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Economic Analyses in Anterior Cruciate Ligament Reconstruction: A Qualitative and Systematic Review Bryan M. Saltzman, Gregory L. Cvetanovich, Benedict U. Nwachukwu, Nathan A. Mall, Charles A. Bush-Joseph and Bernard R. Bach, Jr Am J Sports Med published online April 30, 2015 DOI: 10.1177/0363546515581470 The online version of this article can be found at: http://ajs.sagepub.com/content/early/2015/04/30/0363546515581470

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Economic Analyses in Anterior Cruciate Ligament Reconstruction A Qualitative and Systematic Review Bryan M. Saltzman,*y MD, Gregory L. Cvetanovich,y MD, Benedict U. Nwachukwu,y MD, MBA, Nathan A. Mall,z MD, Charles A. Bush-Joseph,y MD, and Bernard R. Bach Jr,y MD Investigation performed at Rush University Medical Center, Chicago, Illinois, USA Background: As the health care system in the United States (US) transitions toward value-based care, there is an increased emphasis on understanding the cost drivers and high-value procedures within orthopaedics. To date, there has been no systematic review of the economic literature on anterior cruciate ligament reconstruction (ACLR). Purpose: To evaluate the overall evidence base for economic studies published on ACLR in the orthopaedic literature. Data available on the economics of ACLR are summarized and cost drivers associated with the procedure are identified. Study Design: Systematic review. Methods: All economic studies (including US-based and non–US-based) published between inception of the MEDLINE database and October 3, 2014, were identified. Given the heterogeneity of the existing evidence base, a qualitative, descriptive approach was used to assess the collective results from the economic studies on ACLR. When applicable, comparisons were made for the following cost-related variables associated with the procedure for economic implications: outpatient versus inpatient surgery (or outpatient vs overnight hospital stay vs .1-night stay); bone–patellar tendon–bone (BPTB) graft versus hamstring (HS) graft source; autograft versus allograft source; staged unilateral ACLR versus bilateral ACLR in a single setting; single- versus double-bundle technique; ACLR versus nonoperative treatment; and other unique comparisons reported in single studies, including computer-assisted navigation surgery (CANS) versus traditional surgery, early versus delayed ACLR, single- versus doubleincision technique, and finally the costs of ACLR without comparison of variables. Results: A total of 24 studies were identified and included; of these, 17 included studies were cost identification studies. The remaining 7 studies were cost utility analyses that used economic models to investigate the effect of variables such as the cost of allograft tissue, fixation devices, and physical therapy, the percentage and timing of revision surgery, and the cost of revision surgery. Of the 24 studies, there were 3 studies with level 1 evidence, 8 with level 2 evidence, 6 with level 3 evidence, and 7 with level 4 evidence. The following economic comparisons were demonstrated: (1) ACLR is more cost-effective than nonoperative treatment with rehabilitation only (per 3 cost utility analyses); (2) autograft use had lower total costs than allograft use, with operating room supply costs and allograft costs most significant (per 5 cost identification studies and 1 cost utility analysis); (3) results on hamstring versus BPTB graft source are conflicting (per 2 cost identification studies); (4) there is significant cost reduction with an outpatient versus inpatient setting (per 5 studies using cost identification analyses); (5) bilateral ACLR is more cost efficient than 2 unilateral ACLRs in separate settings (per 2 cost identification studies); (6) there are lower costs with similarly successful outcomes between single- and double-bundle technique (per 3 cost identification studies and 2 cost utility analyses). Conclusion: Results from this review suggest that early single-bundle, single (endoscopic)-incision outpatient ACLR using either BPTB or HS autograft provides the most value. In the setting of bilateral ACL rupture, single-setting bilateral ACLR is more costeffective than staged unilateral ACLR. Procedures using CANS technology do not yet yield results that are superior to the results of a standard surgical procedure, and CANS has substantially greater costs. Keywords: anterior cruciate ligament reconstruction; cost drivers; cost; economic analysis

(ACLR) has increased dramatically, from an estimated 86,687 procedures performed in 1994 to 129,836 procedures by 2006 in the United States (US) alone. Over this 12-year period, use of this procedure has increased most significantly in female patients and in patients younger than 20 years or older than 40 years; the procedure is most commonly performed with concomitant partial meniscectomy

Anterior cruciate ligament (ACL) injury is among the most commonly studied musculoskeletal injuries within the orthopaedic literature. The incidence of ACL reconstruction

