title: Cost-effectiveness analysis of autologous chondrocyte implantation: a comparison of periosteal patch versus type I/III collagen membrane.
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.
  
  
  OBJECTIVE
  To examine the cost effectiveness of ACI and determine whether ACI-C is more cost effective than ACI-P.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, 981080 Nebraska Medical Center, Omaha, NE 68198-1080, USA. esamuels@unmc.edu
authors.forename: Eric M
authors.initials: EM
authors.lastname: Samuelson
authors.forename: David E
authors.initials: DE
authors.lastname: Brown
mesh_terms: D000328:Adult; D002358:Cartilage, Articular / Q000601:surgery; D019902:Chondrocytes / Q000637:transplantation*; D003094:Collagen / Q000191:economics / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D008297:Male; D010521:Periosteum / Q000637:transplantation*; D019057:Quality-Adjusted Life Years; D012189:Retrospective Studies; D014182:Transplantation, Autologous / Q000191:economics / Q000379:methods; D016896:Treatment Outcome; D014481:United States
chemical_list: D003094:Collagen