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Nin DZ, Chen YW, Talmo CT, Hollenbeck BL, Niu R, Chang DC, Smith EL, Mattingly D. Arthroscopic Procedures Are Performed in 5% of Patients With Knee Osteoarthritis 1 Year Preceding Total Knee Arthroplasty and Are Associated With Increased Stiffness and Increased Costs. Arthrosc Sports Med Rehabil 2023; 5:100776. [PMID: 38155763 PMCID: PMC10753171 DOI: 10.1016/j.asmr.2023.100776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 06/15/2023] [Indexed: 12/30/2023] Open
Abstract
Purpose To describe the different types of arthroscopic procedures that patients undergo in the year prior to total knee arthroplasty (TKA), reveal the cost associated with these procedures, and understand the relationship between preoperative arthroscopy and clinical outcomes after TKA. Methods An observational cohort study was conducted using the IBM Watson Health MarketScan databases. Patients with knee osteoarthritis who underwent unilateral isolated primary TKA between January 1, 2018, and September 30, 2019, were included. Knee arthroscopic procedures performed in the 1-year period before a primary TKA was identified. The primary outcomes of interest were cost of these procedures and the risk of 90-day postoperative complications. Results In total, 2,904 patients, representing 5.2% of the analyzed cohort, underwent arthroscopic procedures in the year prior to TKA. The most common procedure and diagnosis were meniscectomy and meniscal tear, respectively, with procedures performed an average of 7.2 ± 3.0 months before TKA. Average per patient costs were $9,716 ± $5,500 in the highest payment quartile vs $1,789 ± 636 in the lowest payment quartile. Patients with a history of arthroscopy were more likely to develop postoperative stiffness (P = .001), while no difference was found in the risk of 90-day periprosthetic joint infection (PJI). Conclusions Of the patients, 5.2% underwent knee arthroscopy in the year prior to TKA. While no association was seen with PJI risk, the costs associated with these procedures are high and may increase the overall cost of management of knee osteoarthritis. Level of Evidence Level III, retrospective comparative study.
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Affiliation(s)
- Darren Z. Nin
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts, U.S.A
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Ya-Wen Chen
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Carl T. Talmo
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts, U.S.A
| | - Brian L. Hollenbeck
- Division of Infectious Diseases, New England Baptist Hospital, Boston, Massachusetts, U.S.A
| | - Ruijia Niu
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts, U.S.A
| | - David C. Chang
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts, U.S.A
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Eric L. Smith
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts, U.S.A
| | - David Mattingly
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts, U.S.A
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Randall DJ, Peacock K, Nickel KB, Olsen MA, Kazmers NH. Moving Minor Hand Surgeries Out of the Operating Room and Into the Office-Based Procedure Room: A Population-Based Trend Analysis. J Hand Surg Am 2022; 47:1137-1145. [PMID: 36471499 PMCID: PMC9731346 DOI: 10.1016/j.jhsa.2022.08.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 07/22/2022] [Accepted: 08/17/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Our primary purpose was to quantify the proportion of minor hand surgeries performed in the procedure room (PR) setting in a population-based cohort. Given the increase in the literature that has emerged since the mid-2000s highlighting the benefits of the PR setting, we hypothesized that a trend analysis would reveal increased utilization over time. METHODS We used the 2006-2017 MarketScan Commercial Database to identify adults who underwent isolated minor hand surgeries performed in PR and operation room surgical settings in the United States. The Cochran-Armitage trends test was used to determine