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and chondroplasty.25 In addition to changing demographics for ACLR, there has been a trend toward same-day or shortstay procedures; 95% of ACLRs were performed in the outpatient setting in 2006, an increase from 43% in 1994.25 As the US health care system transitions toward valuebased care, there is an increased emphasis on understanding the cost drivers and high-value procedures within orthopaedics. Specifically, there is a focus on identifying high-volume procedures and determining the value provided by these interventions. ACLR is a high-volume procedure within orthopaedic sports medicine, and recent evidence suggests that increased attention is being paid to understanding the economics of ACLR surgeries. A recent systematic review by Nwachukwu et al37 of the cost-effectiveness analysis (CEA) literature on orthopaedic sports medicine procedures found 12 studies, 5 of which examined ACLR, and reported that the overall CEA literature in sports medicine is good although continued work is needed to quantify the cost-effectiveness of ACLR and other procedures within sports medicine. The prior review by Nwachukwu et al37 advanced our understanding of the cost-effectiveness of ACLR; however, there is still a need to understand the cost variables driving the economics of the procedure. In the past several decades, health care delivery structures have changed, and innovative delivery models such as outpatient versus inpatient centers of care for ACLR have received attention as a means of decreasing health care costs.8 Similarly, the efficacy and costs associated with different ACLR techniques have gained increased attention. There is an increasing economic analysis evidence base for ACLR; although this evidence may not be based on formal CEAs, it may provide valuable information to inform health care delivery models and reform. The goal of this review was to evaluate the overall evidence base for economic studies published on ACLR in the orthopaedic literature. We summarized the data available on the economics of ACLR and identified the cost drivers associated with the procedure.

METHODS Background on Economic Terms A thorough review of modalities for economic analysis in orthopaedic surgery has been previously published and is beyond the scope of this text.36 We briefly provide here a contextual background on relevant economic analyses in orthopaedic surgery. Value as defined in health care refers to outcomes achieved per dollar spent. As such, high-value interventions obtain excellent outcome with fewer dollars spent. Equating cost with outcome is essential to avoid cost rationing in health care. Cost utility analysis is the preferred modality in health care economics for analyzing and reporting the

value of an intervention. As part of cost utility analysis, health care interventions are evaluated on the basis of cost to achieve a utility (usually quality-adjusted life-year). Cost utility analyses are often generally referred to as costeffectiveness analyses; however, to be classified as a CEA, a study may not necessarily compare against a subjective patient outcome but may assess the cost required to avoid complications or adverse events (eg, infection or revision). Cost minimization analysis is another form of economic analysis wherein the costs required to undertake 2 health care interventions are compared and the intervention requiring less cost is chosen as the most cost-efficient alternative (ie, the intervention that best minimizes costs). However, to avoid cost rationing, cost minimization analysis has a strict requirement of parity in outcome among alternatives such that cost is the only factor taken into account. As such, cost minimization is rarely correctly applied and can be misleading.4 To capture economic studies attempting to tabulate cost of health care interventions without clearly falling into these predefined cost analysis groups, authors often use the term ‘‘cost identification.’’ We adopt this convention in this text. Cost identification analyses, similar to cost minimization analyses, identify costs associated with various interventions; however, it is understood in the nomenclature of the former that there is not necessarily parity in outcome between interventions. This distinction is important to highlight that cost identification analyses only weigh costs/economics and that comparative outcome assessment is not necessarily made among alternatives.

Overview and Eligibility Criteria for Review A thorough review of the literature was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with a PRISMA checklist.30 All economic studies (including US-based and non–US-based) published between inception of the MEDLINE database and October 3, 2014, were identified. The following inclusion criteria were used: (1) cost analysis was performed on the ACLR procedure; (2) the analysis used original, real data or was based on an economic model; (3) the study was clinically based and relevant to ACLR. To isolate the economic effect of ACLR, we excluded those analyses that did not report on ACLR-related cost values or perform a cost utilization analysis, nonclinical studies, and studies that included additional surgical intervention beyond ACLR.

Search Method for Identification of Studies and Data Collection The search method was similar to that used in previous publications of this genre.35,37,38 We used the PubMed interface to search the MEDLINE database after

*Address correspondence to Bryan M. Saltzman, MD, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, USA (email: [email protected]). y Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA. z St Louis Center for Cartilage Restoration and Repair Sports Medicine, St Louis, Missouri, USA. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.

