Abstract
Background:
Rupture of the anterior cruciate ligament (ACL) is a common injury in young athletes. Safe return-to-play (RTP, i.e. sports competition) is important to patient satisfaction, and appropriate criteria for RTP may reduce the risk of graft injury.
Purpose:
The purpose of this study is to assess the cost-effectiveness of a comprehensive RTP rehabilitation protocol relative to standard post-ACL reconstruction rehabilitation.
Methods:
A decision-analysis model was utilized to compare standard rehabilitation with an RTP program which included supplemental neuromuscular retraining, functional testing, and clinical follow-up. Cost-effectiveness was evaluated from a payer perspective. Costs of surgical procedures and rehabilitation protocols, risks of ipsilateral graft rupture and contralateral ACL injury, risk reductions due to the RTP program, and relevant utilities based on International Knee Documentation Committee (IKDC) outcomes were derived from the available literature. An incremental cost-effectiveness ratio (ICER) of <$100,000/QALY was used to determine cost-effectiveness. Sensitivity analyses were performed on pertinent model parameters to measure their effect on base-case conclusions. In the base-case analysis, the cost of an RTP program was conservatively assumed to be $1,721 more than the standard rehabilitation protocol. The relative risk of ACL graft rupture following completion of the RTP program was assumed to be 0.75 (25% reduction).
Results:
In the base-case analysis, the RTP program was cost-effective compared with the standard rehabilitation protocol (ICER $54,939/QALY). Based on one-way threshold analyses, the RTP program was cost-effective as long as the additional cost was <$2,092 or the RTP program decreased the incidence of graft rupture by >7.7%.
Conclusion:
Our data suggests that, assuming modest associated decreases in graft failure, the addition of neuromuscular retraining, functional testing, and clinical follow-up to a formal rehabilitation program is cost-effective. The cost-effectiveness of such additions is related to the costs as well as any associated decreases in subsequent event risk, as shown in Figure 1.
Figures:
Two-way sensitivity analysis of the additional cost of an RTP program (relative to standard rehabilitation) versus the relative risk of graft rupture following completion of an RTP program. The black line represents the base-case assumption of additional cost of an RTP program ($1,721). The white line represents the base-case assumption of the relative risk of graft rupture following completion of an RTP program (0.75).