Comparison of four alternative national universal anterior cruciate ligament injury prevention program implementation strategies to reduce secondary future medical costs

Anterior cruciate ligament (ACL) injury is a common and devastating sporting injury. With or without ACL reconstruction, the risk of knee osteoarthritis (OA) and permanent disability later in life is markedly increased.

While neuromuscular training programmes can prevent 50–80% of ACL injuries, no national implementation strategies exist in Australia. The aim of this study was to compare the ability of four alternative national universal ACL injury prevention programme implementation strategies to reduce future medical costs secondary to ACL injury.

METHODS
A Markov economic decision model was constructed to estimate the value in lifetime future medical costs prevented by implementing a national ACL prevention programme among four hypothetical cohorts: high-risk sport participants (HR) aged 12–25 years; HR 18–25 years; HR 12–17 years; all youths (ALL) 12–17 years.

RESULTS
Of the four programmes examined, the HR 12–25 programme provided the greatest value, averting US$693 of direct healthcare costs per person per lifetime or US$221 870 880 in total. Without training, 9.4% of this cohort will rupture their ACL and 16.8% will develop knee OA. Training prevents 3764 lifetime ACL ruptures per 100 000 individuals, a 40% reduction in ACL injuries. 842 lifetime cases of OA per 100 000 individuals and 584 TKRs per 100 000 are subsequently averted. Numbers needed to treat ranged from 27 for the HR 12–25 to 190 for the ALL 12–17.

CONCLUSIONS
The HR 12–25 programme was the most effective implementation strategy. Estimation of the break-even cost of health expenditure savings will enable optimal future programme design, implementation and expenditure.

KEY FINDINGS

• A programme targeting 12–25 year olds participating in high-risk sports represents the optimal implementation strategy for an Australian national ACL prevention programme.
• Implementation of a national ACL prevention programme would prevent 40% of lifetime ACL injuries among this cohort.
• A reduction in ACL injuries among this cohort would provide a substantial cost saving to society by reducing the direct healthcare costs of treating ACL rupture and subsequent osteoarthritis.

How might it impact on clinical practice in the future?

• Defining approximate cost savings of a national youth sports injury prevention programme emphasises the potential benefit to society of programme implementation.
• Defining an optimum implementation strategy provides the opportunity to target a specific population of at-risk sports participants to maximise programme value.
• This study provides government sports and health policymakers with the information required to facilitate the provision of an important public musculoskeletal disease prevention intervention.

FUNDING

This research was funded by a grant from Knee Research Australia.

REFERENCE

Lewis, D.A., Kirkbride, B. (NSWIS), Vertullo, C.J, Gordon, L. & Comans, T. A. (2016). Comparison of four alternative national universal anterior cruciate ligament injury prevention programme implementation strategies to reduce secondary future medical costs. British Journal of Sports Medicine. Epub ahead of print.