Outline. The development of a cost-effective intervention program the case of ankle injury. Ankle sprains & sports. Sequence of prevention

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The development of a cost-effective intervention program the case of ankle injury K Janssen, MDW Hupperets, EALM Verhagen, W van Mechelen,

ABBA, 2Bfit & ABrCt studies as examples Cost-effectiveness evaluation Ankle sprains & sports o one ankle sprain per 10,000 persons, each day o

post-injury o despite medical treatment: re-injury risk remains o preventive measures: only effective for history ankle sprain PREVIOUS ANKLE

1 The development of a cost-effective intervention program the case of ankle injury K Janssen, MDW Hupperets, EALM Verhagen, W van Mechelen, Amsterdam, the Netherlands Outline What is the problem? ABBA, 2Bfit & ABrCt studies as examples Cost-effectiveness evaluation Ankle sprains & sports o one ankle sprain per 10,000 persons, each day o some sports ankle sprains account for 50% of all injuries o annual Dutch costs: 71,500,000 o twofold risk for re-injury, first year post-injury o despite medical treatment: re-injury risk remains o preventive measures: only effective for history ankle sprain PREVIOUS ANKLE SPRAIN Sequence of prevention identify the magnitude of the problem: - incidence - severity identify aetiological factors and injury mechanism RCT evaluate effect introduce preventive measures Verhagen et al. Br J Sports Med 2004; 38(4):

Risk factor identification should lead to

followup randomization outcome regions B & D

vs. control Measurements baseline (September)

normal training routine group 48 group 41

group: normal training routine + balance

2 Risk factor identification should lead to risk reduction by intervention----> (R)CT followup randomization outcome regions B & D regions A & C target population intervention vs. control Measurements baseline (September) instruction & questionnaire training & game exposure injuries follow-up 1 (January) questionnaire booster visit control group: normal training routine group 48 group 41 follow-up 2 (May) questionnaire intervention group: normal training routine + balance board program Training program basic exercises Variations 3. Increasing difficulty 4. Warming-up No material Balance board Ball Ball & Balance Board 2

Acute injury incidence ABBA-STUDY RESULTS n Incidence n/1000 hours (SD) n Incidence n/1000 hours (SD) RD 95% CI Ankle 41 1.0 (0.3) 29 0.5 (0.2) 0.4 0.1 0.7 Knee 5 14 0.2 (0.1) -0.1-0.3 0.

Am J Sports Med 2004, 32: 1385-93 Is this intervention cost-effective? To fund or not to fund? is it worth the investment?

3 Acute injury incidence ABBA-STUDY RESULTS n Incidence n/1000 hours (SD) n Incidence n/1000 hours (SD) RD 95% CI Ankle (0.3) (0.2) Knee (0.1) Lower extr (0.2) (0.1) Back Shoulder (0.1) Upper extr (0.1) (0.2) Total (0.4) (0.4) Verhagen et al. Am J Sports Med 2004, 32: Is this intervention cost-effective? To fund or not to fund? is it worth the investment? Decision maker 5/20 2Bfit Study: objective Evaluate cost-effectiveness on ankle sprain recurrences of individual home-based proprioceptive training program used after rehabilitation & usual care treatment Design o Randomized led Trial o Recently sprained athletes between 12 & 70 years o Recruitment through ER, GP, PT and media o Randomization to intervention or control group after termination of usual care o Athletes were prospectively followed for 12 months 3

Flowchart recently sprained athletes Home-based training programme 12 months 522 recently sprained athletes Usual care group (n=25) group (n=2) Registration of ankle injuries and exposure

ankle injuries and exposure Group Population Mean (SD) Mean (SD) N 25 2 Age (yrs) 28. (11.8) 28.0 (11.) Weight (kg) 73.4 (13.3) 71.7 (13.0) Height (cm) 17.9 (9.9) 177.4 (9.

