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Hong M, Krauss J, Wang G, Cohen K, Chaisson CE, Gulati A. Effectiveness of Hybrid Form Impulse Therapy (HFIT) Compared to Traditional Transcutaneous Electronic Nerve Stimulation (TENS) in Patients with Chronic Low Back and Knee Pain: A Randomized Controlled Trial. J Pain Res 2024; 17:2417-2430. [PMID: 39050679 PMCID: PMC11268852 DOI: 10.2147/jpr.s461343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 07/03/2024] [Indexed: 07/27/2024] Open
Abstract
Purpose Physical therapy (PT) and conservative care are recommended first-line treatments for musculoskeletal (MSK) pain. While essential to high-quality care, these solutions often do not provide immediate or sufficient pain relief. Traditional transcutaneous electronic nerve stimulation (TENS) devices are often recommended; however, there is mixed evidence behind their effectiveness. A novel approach called hybrid form impulse therapy (HFIT) incorporates a priming pulse with a traditional TENS pulse width and frequency. This randomized controlled trial (RCT) aimed to compare the effectiveness of HFIT versus traditional TENS versus usual care among members of a digital MSK program. Patients and Methods A three-arm RCT comparing HFIT versus TENS versus usual care was conducted. A total of 325 people with chronic back or knee pain who were members of a digital MSK program consisting of PT-guided exercise therapy, education, and coaching were randomized. Outcomes including pain, function, anxiety, and depression were examined at 1, 2, and 4 weeks (primary endpoint). Engagement was measured through exercise therapy (ET) sessions completed. Unadjusted and adjusted logistic generalized estimating equations were conducted. Results Adjusted per-protocol results at 4 weeks showed significantly lower odds of achieving pain improvement for both TENS (OR: 0.42, 95% CI: [0.19, 0.92]) and usual care (OR: 0.35, 95% CI: [0.17, 0.72]) groups, compared to HFIT group. Both HFIT and usual care users had significantly higher engagement than the TENS users (p=0.026 and p=0.002, respectively). No adverse events were reported throughout the study. Conclusion More participants of a digital MSK program who were randomized to the HFIT group experienced meaningful pain improvement at 4 weeks than participants who used TENS and usual care. HFIT can be an effective, non-pharmaceutical solution for relief as a complement to first-line treatments for patients with chronic back and knee pain.
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Affiliation(s)
| | | | | | - Ken Cohen
- Optum Care Center for Research and Innovation, Eden Prairie, MN, USA
| | | | - Amitabh Gulati
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Ranawat A, Guo K, Phillips M, Guo A, Niazi F, Bhandari M, Waterman B. Health Economic Assessments of Hyaluronic Acid Treatments for Knee Osteoarthritis: A Systematic Review. Adv Ther 2024; 41:65-81. [PMID: 37899384 DOI: 10.1007/s12325-023-02691-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 09/19/2023] [Indexed: 10/31/2023]
Abstract
INTRODUCTION Hyaluronic acid (HA) use to treat knee osteoarthritis (OA) has been extensively investigated in the literature. There are also multiple economic assessments comparing intra-articular HAs with oral anti-inflammatory medicines and other conservative measures (NSAIDs), as well as different types and formulations of HA. Owing to the broad landscape of evidence across this area, it is important to further understand the empirical data comparing HA products, as well as the health economic implications that exist between commercially available HAs. This systematic review aims to identify and summarize the available evidence comparing commercially available HA products in the USA, as well as the health economic evidence and socioeconomic outcomes associated with HA use for knee OA. METHODS A systematic literature review within the OVID Medline, Embase, HealthStar, and Cochrane EBM HTA databases was conducted. Articles were screened for eligibility, and a qualitative summary of the findings was provided based on specific themes: (1) trials comparing the safety and/or efficacy of two or more HA products in knee OA, (2) economic/cost analyses of HA use in knee OA, and (3) studies investigating healthcare resource utilization in patients treated with HA for knee OA. RESULTS The search strategy identified 398 studies, 27 of which were deemed eligible: 21 health economic analyses with US relevance and six head-to-head trials of HA products available in the USA, cumulatively assessing 5,782,156 patients with knee OA. The evidence demonstrates a clear distinction between high and low molecular weight HAs, as both efficacy and cost analyses provided favorable results for the high molecular weight options. In all but one cost analysis, HA use was a cost-effective option