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nonoperative treatment; and other unique comparisons reported in single studies, including computer-assisted navigation surgery (CANS) versus traditional surgery, early versus delayed ACLR, single- versus double-incision technique, and the costs of ACLR without comparison of variables.

RESULTS Overview of Included Studies

Figure 1. Study flow diagram. constructing an a priori search algorithm with the following search terms: ‘‘ACL,’’ ‘‘ACL reconstruction,’’ ‘‘anterior cruciate ligament,’’ ‘‘economic,’’ ‘‘cost,’’ ‘‘cost effectiveness,’’ ‘‘cost utility,’’ ‘‘cost benefit,’’ ‘‘cost minimization.’’ The search strategy identified 239 studies. Studies were included or excluded based on the aforementioned criteria after review of the study titles and abstracts. For studies with ambiguity regarding inclusionary status, the article was retrieved for further review. After review of these 239 studies, 24 total studies were identified as appropriate for inclusion in our study (Figure 1). In an effort to be certain that all potentially appropriate studies were identified in our initial search process, the PubMed ‘‘related citations’’ search function was used for each of the 24 identified studies, and all associated abstracts were thereafter reviewed. Manual search of the reference lists of included studies was also performed. This method identified 1 additional study that met the inclusion criteria for this study, and it was thus included in analysis. The related citations for this additional study were also reviewed, with no further studies identified. The full text of eligible studies was reviewed by 2 of the authors (B.M.S., G.L.C.) to extract data in duplicate from all studies using a standardized form created by the authors at the onset of the review. Inconsistencies between reviewers were resolved by joint review of the involved studies.

Data Synthesis and Qualitative Analysis of Studies All outcome variables reported in the included literature were extracted into the prespecified data extraction form. Given the heterogeneity of the existing evidence base, a qualitative, descriptive approach was used to assess the collective results from the economic studies on ACLR. When applicable, comparisons were made for the following cost-related variables associated with the procedure for economic implications: outpatient versus inpatient surgery (or outpatient vs overnight hospital stay vs .1-night stay); bone–patellar tendon–bone (BPTB) graft versus hamstring (HS) graft source; autograft versus allograft source; staged unilateral ACLR versus bilateral ACLR in a single setting; single- versus double-bundle technique; ACLR versus

A total of 24 studies were identified and included. Of these, 17 studies were cost identification analyses and were published between the years of 1995 and 2014.§ This included 5 studies1,6,7,15,31 directly comparing the costs associated with autograft and allograft ACLR, 2 studies3,10 comparing the costs associated with HS and BPTB ACLR, 5 studies3,8,18,20,33 directly comparing the costs associated with outpatient and inpatient ACLR, 2 studies17,21 comparing the costs associated with unilateral staged ACLR to bilateral ACLR in a single setting, 1 study26 comparing the costs associated with CANS ACLR and traditional surgical technique, 1 study34 directly comparing the costs associated with singleand double-bundle ACLR, 1 study32 comparing the costs associated with single- and double-incision ACLR, and 1 study24 evaluating the costs of ACLR without a comparison of variable groups. The sum of these studies being greater than 17 total comes from the fact that 1 study by Bonsell3 included multiple variable comparisons within ACLR. The remaining 7 studies5,9,12,14,28,29,39 published between 1999 and 2014 were cost utility analyses that used economic models to investigate the effect of variables such as the cost of allograft tissue, fixation devices, physical therapy, percentage and timing of revision surgery, and cost of revision surgery. These included 3 studies9,14,29 comparing the cost utility and cost efficacy of ACLR versus nonoperative (rehabilitation only) treatment, 2 studies5,39 comparing the cost utility and cost minimization of the single- versus double-bundle technique, 1 study28 comparing the cost utility of early versus delayed ACLR, and 1 study12 comparing the cost utility of autograft (BPTB and HS) versus allograft. Of these 24 studies, there were 3 studies with level 1 evidence, 8 with level 2 evidence, 6 with level 3 evidence, and 7 with level 4 evidence. Nineteen studies were from the United States, and the remaining studies came from the United Kingdom, Spain, France, Switzerland, and Sweden. Cohort sizes in the cost identification studies ranged from 20 to 525 patients. Figure 2 demonstrates the breakdown of cost determination focus, economic analysis perspective, and currency used in the included studies. Studies focused primarily on charge data or direct expenses (37.5%), were most often of the patient’s perspective in analysis (50.0%), and used the US dollar as currency (83.3%). Appendix Table A1 (available in the online version of this article at http://ajsm.sagepub.com/supplemental) demonstrates the specifics of the included economic studies on §

References 1, 3, 6-8, 10, 15, 17, 18, 20, 21, 24, 26, 31-34.

