Cost-effectiveness analysis of ambulatory versus in-patient ACL reconstruction surgery

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Authors (including presenting author) :
Chan KKY(1), Yip WH(1), Wong YB(1), Li W(1)
Affiliation :
Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital
Introduction :
Ambulatory orthopaedic surgery has been increasingly adopted worldwide, the advantages of which include its cost-effectiveness and hastened post-operative rehabilitation. However, local commitment to ambulatory lower limb orthopaedic surgery is still lacking. Since 2012, our department has started performing anterior cruciate ligament reconstruction (ACLR) in a day-surgery basis.
Objectives :
In this study, we determine the cost-effectiveness of ambulatory ACLR and compare it with in-patient ACLR, by calculating the quality adjusted life-years (QALY) gained after surgery among our patients.
Methodology :
Patients with ACLR done in the period of January 2012 to June 2013 were reviewed. They were divided into three groups of patients: (1) day surgery for ACLR (2) same day admission with one overnight stay and (3) in-patient stay of > two days. Minimum follow-up period was four years. Cases selected to undergo ambulatory ACLR are those of age < 35, without significant cardiopulmonary co-morbidies and with no co-existing knee pathologies that have to be addressed in the same operation. Principal outcome measures included functional scores pre-op and at four years post-op, quality-adjusted life years (QALYs) gained at four years post-op, average surgical cost and hospital charge, as well as the incremental cost-effectiveness ratio(as derived by QALYs gained) for each group. Surgical cost and hospital charges were calculated using the Hospital Authority published charge rates for non-entitled persons. Student t test was used to determine difference in continuous variables among the three groups.
Result & Outcome :
A total of 84 patients were included in our study: 31 patients in Group 1, 11 in Group 2 and 42 in Group 3. Average operating time for Group 1 cases was significantly shorter than that of Group 3, with no significant difference for post-op complications. None of the ambulatory cases (i.e. Group 1 or 2) require re-admission of any form. The monetary costs for both Groups 1 and 2 were both significantly lower than group 3. Regarding the surgical outcomes, the ambulatory ACLR cases did not differ significantly from in-patient cases at four years post-op in terms of knee functional scores. QALYs gained by ambulatory cases and in-patient cases at four years did not differ significantly (0.72 vs 0.65). Incremental cost-effectiveness ratio was thence proven to be significantly lower for the ambulatory ACLR groups. The monetary costs per QALY gained for our ambulatory cases were well below the US and UK funding threshold for cost-effective surgical procedures.

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