when compared to routine nonoperative care, captured in administrative databases, which typically included NSAID use and/or corticosteroids. HA saw benefits in delaying the need for total knee arthroplasty (TKA), decreasing the use of rescue medication, and limiting the need for additional corticosteroid injection. The included evidence highlights that the treatment's cost-effectiveness is improved when HA is utilized in earlier stages of the disease, as opposed to when HA is reserved for late stages of knee OA. Additionally, among HAs, Bio-HA and Hylan G-F 20 evidence made up the majority of available literature with beneficial efficacy and cost outcomes. Head-to-head evidence between them indicated similar pain outcomes; however, Bio-HA required less rescue with acetaminophen and had fewer joint effusions in this comparison. CONCLUSIONS The available efficacy and safety data as well as health economic analyses on the use of HA for knee OA management suggest that there are economic benefits of this treatment option. From a healthcare system perspective, the body of HA literature summarizes favorable costs profile, decreased opioid and corticosteroid use as rescue medication, and a delay to the need for TKA in patients who have HA included in their treatment regimen.
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Affiliation(s)
- Anil Ranawat
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Kaiwen Guo
- Ferring Pharmaceuticals, Inc., Parsippany, NJ, USA.
| | - Mark Phillips
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Amy Guo
- Ferring Pharmaceuticals, Inc., Parsippany, NJ, USA
| | - Faizan Niazi
- Ferring Pharmaceuticals, Inc., Parsippany, NJ, USA
| | - Mohit Bhandari
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Brian Waterman
- Department of Orthopaedics, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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Jin X, Liang W, Zhang L, Cao S, Yang L, Xie F. Economic and Humanistic Burden of Osteoarthritis: An Updated Systematic Review of Large Sample Studies. PHARMACOECONOMICS 2023; 41:1453-1467. [PMID: 37462839 DOI: 10.1007/s40273-023-01296-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE A previous systematic literature review demonstrated a significant economic and humanistic burden on patients with osteoarthritis (OA). The aim of this study was to systematically review and update the burden of OA reported by large sample studies since 2016. METHODS We searched Medline (via Ovid) and Embase using the updated search strategy based on the previous review. Those studies with a sample size ≥ 1000 and measuring the cost (direct or indirect) or health-related quality of life (HRQL) of OA were included. Pairs of reviewers worked independently and in duplicate. An arbitrator was consulted to resolve discrepancies between reviewers. The Kappa value was calculated to examine the agreement between reviewers. All costs were converted to 2021 US dollars according to inflation rates and exchange rates. RESULTS A total of 1230 studies were screened by title and abstract and 159 by full text, and 54 studies were included in the review. The Kappa value for the full-text screening was 0.71. Total annual OA-related direct costs ranged from US$326 in Japan to US$19,530 in the US. Total annual all-cause direct costs varied from US$173 in Italy to US$41,433 in the US. The annual indirect costs ranged from US$736 in the US to US$18,884 in the Netherlands. Thirty-four studies reported HRQL, with EQ-5D (13, 38%) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (6, 18%) being the most frequently used instruments. The EQ-VAS and utility scores ranged from 41.5 to 81.7 and 0.3 to 0.9, respectively. The ranges of WOMAC pain (range 0-20, higher score for worse health), stiffness (range 0-8), and physical functioning (range 0-68) were 2.0-3.0, 1.0-5.0, and 5.8-42.8, respectively. CONCLUSION Since 2016, the ranges of direct costs of OA became wider, while the HRQL of patients remained poor. More countries outside the US have published OA-related disease burden using registry databases.
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Affiliation(s)
- Xuejing Jin
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, China
| | - Wanxian Liang
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, China
| | - Lining Zhang
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, China
| | - Shihuan Cao
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, China
| | - Lujia Yang
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, China
| | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact (formerly Clinical Epidemiology and Biostatistics), Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
- Centre for Health Economics and Policy Analysis, Faculty of Health Sciences, McMaster University, 1280 Main Street West, Hamilton, ON, Canada.