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Figure 2. Percentage of included articles by (A) cost determination, (B) analysis perspective, and (C) currency. Total percentages may add to more than 100% given that multiple cost determination methods and analysis perspectives may have been used in a single manuscript. ACLR, in addition to the breakdown of graft types, concomitant procedures, and location of ACLR procedure for these studies.

expensive than autograft ACLR ($4622 vs $5694) had lower associated costs (hospital, surgical center, pharmacy, anesthesia and anesthesia supply, and radiology) for allograft compared with autograft.

ACLR Versus Nonoperative Treatment BPTB Graft Versus HS Graft Source Three studies using economic modeling—all cost utility analyses—compared ACLR to nonoperative treatment with rehabilitation only, and each concluded that ACLR is the more cost-effective method for treatment of ACL tears (Appendix Table A2, available online). Mather et al29 reported lower mean total costs with ACLR in the short-term ($27,452 vs $32,276) and long-term ($38,411 vs $92,786) sensitivity analyses; results from Farshad et al9 of cost per quality-adjusted life-year (QALY) were $20,612 per QALY for ACLR and $23,391 per QALY for nonoperative treatment, with ACLR providing incremental effectiveness at a cost of $4890 per QALY.

Autograft Versus Allograft Source Five cost identification studies compared autograft and allograft. Four of these studies reported significantly lower total costs associated with use of autografts (range, $2983$4872) than with allografts (range, $4283-$5465) (Appendix Table A3, available online). The single cost utility analysis on this topic12 reported the greatest cost utility with HS autograft ($5373 per surgery), with greater costs per case from BPTB autograft ($207 per case more than HS autograft) and allograft ($1585 per case more than HS autograft). Sensitivity analyses suggested that with increased effectiveness of BPTB (decreased rates of instability and anterior knee pain), this procedure could become an incrementally cost-effective choice. Cost variables most commonly identified as influencing the economics of ACLR included operating room (OR) supply costs necessary for each case and allograft costs. Procedural costs did not appear to be significant (anesthesia costs, personnel costs, facility costs, and recovery room costs) and were similar between use of the 2 graft sources, as were the reoperation requirements and complication rates. The one study that found allograft ACLR to be less

The 2 studies using cost identification to compare HS to BPTB provided conflicting economic results (Appendix Table A4, available online). One of the studies found significantly lower procedural costs with BPTB ACLR (e197 vs e436 [$236.40 vs $523.20]), while the other study found significantly lower hospital charges with HS ACLR ($6444 vs $7459, and $565 less per case with HS).

Inpatient Versus Outpatient Surgery Of the 5 studies using cost identification analysis to evaluate outpatient and inpatient ACLR, the general consensus among all studies was that a significant cost reduction was obtained by performing the procedure in an outpatient setting compared with an inpatient setting (ie, postoperative hospitalization) (Appendix Table A5, available online). Outpatient ‘‘surgicenter’’ total charges were additionally significantly lower than those accompanying ACLR performed in the ‘‘main OR.’’ Total hospital charges with outpatient surgery ranged from £1111 to £6822 ($677.44 to $4159.76), whereas total charges for overnight hospitalization and longer than 1-postoperative day inpatient stay ranged from $7692 to $12,040 and $1329 to $13,503, respectively. The 4 studies that evaluated patient outcomes each concluded that outpatient ACLR was highly cost efficient, with high patient savings and maintained patient satisfaction, low reoperation requirements and complications, and adequate rehabilitation abilities.

Unilateral Versus Bilateral Procedure Two cost identification studies compared unilateral ACLR and bilateral ACLR, with both reporting bilateral ACLR as a safe, efficient, and cost-efficient option (Appendix Table A6, available online). Larson et al21 evaluated bilateral

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ACLR performed in a single setting in comparison with 2 unilateral ACLRs performed in 2 separate settings and reported that bilateral ACLR entailed significant total cost savings per knee of $3751.59; the investigators further noted savings in OR costs, surgeon costs, and rehabilitation costs of $1450.59, $490.68, and $546.72, respectively, per knee. This was in the context of similar postoperative length of physical therapy (PT) requirements, International Knee Documentation Committee (IKDC) knee scores, Lysholm knee scores, physical examination findings, and infectious complications. Jari and Shelbourne17 similarly reported the cost efficacy of bilateral versus unilateral knee ACLR. They reported total hospital costs of $4307 for ACLR on 1 knee and only a 55% increase in total hospital costs ($6687) for ACLR on both knees at the same time. Their postoperative narcotic use, time to return of full-time work and sports activity, and complication rate were not significantly different between the 2 cohorts.

