Pedro Diniz1,2,3,4, André Soares Ferreira5, Lígia Figueiredo6, Jorge Pablo Batista7, Nasef Abdelatif8, Hélder Pereira9,10,11, Gino M M J Kerkhoffs12, Stan N Finkelstein13,14, Frederico Castelo Ferreira15,16. 1. Department of Orthopaedic Surgery, Hospital de Sant'Ana, Rua de Benguela, 501, 2775-028, Parede, Lisbon, Portugal. pedro.diniz@scml.pt. 2. Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal. pedro.diniz@scml.pt. 3. Associate Laboratory i4HB, Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal. pedro.diniz@scml.pt. 4. Fisiogaspar, Lisbon, Portugal. pedro.diniz@scml.pt. 5. Department of Orthopaedic Surgery, Hospital de Sant'Ana, Rua de Benguela, 501, 2775-028, Parede, Lisbon, Portugal. 6. Clinical Department Club Atletico Boca Juniors, CAJB Centro Artroscopico, Buenos Aires, Argentina. 7. Head of Orthopedic Department, Dr Nasef OrthoClinic, Private Practice, Cairo, Egypt. 8. Orthopaedic Department, Centro Hospitalar Póvoa de Varzim, Vila Do Conde, Portugal. 9. Ripoll y De Prado Sports Clinic: FIFA Medical Centre of Excellence, Murcia/Madrid, Spain. 10. PT Government Associate Laboratory, University of Minho ICVS/3B's, Braga/Guimarães, Portugal. 11. Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam University Medical Centers, Amsterdam Collaboration for Health and Safety in Sports (ACHSS), Amsterdam, The Netherlands. 12. Institute for Data, Systems and Society, Massachusetts Institute of Technology, Cambridge, MA, USA. 13. Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA, USA. 14. Bioceramed - Cerâmicos para Aplicações Médicas S.A., Loures, Portugal. 15. Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal. 16. Associate Laboratory i4HB, Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal.
Abstract
PURPOSE: Current options for treating an Achilles tendon rupture (ATR) include conservative and surgical approaches. Endoscopic flexor hallucis longus (FHL) transfer has been recently proposed to treat acute ruptures, but its cost-effectiveness potential remains to be evaluated. Therefore, the objective of this study was to perform an early cost-effectiveness analysis of endoscopic FHL transfer for acute ATRs, comparing the costs and benefits of current treatments from a societal perspective. METHODS: A conceptual model was created, with a decision tree, to outline the main health events during the treatment of an acute ATR. The model was parameterized using secondary data. A systematic review of the literature was conducted to gather information on the outcomes of current treatments. Data related to outcomes of endoscopic FHL transfers in acute Achilles ruptures was obtained from a single prospective study. Analysis was limited to the two first years. The incremental cost-effectiveness ratio was the main outcome used to determine the preferred strategy. A willingness-to-pay threshold of $100,000 per quality-adjusted life-year was used. Sensitivity analyses were performed to determine whether changes in input parameters would cause significant deviation from the reference case results. Specifically, a probability sensitivity analysis was conducted using Monte Carlo simulations, and a one-way sensitivity analysis was conducted by sequentially varying each model parameter within a given range. RESULTS: For the reference case, incremental cost-effectiveness ratios exceeded the willingness-to-pay threshold for all the surgical approaches. Overall, primary treatment was the main cost driver. Conservative treatment showed the highest direct costs related to the treatment of complications. In the probabilistic sensitivity analysis, at a willingness-to-pay threshold of $100,000, open surgery was cost-effective in 50.9%, minimally invasive surgery in 55.8%, and endoscopic FHL transfer in 72% of the iterations. The model was most sensitive to parameters related to treatment utilities, followed by the costs of primary treatments. CONCLUSION: Surgical treatments have a moderate likelihood of being cost-effective at a willingness-to-pay threshold of $100,000, with endoscopic FHL transfer showing the highest likelihood. Following injury, interventions to improve health-related quality of life may be better suited for improved cost-effectiveness. LEVEL OF EVIDENCE: Level III.
PURPOSE: Current options for treating an Achilles tendon rupture (ATR) include conservative and surgical approaches. Endoscopic flexor hallucis longus (FHL) transfer has been recently proposed to treat acute ruptures, but its cost-effectiveness potential remains to be evaluated. Therefore, the objective of this study was to perform an early cost-effectiveness analysis of endoscopic FHL transfer for acute ATRs, comparing the costs and benefits of current treatments from a societal perspective. METHODS: A conceptual model was created, with a decision tree, to outline the main health events during the treatment of an acute ATR. The model was parameterized using secondary data. A systematic review of the literature was conducted to gather information on the outcomes of current treatments. Data related to outcomes of endoscopic FHL transfers in acute Achilles ruptures was obtained from a single prospective study. Analysis was limited to the two first years. The incremental cost-effectiveness ratio was the main outcome used to determine the preferred strategy. A willingness-to-pay threshold of $100,000 per quality-adjusted life-year was used. Sensitivity analyses were performed to determine whether changes in input parameters would cause significant deviation from the reference case results. Specifically, a probability sensitivity analysis was conducted using Monte Carlo simulations, and a one-way sensitivity analysis was conducted by sequentially varying each model parameter within a given range. RESULTS: For the reference case, incremental cost-effectiveness ratios exceeded the willingness-to-pay threshold for all the surgical approaches. Overall, primary treatment was the main cost driver. Conservative treatment showed the highest direct costs related to the treatment of complications. In the probabilistic sensitivity analysis, at a willingness-to-pay threshold of $100,000, open surgery was cost-effective in 50.9%, minimally invasive surgery in 55.8%, and endoscopic FHL transfer in 72% of the iterations. The model was most sensitive to parameters related to treatment utilities, followed by the costs of primary treatments. CONCLUSION: Surgical treatments have a moderate likelihood of being cost-effective at a willingness-to-pay threshold of $100,000, with endoscopic FHL transfer showing the highest likelihood. Following injury, interventions to improve health-related quality of life may be better suited for improved cost-effectiveness. LEVEL OF EVIDENCE: Level III.
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