whether the proportion of all procedures (PR + operation room) changed over time. RESULTS A total of 257,581 surgeries were included in the analysis, of which 24,966 (11.5%) were performed in the PR. There was an increase in the overall number of surgeries under study as well as increased utilization of the PR setting for open carpal tunnel release, trigger digit release, DeQuervain release, hand or finger mass excision, and hand or finger cyst excision. The magnitude of the increases in PR utilization was small: between 2006 and 2017, the PR utilization increased by 1.4% for open carpal tunnel release, 5.4% for trigger digit release, 2.9% for DeQuervain release, 10.1% for hand or finger mass excision, and 6.5% for hand or finger cyst excision. CONCLUSIONS Despite the published benefits of the PR setting, we observed that the majority of these 5 common minor hand surgeries are performed in the operation room setting. Between 2006 and 2017, the office-based PR utilization increased slightly. The identification of barriers to PR utilization is needed to improve the value of care. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
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Affiliation(s)
- Dustin J Randall
- Oakland University William Beaumont School of Medicine, Rochester, MI; Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | - Kate Peacock
- Center for Administrative Data Research, Institute of Clinical and Translational Sciences, Washington University in St. Louis, St. Louis, MO
| | - Katelin B Nickel
- Center for Administrative Data Research, Institute of Clinical and Translational Sciences, Washington University in St. Louis, St. Louis, MO
| | - Margaret A Olsen
- Center for Administrative Data Research, Institute of Clinical and Translational Sciences, Washington University in St. Louis, St. Louis, MO
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Affiliation(s)
| | - Sachin H Jain
- SCAN Group and Health Plan, Long Beach, California
- Stanford University, Palo Alto, California
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Kiadaliri A, Bergkvist D, Dahlberg LE, Englund M. Impact of a national guideline on use of knee arthroscopy: An interrupted time-series analysis. Int J Qual Health Care 2020; 31:G113-G118. [PMID: 31725873 PMCID: PMC7076349 DOI: 10.1093/intqhc/mzz089] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/25/2019] [Accepted: 08/27/2019] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To assess the impact of the Swedish health authority recommendation against the use of knee arthroscopy in patients aged ≥40 years with knee osteoarthritis (OA). DESIGN Interrupted time series analysis. SETTING Public health care in Skåne region. PARTICIPANTS Patients aged ≥40 years who underwent knee arthroscopy from January 2010 to December 2015. INTERVENTION(S) National guideline's recommendation against the use of knee arthroscopy in patients with knee OA. MAIN OUTCOME MEASURE(S) 1) proportion of patients aged ≥40 years with a main diagnosis of Knee OA and/or degenerative meniscal lesions (DML) who underwent knee arthroscopy, and 2) overall knee arthroscopy rate per 100,000 Skåne population aged ≥40 years. RESULTS A total of 6,155 knee arthroscopy were performed among people aged ≥40 years during study period. Of 42,044 patients with Knee OA/DML, 3,728 had knee arthroscopy. The recommendation was associated with reductions in the use of knee arthroscopy and two years after the recommendation, there was a reduction of 28.6% (95% CI: 9.3, 47.8) and 34.7% (23.9, 45.4) in proportion of Knee OA/DML patients with knee arthroscopy and the overall knee arthroscopy rate, respectively, relative to that expected if pre-recommendation trend continued. Our sensitivity analysis showed that the use of total knee replacement was stable over the study period. CONCLUSION The national recommendation was associated with reduction in use of knee arthroscopy in public health care in southern Sweden. However, still 4.5% of these patients underwent knee arthroscopy in 2015 implying that more efforts are required to achieve the recommended target.