Single- Versus Double-Bundle Technique Three cost identification studies and 2 cost utility analyses compared ACLR using single-bundle and double-bundle techniques (Appendix Table A7, available online). Nunez et al34 reported that while both techniques led to similarly successful outcomes (Short Form–36 scores) 2 years after ACLR, the single-bundle technique had appreciably lower total cost, OR cost, and implant cost with thus superior cost efficacy. Brophy et al5 used an economic model to investigate the effect of widespread conversion from the single- to the double-bundle technique. The authors reported additional total costs of up to $3962 per surgery with the double-bundle technique and substantial reductions in revision rates required to offset the increased costs. However, Paxton et al39 found through cost utility analysis that the double-bundle technique could be costeffective when utility gains measured by the IKDC scoring system were taken into account.

Unique Comparison Data The remaining 5 studies included 4 with cost identification analysis data (3 with unique cost comparisons within ACLR not shared among any other article, and a single article evaluating costs associated with ACLR without comparison of cohort groups) and a single cost utility analysis (Appendix Table A8, available online). Margier et al26 evaluated CANS versus traditional ACLR intraoperative techniques and found that total cost, OR cost, surgeon cost, and nursing cost were significantly higher with CANS despite equivalent success rates, postoperative radiographic laxity, subjective IKDC results, sports return, and complications, thus concluding against cost efficacy of the procedure with this evolving surgical guidance technique. Nogalski et al32 demonstrated lesser overall costs in terms of total charges, OR and ward charges, pharmacy charges, and PT charges with single (endoscopic)-incision ACLR compared with the double-incision technique. Lubowitz et al,24 looking at the cost efficacy of a cohort of 35 patients who underwent ACLR, reported a high cost

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efficacy for the procedure with cost per QALY of $10,326. Finally, Mather et al28 in a recent cost utility analysis found early ACLR to be more cost effective than delayed ACLR in terms of cost per QALY.

DISCUSSION Numerous economic analyses exist within the literature, and a number over the years have focused on ACLR given the procedure’s high incidence and potential to achieve cost savings. These analyses have proven that ACLR independently is a cost-effective option compared with nonoperative treatment of ACL tears. On the basis of the available evidence, the following variables potentially provide higher economic value: early ACLR instead of delayed surgery, single-bundle technique instead of double-bundle, singleincision technique instead of double-incision, outpatient setting instead of hospital admission, HS autograft instead of BPTB, and allograft and conventional procedural technique instead of CANS assisted. Identifying higher value variables will decrease health systems costs associated with ACLR while maintaining and maximizing patientoriented subjective and objective outcomes. In this study, we found that outpatient ACLR was associated with increased cost savings. Within orthopaedics there has been a trend toward more outpatient or ambulatory surgery.25 In the United States, 95% of ACLRs were performed in an outpatient setting in 2006, while in 1994 only 43% were performed in an ambulatory setting.25 As a whole within the United States, data from the National Survey of Ambulatory Surgery revealed an increase in the number of arthroscopic procedures on the knee of 49% between 1996 and 2006, and in 2006 more than 99% of arthroscopic procedures of the knee were performed in an outpatient setting. The authors reported an incidence of 127,446 ACLRs of the approximately 984,607 arthroscopic procedures performed on the knee in an outpatient setting in 2006. The debate regarding patient outcomes after single- versus double-bundle ACLR is ongoing. A recent randomized controlled trial comparing the 2 techniques and mid- to long-term follow-up found superior Lachman, pivot shift, and KT-1000 arthrometer measurement results with use of the double-bundle technique, although with no significant differences in range of motion, muscle strength, Lysholm score, subjective rating scale, graft retear, or secondary meniscal tear.19 A prospective randomized comparison of the 2 techniques by Sun et al,40 however, demonstrated better anterior and rotational stability and lower rates of arthritic progression and tunnel expansion with double-bundle ACLR than with the single-bundle procedure. A systematic review of overlapping meta-analyses on the comparison reported that the best current available evidence suggests that double-bundle ALCR provides superior postoperative knee stability, although clinical outcomes and risk for graft failure are similar between the 2 techniques.27 Thus, as research continues to evolve with regard to this variable in ACLR, updated cost-efficacy analyses will be valuable to determine whether the