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Tong X, Wang Y, Dong B, Li Y, Lang S, Ma J, Ma X. Effects of genus Epimedium in the treatment of osteoarthritis and relevant signaling pathways. Chin Med 2023; 18:92. [PMID: 37525296 PMCID: PMC10388486 DOI: 10.1186/s13020-023-00788-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/25/2023] [Indexed: 08/02/2023] Open
Abstract
Osteoarthritis (OA) is a common chronic degenerative joint disease in clinical practice with a high prevalence, especially in the elderly. Traditional Chinese Medicine (TCM) believes that OA belongs to the category of "Bi syndrome" and the "bone Bi syndrome". The etiology and pathogenesis lie in the deficiency of the liver and kidney, the deficiency of Qi and blood, and external exposure to wind, cold, and dampness. Epimedium is a yang-reinforcing herb in TCM, which can tonify the liver and kidney, strengthen muscles and bones, dispel wind, cold and dampness, and can treat both the symptoms and the root cause of "bone Bi syndrome". In addition, Epimedium contains a large number of ingredients. Through modern science and technology, more than 270 compounds have been found in Epimedium, among which flavonoids are the main active ingredients. Therefore, our study will review the effects and mechanisms of genus Epimedium in treating OA from two aspects: (1) Introduction of Epimedium and its main active ingredients; (2) Effects of Epimedium and its active ingredients in treating OA and relevant signaling pathways, in order to provide more ideas for OA treatment.
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Affiliation(s)
- Xue Tong
- Orthopaedics Institute of Tianjin, Tianjin Hospital, Tianjin, China
- School of Integrative Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Tianjin Hospital, Tianjin University, Tianjin, China
| | - Yan Wang
- Orthopaedics Institute of Tianjin, Tianjin Hospital, Tianjin, China
- Tianjin Hospital, Tianjin University, Tianjin, China
| | - Benchao Dong
- Orthopaedics Institute of Tianjin, Tianjin Hospital, Tianjin, China
- Tianjin Hospital, Tianjin University, Tianjin, China
| | - Yan Li
- Orthopaedics Institute of Tianjin, Tianjin Hospital, Tianjin, China
- Tianjin Hospital, Tianjin University, Tianjin, China
| | - Shuang Lang
- Orthopaedics Institute of Tianjin, Tianjin Hospital, Tianjin, China
- School of Integrative Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Tianjin Hospital, Tianjin University, Tianjin, China
| | - Jianxiong Ma
- Orthopaedics Institute of Tianjin, Tianjin Hospital, Tianjin, China.
- Tianjin Hospital, Tianjin University, Tianjin, China.
| | - Xinlong Ma
- Orthopaedics Institute of Tianjin, Tianjin Hospital, Tianjin, China.
- Tianjin Hospital, Tianjin University, Tianjin, China.
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Delanois RE, Sax OC, Chen Z, Cohen JM, Callahan DM, Mont MA. Biologic Therapies for the Treatment of Knee Osteoarthritis: An Updated Systematic Review. J Arthroplasty 2022; 37:2480-2506. [PMID: 35609847 DOI: 10.1016/j.arth.2022.05.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 05/05/2022] [Accepted: 05/15/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Use of "orthobiologics" continues to expand for patients who have knee osteoarthritis (OA). We sought to perform a systemic review of biologic therapies relative to comparative groups, including the following: (1) platelet-rich plasma (PRP); (2) bone marrow-derived mesenchymal stem cells (BMSCs); (3) adipose-derived mesenchymal stem cells (ADSCs); and (4) amniotic-derived mesenchymal stem cells (AMSCs). We assessed the following: (1) study methodologies; (2) cell preparations and formulations; (3) patient-reported outcome scores (PROMs); and (4) structural changes. METHODS PubMed, Cochrane Library, and Embase databases were queried (2013-2021) to conduct a systematic review of biologic therapies for knee OA, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eighty-two studies were included: PRP (51); BMSC (15); ADSC (11); and AMSC (5). Study evaluations were made using the Modified Coleman Methodology Score. PROMs included the Western Ontario and McMaster Universities Arthritis Index and the Visual Analog Scale. Structural change evaluations included ultrasounds, radiographs, or magnetic resonance imaging. RESULTS PRP comprised a majority of the studies (n = 51), most with "fair" to "good" Modified Coleman Methodology Score. Studies had variable cell preparations and formulations, with comparison study results leading to inconsistent PROMs, and structural changes. A limited number of studies were included for BMSC, ADSC, and AMSC, all with similar findings to PRP. CONCLUSION Available literature evaluating "orthobiologics" for knee OA remain nonsuperior to comparison cohorts. Higher level studies with larger sample sizes and improved methodologies are warranted to suggest differences. Despite a growth of "orthobiologics" in clinics, this updated systematic review highlights the uncertain efficacy for use in knee OA.