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Affiliation(s)
- Ali Kiadaliri
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Clinical Epidemiology Unit, Lund, Sweden.,Lund University, Faculty of Medicine, EPI@LUND (Epidemiology, Population studies, and Infrastructures at Lund University), Lund, Sweden.,Centre for Economic Demography, Lund University, Lund, Sweden
| | - Dan Bergkvist
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Clinical Epidemiology Unit, Lund, Sweden
| | - Leif E Dahlberg
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund, Sweden
| | - Martin Englund
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Clinical Epidemiology Unit, Lund, Sweden.,Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, MA, USA
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van Munster JJCM, Zamanipoor Najafabadi AH, de Boer NP, Peul WC, van den Hout WB, van Benthem PPG. Impact of surgical intervention trials on healthcare: A systematic review of assessment methods, healthcare outcomes, and determinants. PLoS One 2020; 15:e0233318. [PMID: 32442235 PMCID: PMC7244162 DOI: 10.1371/journal.pone.0233318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/01/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Frameworks used in research impact evaluation studies vary widely and it remains unclear which methods are most appropriate for evaluating research impact in the field of surgical research. Therefore, we aimed to identify and review the methods used to assess the impact of surgical intervention trials on healthcare and to identify determinants for surgical impact. METHODS We searched journal databases up to March 10, 2020 for papers assessing the impact of surgical effectiveness trials on healthcare. Two researchers independently screened the papers for eligibility and performed a Risk of Bias assessment. Characteristics of both impact papers and trial papers were summarized. Univariate analyses were performed to identify determinants for finding research impact, which was defined as a change in healthcare practice. RESULTS Sixty-one impact assessments were performed in 37 included impact papers. Some surgical trial papers were evaluated in more than one impact paper, which provides a total of 38 evaluated trial papers. Most impact papers were published after 2010 (n = 29). Medical records (n = 10), administrative databases (n = 22), and physician's opinion through surveys (n = 5) were used for data collection. Those data were analyzed purely descriptively (n = 3), comparing data before and after publication (n = 29), or through time series analyses (n = 5). Significant healthcare impact was observed 49 times and more often in more recent publications. Having impact was positively associated with using medical records or administrative databases (ref.: surveys), a longer timeframe for impact evaluation and more months between the publication of the trial paper and the impact paper, data collection in North America (ref.: Europe), no economic evaluation of the intervention, finding no significant difference in surgical outcomes, and suggesting de-implementation in the original trial paper. CONCLUSIONS AND IMPLICATIONS Research impact evaluation receives growing interest, but still a small number of impact papers per year was identified. The analysis showed that characteristics of both surgical trial papers and impact papers were associated with finding research impact. We advise to collect data from either medical records or administrative databases, with an evaluation time frame of at least 4 years since trial publication.
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Affiliation(s)
- Juliëtte J. C. M. van Munster
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Center (LUMC), Leiden University, Leiden, the Netherlands
- Leiden University Neurosurgical Center Holland (UNCH), LUMC and The Hague Medical Center (HMC), Leiden, the Netherlands
| | - Amir H. Zamanipoor Najafabadi
- Leiden University Neurosurgical Center Holland (UNCH), LUMC and The Hague Medical Center (HMC), Leiden, the Netherlands
| | - Nick P. de Boer
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Center (LUMC), Leiden University, Leiden, the Netherlands
| | - Wilco C. Peul
- Leiden University Neurosurgical Center Holland (UNCH), LUMC and The Hague Medical Center (HMC), Leiden, the Netherlands
| | - Wilbert B. van den Hout
- Department of Biomedical Data Science–Medical Decision Making, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - Peter Paul G. van Benthem
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Center (LUMC), Leiden University, Leiden, the Netherlands
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Abstract
This study uses the Florida State Ambulatory Surgery and State Inpatient Databases to assess the trends in knee arthroscopy use among patients with osteoarthritis, meniscal tears, and knee pain.
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Affiliation(s)
- David H Howard
- Department of Health Policy and Management, Emory University, Atlanta, Georgia
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Ghomrawi HMK, Marx RG, Pan TJ, Conti M, Lyman S. The effect of negative randomized trials and surgeon volume on the rates of arthroscopy for patients with knee OA. Contemp Clin Trials Commun 2017; 9:40-44. [PMID: 29696223 PMCID: PMC5898476 DOI: 10.1016/j.conctc.2017.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 11/13/2017] [Accepted: 11/29/2017] [Indexed: 01/11/2023] Open
Abstract
Publication of 2 (negative) randomized clinical trials (RCTs) in 2002 and 2008 demonstrating inefficacy of arthroscopic debridement of the knee (ADK) for osteoarthritis, and a 2004 national non-coverage Medicare determination, have decreased overall ADK utilization. However, because of potentially favorable outcomes associated with high volume, surgeons performing high arthroscopy volume may be slower to abandon performing ADK than would low volume surgeons. We examined the trends in ADKs performed by high and low volume surgeons before and after these 2 trials and the Medicare determination. New York state residents 40 years and older undergoing outpatient ADK from 1997 to 2010 were identified from a statewide database, and monthly population-based age and sex-adjusted ADK rates were calculated. We estimated the change in utilization trends over time, stratified by surgeon annual arthroscopy volume, for Medicare and non-Medicare patients. 1386 surgeons performed 29,658 ADKs during the study period, with the proportion performed by high volume surgeons increasing from 22% in 1997 to 66% in 2010. Overall monthly ADK rates declined from 2.4 to 1.3 per 100,000 population (45%) over the study period. Rates of ADK performed by high volume surgeons increased after the first RCT in the non-Medicare population and after the CMS decision in the Medicare population, and decreased after the second RCT. With more definitive evidence from the second negative trial, high volume surgeons performed less ADKs, suggesting that multiple RCTs with consistently negative results are needed to change practice of high volume surgeons.
