Health-economic evaluation of meniscus tear treatments: a systematic review

This systematic review was reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. It was registered in PROSPERO (Registration number: CRD42021262185). All economic studies published on PubMed and Embase databases were identified up to 30 April 2022. The following inclusion criteria were used: (1) cost analysis was performed on the meniscus tear’s treatment procedure; (2) based on either an economic model or a trial; and (3) clinical relevance to meniscus treatment. Analyses that did not report meniscus treatment-related cost values were excluded from the review. Studies issued as commentary, editorials, research protocols, and reviews, and studies not written in English were excluded.

A systematic search was conducted in two major electronic databases, PubMed and EMBASE. The references of the included studies were then reviewed to expand the search further and identify relevant publications. The search had no limitation for date of publication.

The search strategy was developed using the patient/population, intervention, comparison and outcomes (PICO) approach, which includes thesaurus and accessible terms related to or describing the condition and outcome. The PICO model was selected for its known relevance to defining clinical questions based on patients’ specific problems and the research question.

After reviewing the titles and abstracts, studies were included or excluded based on the inclusion criteria. Next, the full text was retrieved for further review for studies needing further inquiry into their inclusion status. Two authors (RD and MD) reviewed the full text of eligible studies for further data extraction. Review inconsistencies were resolved by joint review and consensus between reviewers.

All outcome variables reported in the included studies were extracted into the pre-specified data extraction form. Given the heterogeneity of the existing evidence, a qualitative, descriptive approach was used to assess the pooled results from the economic studies on meniscus treatment. The economic evaluation method of each included study was categorized into one of four approaches based on the availability of (1) comparison of two or more alternative interventions and (2) comparison of the costs and effects of the treatments in each study. The types of economic evaluations are partial economic evaluation (PEE), cost-effectiveness analysis (CEA), cost–benefit analysis (CBA), and cost-utility analysis (CUA) [10]. PEE measures disease cost without intervention comparison and does not relate costs to outcome. The costs of each treatment are analyzed straightforwardly in terms of monetary costs, assuming equal health outcomes for each intervention. CEA estimates the outcomes expressed in a natural health unit, such as number of patients with clinical improvement, cures, and life-years gained. The results of such comparisons may be stated either in terms of incremental cost per unit of effect. CBA measures and compares each intervention in terms of benefit and cost, all aspects expressed in monetary units. The results of CBA express the consequences of an intervention in monetary terms in order to facilitate comparison to program costs. CUA–often the preferred technique–measures and compares each intervention in terms of cost and utilities, indicating preferences for health outcomes using a generic measure of health gain, synthesized in cost per quality-adjusted life-year (QALY) [10, 11].

Regarding financial implications, comparisons were made for the following cost-related variables associated with the procedure: meniscus repair, arthroscopic partial meniscectomy (meniscectomy), physical therapy, non-operative treatment, meniscus allograft transplantation, meniscus scaffold, and other unique comparisons reported in a single study. Further, the type of meniscus tears behind these procedures was also classified as either reparable or irreparable meniscus tears. Costs included in this systematic review were converted to 2020 US dollars ($) using CCEMG-EPPI-Centre Cost Converter v.1.6 (accessible online at https://​eppi.​ioe.​ac.​uk/​costconversion/​), as suggested by Mastrigt et al. [11, 12].

A narrative data synthesis was performed by presenting all findings in summative form, including tables and figures. Primary outcomes were the average costs, effectiveness, and incremental cost-effectiveness ratio (ICER). Secondary outcome was the type of economic evaluation and the specificities of each study.

The CHEC list, which comprises 19 questions, was used to investigate the methodological quality of the economic studies by two independent reviewers (DI and AK). Each question is assigned either a “yes” or “no”. The two reviewers evaluated the papers and confirmed or disconfirmed compliance with each assessment question. Any disagreement was resolved by a joint review and consensus between reviewers. Each question in the CHEC list was rated with three possible answers: N = no, with no points; U = unclear, with half a point; and Y = yes, with one point. As the CHEC list does not define the summary scores specifically, we defined the score limits for the methodological quality of the studies; a total score ≥ 14.5 was considered a high-quality economic evaluation, a total score of 10–14 a moderate-quality economic evaluation, and a score < 10 a low-quality evaluation [8, 11, 13]. The agreement levels of interobserver assessment were determined by kappa value.

Statistical analyses were performed using SPSS Statistics version 26.0 (IBM).

The search strategy identified 473 studies; after review of these initially selected studies, 16 were considered eligible for inclusion in our study (Fig. 1).