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Affiliation(s)
- Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Oliver C Sax
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Zhongming Chen
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jacob M Cohen
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Daniel M Callahan
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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6
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Poliwoda S, Noor N, Mousa B, Sarwary Z, Noss B, Urits I, Viswanath O, Behara R, Ulicny K, Howe A, Mychaskiw G, Kaye AD. A comprehensive review of intraarticular knee injection therapy, geniculate injections, and peripheral nerve stimulation for knee pain in clinical practice. Orthop Rev (Pavia) 2022; 14:38676. [DOI: 10.52965/001c.38676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The knee is the most common joint in adults associated with morbidity. Many pathologies are associated with knee damage, such as gout or rheumathoid arthritis, but the primary condition is osteoarthritis (OA). Not only can osteoarthritis cause significant pain, but it also can result in signficant disability as well. Treatment for this condition varies, starting off with oral analgesics and physical therapy to surgical total knee replacmenet. In the gamut of this various treatments, a conservative approach has included intra articular steroid injections. With time, researchers and clinicians determined that other components injected to the knee may additionally provide relief of this condition. In this investigation, we describe different types of knee injections such as platelet-rich plasma (PRP), hyaluronic acid, stem cells, and prolotherapy. Additionally, we describe the role of geniculate knee injections, radiofrequency, and periopheral nerve stimulation. These treatments should be considered for patients with knee pain refractory to conservative therapies.
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Affiliation(s)
| | | | - Bakir Mousa
- University of Arizona, College of Medicine-Phoenix
| | | | | | - Ivan Urits
- Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Omar Viswanath
- Creighton University School of Medicine, University of Arizona College of Medicine
| | - Raju Behara
- Louisiana State University Health Sciences Center – Shreveport
| | - Kenneth Ulicny
- Louisiana State University Health Sciences Center – Shreveport
| | - Austin Howe
- Louisiana State University Health Sciences Center – Shreveport
| | | | - Alan D. Kaye
- Louisiana State University Health Sciences Center – Shreveport
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Waters P, Anderson R, Anderson JM, Scott J, Detweiler B, Streck S, Hartwell M, Torgerson T, Vassar M. Analysis of the Evidence Underpinning the American Academy of Orthopedic Surgeons Knee Osteoarthritis Clinical Practice Guidelines. Sports Health 2022; 15:11-25. [PMID: 35915571 PMCID: PMC9808825 DOI: 10.1177/19417381221112674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
CONTEXT Clinical practice guidelines (CPGs) are vital to establishing a standardized and evidence-based approach in medicine. These guidelines rely on the use of methodologically sound clinical trials, and the subsequent reporting of their methodology. OBJECTIVE To evaluate the completeness of randomized controlled trials (RCTs) underpinning CPGs published by the American Academy of Orthopedic Surgeons (AAOS) for management of osteoarthritis of the knee. DATA SOURCES We searched the most recent AAOS CPGs for surgical and nonsurgical management of osteoarthritis of the knee for RCTs. To estimate the necessary sample size, we performed a power analysis using OpenEpi 3.0 (openepi.com). STUDY SELECTION Two authors independently screened the reference sections of the included CPGs. Included studies met the definition of an RCT, were retrievable in the English language, and were cited in at least one of the included CPGs. STUDY DESIGN Meta-Analysis. LEVEL OF EVIDENCE Level 1a. DATA EXTRACTION We performed double-blind screening and extraction of RCTs included in the AAOS CPGs. We evaluated each RCT for adherence to the Consolidated Standards of Reporting Trials (CONSORT) 2010 checklist. A multiple regression analysis was conducted to assess CONSORT adherence against characteristics of included studies (ie, type of intervention, funding source, etc). RESULTS Our study included 179 RCTs. The overall adherence was 68.5% with significant differences between those published before and since the development of the 2010 CONSORT guidelines (P = 0.02). We found that RCTs receiving funding from industry/private sources as well as studies that included a conflict of interest statement showed more completeness than RCTs that reported receiving no funding (P < 0.01). CONCLUSION We found suboptimal CONSORT adherence for RCTs cited in AAOS CGPs for management of osteoarthritis of the knee. Therefore, the CPGs are likely supported by outdated evidence and lack of high-quality reporting. It is important that evidence used to guide clinical decision making be of the highest quality in order to optimize patient outcomes. In order for clinicians to confer the greatest benefits to their patients, CPGs should provide the totality of evidence and emphasize emerging high-quality RCTs to ensure up-to-date, evidence-based clinical decision-making.