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Affiliation(s)
- Hassan M K Ghomrawi
- Departments of Surgery and Pediatrics, Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, 633N St. Clair, Chicago, IL 60640, USA
| | - Robert G Marx
- Department of Orthopedics, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Ting-Jung Pan
- Healthcare Research Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Matthew Conti
- Department of Orthopedics, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Stephen Lyman
- Healthcare Research Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
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8
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Amin NH, Hussain W, Ryan J, Morrison S, Miniaci A, Jones MH. Changes Within Clinical Practice After a Randomized Controlled Trial of Knee Arthroscopy for Osteoarthritis. Orthop J Sports Med 2017; 5:2325967117698439. [PMID: 28451610 PMCID: PMC5400146 DOI: 10.1177/2325967117698439] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND In 2002, Moseley et al published a randomized controlled trial (RCT) that showed no difference between knee arthroscopy and placebo for patients with osteoarthritis (OA). We wanted to assess the impact of the trial on clinical practice in the United States. PURPOSE/HYPOTHESIS To evaluate changes in knee arthroscopy practice before and after publication of the article by Moseley et al and to assess the effect of this landmark RCT on the behavior of practicing orthopaedic surgeons. We hypothesized that after publication of the Moseley trial, the overall frequency of knee arthroscopy would decrease, that the mean age of patients undergoing knee arthroscopy would decrease, and that the proportion of arthroscopies for a diagnosis of OA would decrease. STUDY DESIGN Descriptive epidemiology study. METHODS The State Ambulatory Surgery Database was used to analyze cases from 1998 to 2006, which were classified as meniscus tear, OA, or OA with meniscus tear. Changes in age, surgery rates, and case classification were evaluated before and after Moseley's trial using Student t tests and analysis of variance. RESULTS After publication of the trial, the number of knee arthroscopies per year increased from 155,057 in 1998 to 172,317 in 2006 (P ≤ .001). Mean patient age increased from 47.6 to 49.2 years (P < .001). Meniscus tears increased from 69.1% to 70.8%, representing approximately 15,500 additional cases per year. OA decreased from 10.6% to 7.2%, representing approximately 4000 fewer cases per year. OA with meniscus tear increased from 20.3% to 22.0%, representing approximately 6400 additional cases per year. CONCLUSION While overall age and rates of knee arthroscopy increased contrary to our hypothesis, we identified a decrease in rates of knee arthroscopy for OA after publication of the Moseley trial, demonstrating that well-publicized RCTs can influence patterns of clinical practice.
