In a recent study, published in The Journal of Bone & Joint Surgery, researchers found that ACL reconstruction results in more than $50,000 in savings per patient.
The savings generated by ACL surgery add up to an estimated lifetime societal savings of $10.1 billion each year in the United States. One of the study authors Richard Mather, MD, of Duke University Medical Center, shares insight into the study and what its results will mean for the field of orthopedic surgery.
Q: Why did you and the other authors of this study decide to focus on this issue?
Dr. Richard Mather: As our health system moves toward value-based care, payers and policymakers will make coverage decisions based on value. The most common reason poor decisions are made is failure to consider all relevant information.
We set out to ensure that decision-makers, including patients, had all relevant information on the costs and benefits of orthopedic treatments. The pain and dysfunction associated with musculoskeletal disease has a powerful impact on productivity and the ability to work. This impact had not been well quantified previously, but we knew this was a major part of the value equation and wanted to ensure it was better quantified.
In particular, we chose ACL tears as they occur in young people who have a long working life ahead of them. These are also very common, with over 200,000 being performed annually. Lastly, ACL tears are associated with an increased risk of developing osteoarthritis in the future. As such, better understanding the downstream impact of this injury will allow decision-makers to make efficient decisions regarding allocation of societal resources.
Q: Are the results of the study surprising to the orthopedic community?
RM: I think the results are surprising to some members of the orthopedic community. ACL tears are often felt to be a sports injury, and ACL reconstruction facilitates returning to sport primarily. However, this study demonstrated that the decreased knee-related quality of life caused by an ACL tear has substantial negative effects on productivity and employment. Initially, we performed a pilot study at Duke University Medical Center in the department of orthopedic surgery that demonstrated this effect.
It was surprising enough that we felt it was necessary to obtain higher quality data, which led us to collaborate with the Multicenter Orthopaedic Outcomes Network (MOON) and coauthor Kurt P. Spindler MD. This level I study of over 1,200 ACL reconstruction patients confirmed our initial findings. I also reviewed the subjective notes of the initial Duke cohort, and the patient descriptions of their functional limitations were substantial and matched the objective findings of the musculoskeletal value model.
Q: As orthopedic research continues to move forward, do you think surgical reconstruction will remain the most cost-effective treatment for ACL tears for the foreseeable future?
RM: Yes, I do. We continue to improve reconstruction techniques that more accurately replicate the normal anatomy with as little morbidity as possible. Additionally, we are learning more about how to modulate the biochemical environment present in the knee after an ACL tear. Lastly, while ACL reconstruction is more cost effective for the average patient and society, many individual patients can do well without surgery.
Simulations of our model demonstrate that some patients do better with surgery and some do better without surgery. However, those that needed surgery initially but didn't get it did the worst of any patient, with decreased quality of life and increased costs. The optimal cost effective solution lies in finding out how to predict which individuals need surgery and which do not. This is the premise of personalized medicine and is why many experts see personalized medicine as the next major frontier.
Q: What impact will the results of this study have on the field of orthopedics?
RM: This study demonstrates that the societal impact of ACL injuries is substantial and that we need to continue research to develop and discover solutions. Furthermore, it suggests that access to both surgical and non-surgical treatments for ACL tears should be protected. Lastly, as mentioned above, it demonstrates that no single treatment is best for all patients and that a personalized and customized approach offers the optimal solution.
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