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Clinical and cost-effectiveness of autologous chondrocyte implantation for cartilage defects in knee joints : systematic review and economic evaluation
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Clar, C., Cummins, E. (Ewen), McIntyre, Linda, Thomas, Sian, Lamb, J. (John D.), Bain, L. (Lynda), Jobanputra, Paresh and Waugh, Norman (2005) Clinical and cost-effectiveness of autologous chondrocyte implantation for cartilage defects in knee joints : systematic review and economic evaluation. Health Technology Assessment, Vol.9 (No.7). ISSN 1366-5278.
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Official URL: http://www.hta.ac.uk/execsumm/summ947.htm
Abstract
Objective: To support a review of the guidance issued
by the National Institute for Health and Clinical
Excellence (NICE) in December 2000 by examining the
current clinical and cost-effectiveness evidence on
autologous cartilage transplantation.
Data sources: Electronic databases.
Review methods: Evidence on clinical effectiveness
was obtained from randomised trials, supplemented by
data from selected observational studies for longer
term results, and for the natural history of chondral
lesions. Because of a lack of long-term results on
outcomes such as later osteoarthritis and knee
replacement, only illustrative modelling was done, using
a range of assumptions that seemed reasonable, but
were not evidence based.
Results: Four randomised controlled trials were
included, as well as observational data from case series.
The trials studied a total of 266 patients and the
observational studies up to 101 patients. Two studies
compared autologous chondrocyte implantation (ACI)
with mosaicplasty, the third compared ACI with
microfracture, and the fourth compared matrix-guided
ACI (MACI®) with microfracture. Follow-up was 1 year
in one study, and up to 3 years in the remaining three
studies. The first trial of ACI versus mosaicplasty found
that ACI gave better results than mosaicplasty at 1 year.
Overall, 88% had excellent or good results with ACI
versus 69% with mosaicplasty. About half of the
biopsies after ACI showed hyaline cartilage. The second
trial of ACI versus mosaicplasty found little difference in
clinical outcomes at 2 years. Disappointingly, biopsies
from the ACI group showed fibrocartilage rather than
hyaline cartilage. The trial of ACI versus microfracture
also found only small differences in outcomes at
2 years. Finally, the trial of MACI versus microfracture
contained insufficient long-term results at present, but
the study does show the feasibility of doing ACI by the
MACI technique. It also suggested that after ACI, it
takes 2 years for full-thickness cartilage to be
produced. Reliable costs per quality-adjusted life-year
(QALY) could not be calculated owing to the absence
of necessary data. Simple short-term modelling
suggests that the quality of life gain from ACI versus
microfracture would have to be between 70 and 100%
greater over 2 years for it to be more cost-effective
within the £20,000–30,000 per QALY costeffectiveness
thresholds. However, if the quality of life
gains could be maintained for a decade, increments
relative to microfracture would only have to be
10–20% greater to justify additional treatment costs
within the cost-effectiveness band indicated above.
Follow-up from the trials so far has only been up to
2 years, with longer term outcomes being
uncertain.
Conclusions: There is insufficient evidence at present
to say that ACI is cost-effective compared with
microfracture or mosaicplasty. Longer term outcomes
are required. Economic modelling using some
assumptions about long-term outcomes that seem
reasonable suggests that ACI would be cost-effective because it is more likely to produce hyaline cartilage,
which is more likely to be durable and to prevent
osteoarthritis in the longer term (e.g. 20 years).
Further research is needed into earlier methods of
predicting long-term results. Basic science research is
also needed into factors that influence stem cells to
become chondrocytes and to produce high-quality
cartilage, as it may be possible to have more patients
developing hyaline cartilage after microfracture. Study
is also needed into cost-effective methods of
rehabilitation and the effect of early mobilisation on
cartilage growth.
Item Type: | Journal Article | ||||
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Subjects: | R Medicine > RC Internal medicine | ||||
Divisions: | Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Health Sciences > Population, Evidence & Technologies (PET) > Warwick Evidence Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Health Sciences Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School |
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Library of Congress Subject Headings (LCSH): | Knee -- Wounds and injuries -- Treatment, Cartilage cells -- Transplantation | ||||
Series Name: | NHS R&D HTA Programme | ||||
Journal or Publication Title: | Health Technology Assessment | ||||
Publisher: | NIHR Health Technology Assessment programme | ||||
Place of Publication: | University of Southampton | ||||
ISSN: | 1366-5278 | ||||
Official Date: | 2005 | ||||
Dates: |
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Volume: | Vol.9 | ||||
Number: | No.7 | ||||
Number of Pages: | 49 | ||||
Status: | Peer Reviewed | ||||
Publication Status: | Published | ||||
Access rights to Published version: | Open Access (Creative Commons) | ||||
Date of first compliant deposit: | 22 December 2015 | ||||
Date of first compliant Open Access: | 22 December 2015 | ||||
Funder: | NIHR Health Technology Assessment Programme (Great Britain) |
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