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potentially increased efficacy benefits associated with the double-bundle procedure outweigh the higher costs incurred by hospitals and patients for the procedure. Traditionally, a double-incision technique has been used in ACLR, but more recently, in line with economic findings from Nogalski et al,32 the single-incision tibial endoscopic technique has been the focus of attention for its potential reduction in operative time and surgical morbidity.11 The double-incision technique has been proposed to allow the surgeon to freely position the femoral tunnel, thus obviating a more vertical and central nonanatomic femoral tunnel that may result in rotational instability that has been associated with many transtibial endoscopic crated femoral tunnels.23 Additionally, outcomes from the Hess et al16 study indicated improved dynamic muscle function with use of single-incision technique as compared with the double-incision technique due to avoidance of dissection into the vastus lateralis muscle. Graft choice in ACLR continues to be evaluated, as no single graft for all patient populations has been designated as the sole option from the standpoint of patient outcomes and satisfaction. The studies identified in this review suggest that autograft options are more cost saving given the cost associated with allografts and the highly satisfactory patient outcomes with autograft use. There is a relative paucity of evidence on this topic, with one cost utility analysis12 suggesting higher value associated with HS compared with BPTB. A systematic review by Li et al22 showed equivocal final results: The investigators reported significantly better pivot shift and trending toward a lower rate of graft failure with BPTB yet significantly less anterior and kneeling knee pain and extension loss with HS use. A systematic review by Xie et al41 reported superiority of BPTB in resuming stability of the knee joint and allowing return to higher activity levels, although BPTB had a higher postoperative complication rate than HS. Goldblatt et al13 demonstrated in their meta-analysis that the incidences of instability between BPTB and HS were not significantly different; however, BPTB resulted in more normal Lachman test, pivot-shift test, and KT1000 arthrometer findings and less flexion loss, and HS had reduced incidence of kneeling pain, extension loss, and patellofemoral crepitance. More work needs to be done to understand which intervention provides greater value and which patient populations may benefit the most from either graft choice. This review, however, has certain limitations. Foremost is that the heterogeneity between how cost data and patient outcomes were reported precluded pooling of the data and thus prevented a quantitative statistical analysis of the economic data on ACLR. Additionally, for several topics including CANS, single- or double-bundle, early or delayed ACLR, and single- or double-incision techniques, only a single economic analysis was present, thereby preventing us from providing a definitive recommendation of the economic effect of the variable. More economic and patient follow-up data on these variables within ACLR are required to provide a higher quality consensus on the utility of CANS or the aforementioned surgical techniques

from a cost perspective. As only a single cost identification analysis and a single cost utility analysis on the procedure were performed in 2014, updated critical economic CEA and cost utility analyses of ACLR are required to provide a more current view of the costs and outcomes of the procedure in a time with heightened focus on health care finances and pay-for-performance approaches.2 Further, this study does not capture the effect of indirect costs (ie, although a BPTB allograft is associated with more costs, this may be offset by an earlier return to work than a BPTB autograft). Indirect cost assessment in health care is typically measured through lost productivity and missed work days. None of the included studies assessed this cost element, and thus we are unable to provide indirect cost reporting. Finally, further economic evaluations of the costs of specific equipment used to perform ACLR are important, given that certain equipment can be very effective but also expensive.

CONCLUSION It has been increasingly established that ACLR can be a highly cost-effective intervention. Given the increasing use of this procedure, the goal of this study was to identify the cost variables associated with highest value in ACLR. Results from this review suggest that early single-bundle, single (endoscopic)-incision outpatient ACLR using either BPTB or HS autograft provides the most value. In the setting of bilateral ACL rupture, single-setting bilateral ACLR is more cost effective than staged unilateral ACLR. Procedures using CANS technology in ACLR do not yet yield superior results to standard surgical procedure, and CANS has substantially greater costs.

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Economic Analyses in Anterior Cruciate Ligament Reconstruction: A Qualitative and Systematic Review.

As the health care system in the United States (US) transitions toward value-based care, there is an increased emphasis on understanding the cost driv...
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