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Affiliation(s)
- Nirav H Amin
- Loma Linda University, Loma Linda, California, USA
| | | | - John Ryan
- Ohio State University, Columbus, Ohio, USA
| | - Shannon Morrison
- Cleveland Clinic Center for Sports Health, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Anthony Miniaci
- Cleveland Clinic Center for Sports Health, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Morgan H Jones
- Cleveland Clinic Department of Orthopaedic Surgery, Cleveland, Ohio, USA
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9
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Howard DH, Soulos PR, Chagpar AB, Mougalian S, Killelea B, Gross CP. Contrary To Conventional Wisdom, Physicians Abandoned A Breast Cancer Treatment After A Trial Concluded It Was Ineffective. Health Aff (Millwood) 2016; 35:1309-15. [DOI: 10.1377/hlthaff.2015.1490] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- David H. Howard
- David H. Howard ( ) is an associate professor in the Department of Health Policy and Management and Winship Cancer Institute at Emory University, in Atlanta, Georgia
| | - Pamela R. Soulos
- Pamela R. Soulos is a program manager and data analyst at the Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at the Yale University School of Medicine and the Yale Cancer Center, in New Haven, Connecticut
| | - Anees B. Chagpar
- Anees B. Chagpar is an associate professor of surgery in the Department of Surgery at the Yale University School of Medicine
| | - Sarah Mougalian
- Sarah Mougalian is an associate professor of surgery at the COPPER Center at the Yale University School of Medicine and the Yale Cancer Center
| | - Brigid Killelea
- Brigid Killelea is an associate professor of surgery at the COPPER Center at the Yale University School of Medicine and the Yale Cancer Center
| | - Cary P. Gross
- Cary P. Gross is a professor of medicine in the Section of General Internal Medicine at the Yale University School of Medicine
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Arthroscopy for Knee Osteoarthritis Has Not Decreased After a Clinical Trial. Clin Orthop Relat Res 2016; 474:489-94. [PMID: 26290345 PMCID: PMC4709284 DOI: 10.1007/s11999-015-4514-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 08/10/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multiple clinical trials have shown that arthroscopy for knee osteoarthritis is not efficacious. It is unclear how these studies have affected orthopaedic practice in the USA. QUESTIONS/PURPOSES We questioned whether, in the Veterans Health Administration system, rates of knee arthroscopy in patients with osteoarthritis have changed after publication of the initial clinical trial by Moseley et al. in 2002, and whether rates of arthroplasty within 2 years of arthroscopy have changed during the same period. METHODS Patients 50 years and older with knee osteoarthritis who underwent arthroscopy between 1998 and 2010 were retrospectively identified and an annual arthroscopy rate was calculated from 1998 through 2002 and from 2006 through 2010. Patients who underwent knee arthroplasty within 2 years of arthroscopy during each period were identified, and a 2-year conversion to arthroplasty rate was calculated. RESULTS Between 1998 and 2002, the annual arthroscopy rate decreased from 4% to 3%. Of these arthroscopies, 4% were converted to arthroplasty within 2 years. Between 2006 and 2010, the annual arthroscopy rate increased from 3% to 4%. Of these arthroscopies, 5% were converted to arthroplasty within 2 years. CONCLUSIONS Rates of arthroscopy in patients with knee osteoarthritis and conversion to arthroplasty within 2 years have not decreased with time. It may be that evidence alone is not sufficient to alter practice patterns or that arthroscopy rates for arthritis for patients in the Veterans Health Administration system were already so low that the results of the initial clinical trial had no substantial effect. LEVEL OF EVIDENCE Level III, Retrospective cohort study.
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Marsh JD, Birmingham TB, Giffin JR, Isaranuwatchai W, Hoch JS, Feagan BG, Litchfield R, Willits K, Fowler P. Cost-effectiveness analysis of arthroscopic surgery compared with non-operative management for osteoarthritis of the knee. BMJ Open 2016; 6:e009949. [PMID: 26758265 PMCID: PMC4716206 DOI: 10.1136/bmjopen-2015-009949] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 11/27/2015] [Accepted: 12/10/2015] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine the cost-effectiveness of arthroscopic surgery in addition to non-operative treatments compared with non-operative treatments alone in patients with knee osteoarthritis (OA). DESIGN, SETTING AND PARTICIPANTS We conducted an economic evaluation alongside a single-centre, randomised trial among patients with symptomatic, radiographic knee OA (KL grade ≥ 2). INTERVENTIONS Patients received arthroscopic debridement and partial resection of degenerative knee tissues in addition to optimised non-operative therapy, or optimised non-operative therapy only. MAIN OUTCOME MEASURES Direct and indirect costs were collected prospectively over the 2-year study period. The effectiveness outcomes were the Western Ontario McMaster Osteoarthritis Index (WOMAC) and quality-adjusted life years (QALYs). Cost-effectiveness was estimated using the net benefit regression framework considering a range of willingness-to-pay values from the Canadian public payer and societal perspectives. We calculated incremental cost-effectiveness ratios and conducted sensitivity analyses using the extremes of the 95% CIs surrounding mean differences in effect between groups. RESULTS 168 patients were included. Patients allocated to arthroscopy received partial resection and debridement of degenerative meniscal tears (81%) and/or articular cartilage (97%). There were no significant differences between groups in use of non-operative treatments. The incremental net benefit was negative for all willingness-to-pay values. Uncertainty estimates suggest that even if willing to pay $400,000 to achieve a clinically important improvement in WOMAC score, or ≥$50,000 for an additional QALY, there is <20% probability that the addition of arthroscopy is cost-effective compared with non-operative therapies only. Our sensitivity analysis suggests that even when assuming the largest treatment effect, the addition of arthroscopic surgery is not economically attractive compared with non-operative treatments only. CONCLUSIONS Arthroscopic debridement of degenerative articular cartilage and resection of degenerative meniscal tears in addition to non-operative treatments for knee OA is not an economically attractive treatment option compared with non-operative treatment only, regardless of willingness-to-pay value. TRIAL REGISTRATION NUMBER NCT00158431.
