# Cost-utility analysis of early reconstruction surgery versus conservative treatment for anterior cruciate ligament injury in a lower-middle income country

## TL;DR

The study compares the cost-effectiveness of early ACL reconstruction surgery versus conservative treatment for ACL injuries in Indonesia, finding conservative treatment more cost-effective.

## Contribution

This study provides a cost-utility analysis specific to a lower-middle income country, Indonesia, for ACL injury treatment strategies.

## Key findings

- Early ACLR surgery had an ICER of US$19,524 per QALY, exceeding the WTP threshold of US$12,876.
- Conservative treatment had a 64% probability of being preferred over early ACLR based on the model.

## Abstract

The ideal approach for treating anterior cruciate ligament (ACL) injury is still disputed. This study aimed to determine the more cost-effective strategy by comparing early ACL reconstruction (ACLR) surgery to conservative treatment (rehabilitation with optional delayed reconstruction) for ACL injury in a lower/middle-income country (LMIC), Indonesia.

A decision tree model was constructed for cost-utility analysis of early ACLR versus conservative treatment. The transition probabilities between states were obtained from the literature review. Utilities were measured by the EQ-5D-3 L from a prospective cohort study in a local hospital. The costs were obtained from a previous study that elaborated on the burden and cost of ACLR in Indonesia. Effectiveness was expressed in quality-adjusted life years gained (QALYs). Principal outcome measure was the incremental cost-effectiveness ratios (ICER). Willingness-to-pay was set at US$12,876 — three times the Indonesian GDP per capita in 2021 — the currently accepted standard in Indonesia as suggested by the World Health Organization Choosing Interventions that are Cost-Effective criterion (WHO-CHOICE).

The early ACLR group showed an incremental gain of 0.05 QALYs over the conservative treatment group, with a higher overall cost to society of US$976. The ICER of ACLR surgery was US$19,524 per QALY, above the WTP threshold of US$12,876. The ICER was sensitive to cost of conservative treatment, cost of ACLR, and rate of cross-over to delayed ACLR numbers in the conservative treatment group. Using the WTP threshold of US$12,876, the probability of conservative treatment being preferred over early ACLR was 64%.

Based on the current model, early ACLR surgery does not seem more cost-effective compared to conservative treatment for ACL injury patients in Indonesia. Because the result was sensitive to the rate of cross-over probabilities from the conservative treatment alone to delayed ACLR, a future study with a long-term perspective is needed to further elucidate its impact.

The online version contains supplementary material available at 10.1186/s12913-024-11212-8.