Cost-Effectiveness Analysis of Autologous Chondrocyte Implantation

Abstract

Background: Autologous chondrocyte implantation (ACI) involves the use of a periosteal patch (ACI-P) as a cover for transplanted chondrocytes. Theoretically, this periosteal patch provides mesenchymal stem cells and growth factors that encourage chondrocyte development/differentiation. However, there is a significant rate of graft hypertrophy with the use of periosteum compared with using a type I/III collagen patch (ACI-C). This type I/III collagen patch, although not approved by the United States Food and Drug Administration for ACI, has been used extensively in Europe and in an “off-label” nature in the United States as a cover during ACI. Purpose: To examine the cost effectiveness of ACI and determine whether ACI-C is more cost effective than ACI-P. Study Design: Economic and decision analysis; Level of evidence, 2. Methods: Outcome data and complication rates from patients undergoing ACI (ACI-P and ACI-C) were derived from the best evidence in the literature. Costs were determined by examining the typical patient charges undergoing ACI at a local orthopaedic hospital. The costs, results, and complication rates were used to develop a decision analysis model comparing ACI-P to ACI-C. Results: The cost of ACI-P was $66,752 and for ACI-C was $66,939.50 ($187.50 difference). The cost per quality-adjusted life year (QALY) for ACI-P was $9466 compared with $9243 for ACI-C. Sensitivity analysis was performed regarding the additional cost of the type I/III collagen patch ($780) in ACI-C as well as the rate of graft hypertrophy after ACI-P (25%). This analysis revealed that the cost of the type I/III collagen patch would have to reach $1721, or the rate of graft hypertrophy after ACI-P reduced to almost 11%, before ACI-P became more cost effective than ACI-C. Conclusion: This cost-effectiveness analysis reveals that, while both ACI-P and ACI-C are cost effective, ACI-C is slightly more cost effective than ACI-P. This is likely secondary to the significant rate of patch-related complications associated with ACI-P, which is significantly reduced with ACI-C. Although the model is very sensitive to differences in outcomes between ACI-P and ACI-C, there is no high-quality evidence to suggest that there is a significant difference between the two. Thus, ACI-P becomes more cost effective if the cost of the type I/III collagen membrane is significantly increased or if the rate of graft hypertrophy after ACI-P were to be markedly reduced.

Autologous chondrocyte implantation in the knee: systematic review and economic evaluation

“…One study was a cross-sectional retrospective study (Derrett 2005 140 ) and the other three studies were decision-analytical modelling studies by Gerlier et al, 141 Samuelson et al 142 and Koerber et al 143 The Derrett study 140 was conducted in the UK, and the other three studies [141][142][143] were based on literature and some trial data from Belgium, Germany and the USA. Three studies assessed the cost-effectiveness of ACI compared with other interventions: mosaicplasty (Derrett 2005 140 ); MF (Gerlier 2010 141 ); mosaicplasty and MF with different versions of ACI (ACI-C, ACI-P and MACI) (Koerber 2013 143 ).…”

“…Three studies assessed the cost-effectiveness of ACI compared with other interventions: mosaicplasty (Derrett 2005 140 ); MF (Gerlier 2010 141 ); mosaicplasty and MF with different versions of ACI (ACI-C, ACI-P and MACI) (Koerber 2013 143 ). Samuelson et al 142 compared ACI-C with ACI-P to see whether or not it was more cost-effective.…”

“…43 Samuelson et al 142 compared adult patients with a mean age of 30 years with a focal chondral injury which satisfied the conditions for an ACI repair.…”

“…The economic model by Gerlier et al 141 used two time horizons: a short-term time horizon of 5 years to take into account knee pain and mobility after the initial intervention (this information was obtained from a 5-year RCT that compared ACI with ChondroCelect and MF) and a long-term time horizon of 40 years to take into account the development of OA after 15 years and the need for a TKR after 20 years. Samuelson et al 142 based their model on a 10-year time horizon that corresponded with the longest-term evidence that was available in the literature. Koerber et al 143 stated that on the basis of the German life expectancy of the patients in the model the time frame was set to 47 years.…”

“…Although the authors did not explicitly state the cycle length -from the information provided this can be deduced as 1 year. Neither Gerlier et al 141 nor Samuelson et al 142 reported the cycle length that was used in the model, and none of the three studies applied a half-cycle correction to the economic models.…”