Summary
While ACLR with LET is likely to be cost-effective when evaluating a 24-month Marx Activity Rating Scale as the outcome, there was uncertainty in interpretation of cost-effectiveness for QALYs and return to sport with negligible differences in effect between groups.
Abstract
Background
The stability RCT demonstrated that the addition of LET to hamstring tendon autograft ACLR in young individuals at high risk of reinjury resulted in a statistically and clinically significant reduction in clinical failure. It is also important to gain a deeper understanding of the economic implications associated with the procedure, specifically whether the additional costs of an LET are outweighed by costs associated with revision ACLR.
Purpose
The objective of the present study was to estimate the cost-effectiveness of ACLR with LET compared to ACLR alone, from a healthcare payer perspective.
Methods
Data from 618 patients included in the Stability RCT were included. We evaluated the cost-effectiveness of ACLR with LET compared to ACLR alone using three different outcome measures of effectiveness: (1) quality-adjusted life years (QUALY) over 24 months, (2) the Marx Activity Rating Scale at 24 months (controlling for the baseline score), and (3) the number of participants who returned to a level of sport equal or greater than the baseline level at 24 months following surgery. We prospectively documented any reported adverse events at post-surgical follow-up visits with the surgeon, including at 2, and 6 weeks, and at 3, 6, 12, and 24 months after ACLR. We recorded costs from the Canadian healthcare payer perspective, which includes any direct costs associated with healthcare resources consumed and covered by Ontario’s publicly funded healthcare system. For each of the three outcomes, we calculated either an incremental cost-utility ratio (ICUR) or incremental cost-effectiveness ratios (ICER).
Results
The mean difference in overall costs between the ACLR with LET group and the ACLR alone group was small (mean difference = 145.18 [95% CI, -128.17 to 418.53]) from a healthcare payer perspective. Only revision ACLR costs were significantly different between groups, where costs were $223.35 (95%CI, 28.73 to 417.96) lower in the ACLR with LET group. Primary ACLR costs were also $348 higher for ACLR with LET. The mean difference between groups in QALY over 24 months was negligible and not statistically significant (mean difference = 0.004 [95% CI, -0.01 to 0.01]). The ACLR with LET group had significantly higher 24-month Marx scores while adjusting for the baseline Marx score (mean difference = 0.72 [95% CI, 0.07 to 1.37]). Using the Marx Activity Rating Scale as the outcome, the ICER was $201.64 per 1-point increase in Marx at 24 months when using the ACLR with LET procedure. Using net benefit regression, ACLR with LET was cost-effective if an individual was willing to pay $300 or more for a 1-unit improvement in the Marx at 24 months after ACLR.
Conclusion
While ACLR with LET is likely to be cost-effective when evaluating a 24-month Marx Activity Rating Scale as the outcome, there was uncertainty in interpretation of cost-effectiveness for QALYs and return to sport with negligible differences in effect between groups. Patient selection and individual characteristics should therefore be considered when deciding between the two approaches. Future research should explore predictors of cost-effectiveness and provide clearer guidelines for the indication of lateral augmentation.