect costs) yields a more comprehensive analysis pertaining to the true costs and benefits of each intervention. As such, with this approach ACLR+ LET was both more effective and less expensive than ACLR alone, making it the superior option overall.
