Monday, July 15, 2024

Economic Evaluation of Early ACL Reconstruction vs. Conservative Treatment in Indonesia

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The ideal treatment for anterior cruciate ligament (ACL) injuries continues to be a topic of debate, particularly in lower to middle-income countries. Recent research conducted in Indonesia has sought to identify the most cost-effective strategy by comparing early ACL reconstruction (ACLR) surgery with conservative treatment options, which include rehabilitation and optional delayed reconstruction.

Study Methodology

Researchers employed a decision tree model to conduct a cost-utility analysis, comparing early ACLR to conservative treatment. Transition probabilities between different health states were derived from a thorough literature review. The study utilized the EQ-5D-3L instrument from a local prospective cohort study to measure utilities, and costs were referenced from previous research detailing the financial burden of ACLR in Indonesia. Effectiveness was quantified in terms of quality-adjusted life years (QALYs) gained, with the primary outcome measure being the incremental cost-effectiveness ratios (ICER).

Key Findings

The early ACLR group demonstrated an incremental gain of 0.05 QALYs compared to the conservative treatment group but incurred a higher societal cost of US$976. The ICER for ACLR surgery was calculated at US$19,524 per QALY, which exceeds Indonesia’s willingness-to-pay (WTP) threshold of US$12,876. This threshold is based on three times the Indonesian GDP per capita for 2021, as recommended by the World Health Organization’s Choosing Interventions that are Cost-Effective (WHO-CHOICE) criterion.

From a market access perspective, the higher cost associated with early ACLR presents a significant barrier for broader implementation in Indonesia. The probability of conservative treatment being favored over early ACLR is 64%, given the current economic constraints and healthcare infrastructure.

Implications for Market Access

The evaluation’s sensitivity to various factors such as the cost of conservative treatment, the expense of ACLR, and the rate of cross-over to delayed ACLR underscores the complexities involved in healthcare decision-making in LMICs. Key insights derived from the study include:

– The high ICER of early ACLR indicates limited cost-effectiveness, challenging market access in resource-constrained settings.
– The preference for conservative treatment reflects economic considerations and existing healthcare capacity in Indonesia.
– Future policies should account for long-term outcomes and the economic burden of different treatment options to optimize healthcare allocation.

The study concludes that early ACLR surgery is not more cost-effective compared to conservative treatment for ACL injury patients in Indonesia. The results highlight the need for further long-term studies to better understand the impact of treatment strategies on healthcare costs and patient outcomes.

Original Article:

BMC Health Serv Res. 2024 Jul 9;24(1):784. doi: 10.1186/s12913-024-11212-8.

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ABSTRACT

BACKGROUND: The ideal approach for treating anterior cruciate ligament (ACL) injury is still disputed. This study aimed to determine the more cost-effective strategy by comparing early ACL reconstruction (ACLR) surgery to conservative treatment (rehabilitation with optional delayed reconstruction) for ACL injury in a lower/middle-income country (LMIC), Indonesia.

METHODS: A decision tree model was constructed for cost-utility analysis of early ACLR versus conservative treatment. The transition probabilities between states were obtained from the literature review. Utilities were measured by the EQ-5D-3 L from a prospective cohort study in a local hospital. The costs were obtained from a previous study that elaborated on the burden and cost of ACLR in Indonesia. Effectiveness was expressed in quality-adjusted life years gained (QALYs). Principal outcome measure was the incremental cost-effectiveness ratios (ICER). Willingness-to-pay was set at US$12,876 – three times the Indonesian GDP per capita in 2021 – the currently accepted standard in Indonesia as suggested by the World Health Organization Choosing Interventions that are Cost-Effective criterion (WHO-CHOICE).

RESULTS: The early ACLR group showed an incremental gain of 0.05 QALYs over the conservative treatment group, with a higher overall cost to society of US$976. The ICER of ACLR surgery was US$19,524 per QALY, above the WTP threshold of US$12,876. The ICER was sensitive to cost of conservative treatment, cost of ACLR, and rate of cross-over to delayed ACLR numbers in the conservative treatment group. Using the WTP threshold of US$12,876, the probability of conservative treatment being preferred over early ACLR was 64%.

CONCLUSIONS: Based on the current model, early ACLR surgery does not seem more cost-effective compared to conservative treatment for ACL injury patients in Indonesia. Because the result was sensitive to the rate of cross-over probabilities from the conservative treatment alone to delayed ACLR, a future study with a long-term perspective is needed to further elucidate its impact.

PMID:38982438 | DOI:10.1186/s12913-024-11212-8

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