The general characteristics of the included studies are presented in Table 1. A total of 16 studies were identified and included; six performed PEEs [7, 14‐18], seven CUAs [6, 19‐24], two CEA [25, 26], and one study performed a CUA, CEA, and CBA simultaneously [12]. Five studies compared meniscus repair vs meniscectomy [6, 7, 19, 20, 22], three studies compared costs of meniscectomy vs non-operative treatment [14, 17, 24], two studies compared physical therapy with delayed meniscectomy vs early meniscectomy [12, 21], two studies directly compared the costs of having vs not having physical therapy after a meniscectomy [15, 16], three studies investigated meniscus transplantation, and one study compared costs associated with conventional arthroscopic instruments vs laser-assisted treatment in meniscectomy [18].

The included studies varied geographically; 11 studies were conducted in the United States [6, 7, 14, 17‐22, 25, 26], three studies in the Netherlands [12, 23, 24], and two in the United Kingdom [15, 16].

Methodological quality of the studies was assessed using the CHEC list and is displayed in Table 2. CHEC scores of the included studies ranged from 8 to 19. Agreement levels of interobserver assessment ranged from − 0.09 to 1 of kappa value. The entire agreement of each point of CHEC is reported in Appendix Table A 1–2.

Five studies compared meniscus repair vs meniscectomy. Two studies performed a direct comparison [6, 7], one study with additional non-operative treatment after medial meniscus root tears [19], one in the setting of ACL reconstruction [20], and another specifically involving red–red zone repair or meniscectomy [22]. In a large database study, Sochacki et al. [7] found that a meniscus repair costs more than a meniscectomy ($7,680 vs $5,871). However, the other four studies showed meniscus repair to be a more cost-effective treatment: Feeley et al. [6] compared meniscus repair vs meniscectomy (ICER $806/QALY vs $975/QALY), Faucett et al. [19] compared the treatment of meniscus root tear cases between meniscus repair, meniscectomy, and non-operation (ICER $3,483/QALY vs $5,127/QALY vs $3,969/QALY), Rogers et al. [22] compared isolated meniscus repair vs meniscectomy for the red–red zone (ICER $1,185/QALY vs $2,362/QALY), and Lester et al. [20] compared meniscus repair vs meniscectomy in the setting of anterior cruciate ligament reconstruction (ICER $1,056/QALY vs $1,533/QALY).

Three studies compared meniscectomy vs non-operative treatment, two using PEE [14, 17] and one using CUA [24]. The two studies agreed that meniscectomy generated more cost than not operating ($3,993 vs $427, and $4,740 vs $1,862, respectively) [14, 17]. In addition, Rongen et al. [24] showed the result of ICER $3,574/QALY vs $2,740/QALY between meniscectomy and non-operative treatment.

Of the studies that compared early meniscectomy vs physical therapy with delayed meniscectomy, one examined patient with a non-obstructive meniscus tear [12]; one investigated patient with a meniscus tear in knee osteoarthritis [21]. Van de Graaf, et al. concluded that early meniscectomy was less cost-effective than physical therapy with delayed meniscectomy (ICER $83,047/QALY), with non-inferiority margins of 0.89 for QALY [12]; and Losina, et al. found that early meniscectomy was less cost-effective than physical therapy with optional delayed meniscectomy (ICER $116,320/QALY) [21].

Two PEE studies investigated physical therapy after meniscectomy [15, 16]. One stated that the mean cost per patient of providing outpatient physical therapy was $120 [15], the other compared the cost incurred by the group that had physical therapy with the group that did not ($3,906 vs $3,576) [16].

Two studies discussed meniscus allograft transplantation [25, 26], one demonstrating that it needs to be approximately one-third more effective in delaying osteoarthritis in previously meniscectomized knees to be cost-effective and stating that the mean costs of meniscus allograft transplantation are higher than those of non-operative treatment ($8,714 vs $3,061, respectively) [25]. The other study stated that meniscus allograft transplantation had been shown to reduce pain and improve function in patients with a discoid lateral meniscus tear and postponed total knee arthroplasty (TKA) rate for more years than meniscectomy, yet a meniscus allograft transplantation is more costly than meniscectomy ($16,007 vs $11,538, respectively) [26]. One study on CUA compared the cost-effectiveness of meniscus scaffold vs meniscectomy, showing that meniscus scaffold was less cost-effective than meniscectomy both for a lifetime (ICER $73,445/QALY) and for a five-year period (ICER $401,492/QALY) [23].

One PPE study discussing conventional instruments vs laser-assisted meniscectomy concluded that conventional meniscectomy was recommended for routine intervention as the cost was lower ($1,796 vs $2,503, respectively) [18]. The results of the included studies are presented in Table 3.