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Affiliation(s)
- Philo Waters
- Philo Waters, BS, Oklahoma
State University Center for Health Sciences, 1111 W 17th St., Tulsa, OK 74107
() (Twitter: @PWaters04)
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Gregory DA, Coppolecchia A, Scotti DJ, Chen Z, Mont MA, Jacofsky D. A 90-Day Episode-of-Care Analysis Including Computed Tomography Scans of Robotic-Arm Assisted versus Manual Total Knee Arthroplasty. J Knee Surg 2022. [PMID: 35817055 DOI: 10.1055/s-0042-1749083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In this observational, retrospective study, we performed economic analyses between robotic arm-assisted total knee arthroplasty (RATKA) and manual total knee arthroplasty (MTKA). Specifically, we compared: (1) index costs including computed tomography (CT) scans; (2) 90-day postoperative health care utilization, (3) 90-day episode-of-care (EOC) costs, and (4) lengths of stay between CT scan-based robotically-assisted versus MTKAs. A large national database, Blue Health Intelligence (BHI), was used for RATKAs and MTKAs performed between April 1, 2017 and September 30, 2019. Based on strict inclusion-exclusion criteria, with propensity score matching, 4,135 RATKAs and 4,135 MTKAs were identified and analyzed. Index costs to the payer for RATKA patients were found to be less than those for MTKA patients ($29,984 vs. $31,280, p <0.0001). Overall, 90-day EOC costs for RATKA patients were found to be less than that for MTKA patients in the inpatient and outpatient settings. This also holds true for the use of skilled nursing facilities, pharmacies, or other services. In conclusion, the results from our study show that RATKA were associated with lower costs than MTKAs, even when including the cost of CT scans. These results are of marked importance given the emphasis to contain and reduce health care costs.
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Affiliation(s)
- David A Gregory
- Department of Orthopaedic Surgery, Baker Tilly Virchow Krause LLP, Madison, Wisconsin
| | | | - Dennis J Scotti
- Department of Orthopaedic Surgery, Fairleigh Dickinson University, Teaneck, New Jersey
| | - Zhongming Chen
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - David Jacofsky
- Department of Orthopaedic Surgery, The CORE Institute, Phoenix, Arizona
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9
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Berkani S, Courties A, Eymard F, Latourte A, Richette P, Berenbaum F, Sellam J, Louati K. Time to Total Knee Arthroplasty after Intra-Articular Hyaluronic Acid or Platelet-Rich Plasma Injections: A Systematic Literature Review and Meta-Analysis. J Clin Med 2022; 11:3985. [PMID: 35887749 PMCID: PMC9322631 DOI: 10.3390/jcm11143985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 02/05/2023] Open
Abstract
Intra-articular (IA) hyaluronic acid (HA) and platelet-rich plasma (PRP) injections are increasingly being prescribed for knee osteoarthritis (KOA). However, failure of the medical treatment may result in total knee arthroplasty (TKA). We wondered if IA HA or PRP injections (intervention) may delay the time to TKA (outcome) among KOA patients (population), compared to KOA patients not receiving these injections (comparator). For this systematic literature review (SLR) and meta-analysis, we selected observational studies with at least one group of patients receiving IA HA or PRP and with TKA data available. The main outcome was time from the diagnosis of KOA to TKA. We included 25 articles in the SLR (2,824,401 patients) and four in the meta-analysis. The mean strengthening the reporting of observational studies in epidemiology (STROBE) score was 63%. For patients receiving versus not receiving HA injections, the delay between a declared diagnosis of KOA to TKA was increased by 9.8 months (95% CI (8.2-11.4)). As compared with standard of care, the effect size of HA injections for this outcome was 0.57 (95% CI (0.36-0.76)). Only one study described a median time from PRP injections to TKA of 4.1 years (range 0.3-14.7). IA HA injections were associated with increased time to TKA. Causality cannot be concluded because of missing confounder factors as comorbidities. Data were insufficient to conclude any effect of PRP injections on TKA delay.