8%) Ankle sprain recurrences Differentiation according to severity grade: o Self-reported ankle sprains recurrences (Self) oankle sprain recurrences loss of sports time (Time) oankle sprain

50) 1.17 (0.82 1.52) 1.08 (0.74 1.42) o IDD = incidence density difference; RR = relative risk 1.04 (0.27 1.82) 0.5* (0.38 0.92) 0.79 (0.41 1.17) 0.3* (0.45 0.88) 0.53* (0.32 0.88) 0.25* (0.

4 Flowchart recently sprained athletes Home-based training programme 12 months 522 recently sprained athletes Usual care group (n=25) group (n=2) Registration of ankle injuries and exposure Training programme Unsupervised home-based proprioceptive training -8 weeks -3 times a week -Gradual increase in difficulty and training load -Recommended as part of warm-up Registration of ankle injuries and exposure Group Population Mean (SD) Mean (SD) N 25 2 Age (yrs) 28. (11.8) 28.0 (11.) Weight (kg) 73.4 (13.3) 71.7 (13.0) Height (cm) 17.9 (9.9) (9.5) Experience (yrs) 10.8 (8.8) 10.8 (8.0) Protective device N (%) N (%) Brace 47 (18.1%) 2 (23.0%) Tape 73 (28.2%) 4 (23.8%) Ankle sprain recurrences Differentiation according to severity grade: o Self-reported ankle sprains recurrences (Self) oankle sprain recurrences loss of sports time (Time) oankle sprain recurrences direct & indirect costs (Cost) Ankle sprain recurrence incidence Conclusions IDD RR Self 1.8 ( ) Time 0.5 ( ) Cost 0.29 ( ) Incidence (95% CI) 2.90 ( ) 1.17 ( ) 1.08 ( ) o IDD = incidence density difference; RR = relative risk 1.04 ( ) 0.5* ( ) 0.79 ( ) 0.3* ( ) 0.53* ( ) 0.25* ( ) o unsupervised home-based proprioceptive training, in addition to usual care, is effective in reducing recurrent ankle sprains o 2-fold reduction in ankle sprain recurrences for SRAS and TLAS o * denotes significant difference between intervention and control Hupperets et al. BMJ in press 4

Is this intervention cost-effective? To fund or not to fund? is it worth the investment? Costs (Euro s) per athlete (n=25) (n=2) Difference Decision maker 5/20 27.50-27.50 Direct Indirect Overall 5.

59) Costs (Euro s) per injured athlete (n=5) (n=89) Difference Incremental savings/injury: Euro 103 27.50-27.50 Direct 22.97 (0.7) 1.04 (129.34) 38.07* ( 74.29 to 2.

5 Is this intervention cost-effective? To fund or not to fund? is it worth the investment? Costs (Euro s) per athlete (n=25) (n=2) Difference Decision maker 5/ Direct Indirect Overall 5.02 (29.79) (132.81) 4.44 (155.50) (79.93) (804.9) (835.83) 15.40* ( to 5.48) 115.0* ( to 39.11) 102.9* ( to 22.59) Costs (Euro s) per injured athlete (n=5) (n=89) Difference Incremental savings/injury: Euro Direct (0.7) 1.04 (129.34) 38.07* ( to 2.29) Annual cost of recurrences: Euro 10 Million Indirect 3.1 (285.) (1,30.08) * ( to 4.19) Annual savings: Euro 3 Million Overall (324.78) (1,403.39) * ( to 2.3) Conclusions o unsupervised home-based proprioceptive training, in addition to usual care is effective in reducing recurrent ankle sprains Highly cost-effective intervention o 2-fold reduction in ankle sprain recurrences for SRAS and TLAS. Should change clinical practice o CAS: 3. higher in control athletes o detailed analysis: proprioceptive training specifically effective in non-medically treated athletes 5

Janssen et al. Janssen et al. BMC Musculoskeletal Disorders 2011, 12:210 (27 September 2011)

Janssen et al. Janssen et al. BMC Musculoskeletal Disorders 2011, 12:210 (27 September 2011) Ankles back in randomized controlled trial (ABrCt): braces versus neuromuscular exercises for the secondary prevention of ankle sprains. Design of a randomised controlled trial Janssen et al. Janssen et