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Affiliation(s)
- Sabryne Berkani
- Rheumatology Department, Inserm UMRS_938, (AP-HP) Saint-Antoine Hospital, Sorbonne Université, 75012 Paris, France; (S.B.); (A.C.); (F.B.)
| | - Alice Courties
- Rheumatology Department, Inserm UMRS_938, (AP-HP) Saint-Antoine Hospital, Sorbonne Université, 75012 Paris, France; (S.B.); (A.C.); (F.B.)
| | - Florent Eymard
- Rheumatology Department, AP-HP Henri Mondor Hospital, 94000 Créteil, France;
| | - Augustin Latourte
- Rheumatology Department, Inserm U1132, DMU Locomotion, AP-HP Lariboisière Hospital, Université de Paris, 75010 Paris, France; (A.L.); (P.R.)
| | - Pascal Richette
- Rheumatology Department, Inserm U1132, DMU Locomotion, AP-HP Lariboisière Hospital, Université de Paris, 75010 Paris, France; (A.L.); (P.R.)
| | - Francis Berenbaum
- Rheumatology Department, Inserm UMRS_938, (AP-HP) Saint-Antoine Hospital, Sorbonne Université, 75012 Paris, France; (S.B.); (A.C.); (F.B.)
| | - Jérémie Sellam
- Rheumatology Department, Inserm UMRS_938, (AP-HP) Saint-Antoine Hospital, Sorbonne Université, 75012 Paris, France; (S.B.); (A.C.); (F.B.)
| | - Karine Louati
- Rheumatology Department, Inserm UMRS_938, (AP-HP) Saint-Antoine Hospital, Sorbonne Université, 75012 Paris, France; (S.B.); (A.C.); (F.B.)
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Hunt C, Provenzano DA, Eshraghi Y, Mittal N, Souza D, Buchheit T. Should intra-articular hyaluronic acid be used routinely for knee osteoarthritis pain? PM R 2022; 14:879-885. [PMID: 34837674 PMCID: PMC9970143 DOI: 10.1002/pmrj.12740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/13/2021] [Accepted: 11/11/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Christine Hunt
- Department of Pain Medicine, Mayo Clinic, Jacksonville, FL, USA 32224
| | | | - Yashar Eshraghi
- Louisiana State University School of Medicine, New Orleans, Louisiana, USA 70112,Department of Anesthesia, Interventional Pain Management, Ochsner Health System, University of Queensland Ochsner Clinical School, New Orleans, Louisiana, USA 70115
| | - Nimish Mittal
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada,Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
| | - Dmitri Souza
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA 44233
| | - Thomas Buchheit
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA 27710,Anesthesiology Service, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA 27705
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11
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Zhu KY, Acuña AJ, Samuel LT, Grits D, Kamath AF. Hyaluronic Acid Injections for Knee Osteoarthritis: Has Utilization Among Medicare Beneficiaries Changed Between 2012 and 2018? J Bone Joint Surg Am 2022; 104:e43. [PMID: 35580316 DOI: 10.2106/jbjs.21.00832] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The utilization of hyaluronic acid (HA) for the management of knee osteoarthritis (OA) remains controversial, and more information is needed regarding how its utilization and financial burden have changed over recent years. The purpose of our analysis was to evaluate changes in overall utilization and health-care costs associated with HA injections among Medicare beneficiaries over a contemporary time frame. METHODS The 2012 to 2018 Medicare Fee-for-Service Provider Utilization and Payment Public Use Files (PUFs) were utilized for our analysis. Organized by Healthcare Common Procedure Coding System (HCPCS) codes, these files capture 100% of Medicare Part B claims. Payment and utilization data were collected for all HCPCS codes corresponding to injection of an HA formulation. The number of services involving HA as well as the total cost of HA administration in 2020 U.S. dollars were tabulated. Mann-Kendall trend tests were used to evaluate trends in utilization for providers nationally and when segregated by specialty. RESULTS Total HA utilization increased significantly from 2012 (n = 1,090,503) through 2018 (n = 1,209,489; p = 0.04). Although orthopaedic surgeons did not demonstrate significant changes in total utilization rates (p = 0.23), the average number of services per orthopaedic surgeon increased significantly (p = 0.02). Reflecting a substantial growth in the number of advanced practice providers (APPs) providing injections, there was a significant increase in utilization and associated costs among physician assistants (p < 0.01) and nurse practitioners (p < 0.01). Total costs associated with HA services increased significantly from $290.10 million to $325.02 million (p < 0.01). CONCLUSIONS Despite the 2013 American Academy of Orthopaedic Surgeons clinical practice guideline recommending against the clinical utility of these injections, HA services continued to be widely implemented among Medicare beneficiaries. Although there were variations across specialties when evaluating overall utilization rates as well as rates per provider, APPs largely contributed to the increase seen in the U.S. over this study period. More data are needed to support continued implementation and spending on this low-value care.
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Affiliation(s)
- Kevin Y Zhu
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Opposing and Operated Side Electroacupuncture Generates Similar Analgesic Effects on Pain after Knee Surgery. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:6616886. [PMID: 33976704 PMCID: PMC8087472 DOI: 10.1155/2021/6616886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 03/17/2021] [Accepted: 03/24/2021] [Indexed: 01/11/2023]
Abstract
The purpose of this study was to investigate whether opposing electroacupuncture (EA) could produce similar analgesic effects as operated side EA after knee surgery in rats. Sprague Dawley rats were randomly divided into the sham surgery group, and three surgery groups: opposing EA, operated side EA, and model. After surgery, compared with the sham surgery group, three kinds of pain behavior test methods (mechanical withdrawal threshold (MWT), cumulative pain score [CPS], and mechanical hypersensitivity of knee) were used to assess the pain behavior of the rats in the surgery groups. After knee surgery, the three surgery groups were intervened for three consecutive days: EA on the nonoperated side in the opposing EA group, EA on the operated side in the operated side EA group, and no intervention in the model group. It was shown that MWT was higher and CPS was lower in the two EA groups than in the model group on the first and second days after surgery. On the third day after surgery, MWT in the two EA groups was the highest among the 3 days, CPS was the lowest among the 3 days, and the number of nonvocalizations in rats also increased compared with the model group. Moreover, the MWT of the nonoperated side increased more in the opposing EA group than in the model and operated side EA groups. This indicated that both opposing EA and operated side EA methods can be used to relieve pain after knee joint surgery.
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Concoff A, Niazi F, Farrokhyar F, Alyass A, Rosen J, Nicholls M. Delay to TKA and Costs Associated with Knee Osteoarthritis Care Using Intra-Articular Hyaluronic Acid: Analysis of an Administrative Database. CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2021; 14:1179544121994092. [PMID: 33814937 PMCID: PMC7989120 DOI: 10.1177/1179544121994092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 01/19/2021] [Indexed: 01/01/2023]
Abstract
Background Total knee arthroplasty (TKA) is a surgical treatment for patients with knee osteoarthritis (KOA) that no longer experience symptom relief from non-operative or pharmacologic treatments. Non-operative KOA management aims to address patient symptoms and improve function, as well as forestall or mitigate the large costs associated with TKA. The primary objective of this study was to examine the relationship between intra-articular hyaluronic acid (IA-HA) treatment and delaying TKA in patients with KOA compared to patients not receiving IA-HA, as well as to identify differences in KOA-related costs incurred among patients who received or did not receive IA-HA. Methods This was a retrospective analysis of an administrative claims database from October 1st, 2010 through September 30th, 2015. Kaplan-Meier survival analysis was conducted to determine the TKA-free survival of patients who received IA-HA, stratified by the number of injection courses received versus those who did not receive any IA-HA. Median KOA-related costs per year were calculated for 2 comparisons: (1) patients who received IA-HA versus patients who did not receive IA-HA, among patients who eventually had TKA, and (2) patients who received IA-HA versus patients who did not receive IA-HA, among patients who did not have TKA. Results A total of 744 734 patients were included in the analysis. A delay to TKA was observed after IA-HA treatment for patients treated with IA-HA compared to those who did not receive IA-HA. At 1 year, the TKA-free survival was 85.8% (95% CI: 85.6%-86.0%) for patients who received IA-HA and 74.1% (95% CI: 74.0%-74.3%) for those who did not receive IA-HA. At 2 years, the TKA free survival was 70.8% (70.5%-71.1%) and 63.7% (63.5%-63.9%) in the 2 groups, respectively. Patients treated with multiple courses of IA-HA demonstrated an incremental increase in delay to TKA with more courses of IA-HA, suggesting that the risk of TKA over the study time period is reduced with additional IA-HA courses. The hazard ratio for the need of TKA was 0.85 (95% CI 0.84-0.86) for a single course and 0.27 (95% CI 0.25-0.28) for ⩾5 courses, both compared to the no IA-HA group. In patients that eventually had TKA, the median KOA-related costs were lower among those who received IA-HA before their TKA ($860.24, 95% CI: 446.65-1722.20), compared to those who did not receive IA-HA ($2659.49, 95% CI: 891.04-7480.38). For patients who did not have TKA, the median and interquartile range (IQR) KOA-related costs per year were similar for patients who received IA-HA compared with those who did not. Conclusion These results demonstrate that within a large cohort of KOA patients, individuals who received multiple courses of IA-HA had a progressively greater delay to TKA compared to patients who did not receive IA-HA treatment. Also, for patients who progressed to TKA, IA-HA treatment was associated with a large reduction in KOA-related healthcare costs. Based on these results, multiple, repeat courses of IA-HA may be beneficial in substantially delaying TKA in KOA patients, as well as minimizing KOA-related healthcare costs.
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Affiliation(s)
| | | | - Forough Farrokhyar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Akram Alyass
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffrey Rosen
- Department of Orthopaedics & Rehabilitation, New York Presbyterian Queens, Weill Medical College of Cornell University, New York, NY, USA
| | - Mathew Nicholls
- Virginia Mason Orthopedics and Sports Medicine, Seattle, WA, USA
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Hohmann E. Editorial Commentary: Platelet-Rich Plasma and Hyaluronic Acid Injection for Knee Osteoarthritis Are Both Cost Effective. Arthroscopy 2020; 36:3079-3080. [PMID: 33276894 DOI: 10.1016/j.arthro.2020.09.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 09/11/2020] [Accepted: 09/24/2020] [Indexed: 02/02/2023]
Abstract
Knee osteoarthritis is associated with an annual cost to society exceeding US$27 billion. Value-based treatment is an important consideration, and cost-benefit analyses are crucial to determine the benefits to both patients and society. The quality-adjusted life year (QALY) is a generic measure of burden including both quality and quantity. Recent studies have suggested that intra-articular injection of platelet-rich plasma (PRP) is effective treatment for knee osteoarthritis and comparable to hyaluronic acid (HA). Although the costs (dollars) per QALY were higher for PRP ($8,635) than for HA ($5,331), PRP was more cost effective at 1 year and was associated with an incremental cost-effectiveness ratio (ICER) of $12,628 QALY. Similarly, the utility value (proportion of QALY compared with perfect health) of PRP was higher by 0.11 QALY: 0.69 versus 0.58.
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