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Affiliation(s)
- Jacquelyn D Marsh
- Faculty of Health Sciences; Bone and Joint Institute; Western University, London, Ontario, Canada
| | - Trevor B Birmingham
- School of Physical Therapy, Faculty of Health Sciences; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada
| | - J Robert Giffin
- Department of Surgery, Schulich School of Medicine and Dentistry; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada
| | - Wanrudee Isaranuwatchai
- Centre for Excellence in Economic Analysis Research (CLEAR), St. Michael's Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey S Hoch
- Department of Public Health Sciences, University of California, Davis (UCD); Center for Healthcare Policy and Research, UCD; Centre for Excellence in Economic Analysis Research (CLEAR), St. Michael's Hospital; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario Canada
| | - Brian G Feagan
- Departments of Medicine, and Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry; Robarts Clinical Trials, Robarts Research Institute; Western University, London, Ontario, Canada
| | - Robert Litchfield
- Department of Surgery, Schulich School of Medicine and Dentistry; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada
| | - Kevin Willits
- Department of Surgery, Schulich School of Medicine and Dentistry; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada
| | - Peter Fowler
- Department of Surgery, Schulich School of Medicine and Dentistry; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada
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Ghomrawi HMK, Alexiades M, Pavlov H, Nam D, Endo Y, Mandl LA, Mushlin AI. Evaluation of Two Appropriateness Criteria for Total Knee Replacement. Arthritis Care Res (Hoboken) 2014; 66:1749-53. [DOI: 10.1002/acr.22390] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 04/22/2014] [Accepted: 06/17/2014] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | - Denis Nam
- Washington University Orthopedics, Barnes Jewish Hospital; St. Louis Missouri
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13
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Smieliauskas F, Lam S, Howard DH. Impact of Negative Clinical Trial Results for Vertebroplasty on Vertebral Augmentation Procedure Rates. J Am Coll Surg 2014; 219:525-33.e1. [DOI: 10.1016/j.jamcollsurg.2014.03.047] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 03/04/2014] [Accepted: 03/04/2014] [Indexed: 10/25/2022]
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Katz JN, Brownlee SA, Jones MH. The role of arthroscopy in the management of knee osteoarthritis. Best Pract Res Clin Rheumatol 2014; 28:143-56. [PMID: 24792949 DOI: 10.1016/j.berh.2014.01.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Technological advances throughout the 20th century enabled an increase in arthroscopic knee surgery, particularly arthroscopic debridement for osteoarthritis (OA) and arthroscopic partial meniscectomy for symptomatic meniscal tear in the setting of OA. However, evaluation of the outcomes of these procedures lagged behind their rising popularity. Not until the early 2000s were rigorous outcomes studies conducted; these showed that arthroscopic debridement for OA was no better than a sham procedure in relieving knee pain or improving functional status, and that patients who underwent arthroscopic partial meniscectomy for a degenerative meniscal tear generally did not show more improvement than those who underwent sham meniscal resection or an intensive course of physical therapy. Though the number of arthroscopic knee procedures for OA performed each year has begun to decline, there remains a significant gap between the evidence and actual practice. Further investigation is needed to shore up the evidence base and bring policy and practice in line with rigorous research.
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Affiliation(s)
- Jeffrey N Katz
- Orthopedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Orthopedic and Arthritis Center for Outcomes Research, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA.
| | - Sarah A Brownlee
- Orthopedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Morgan H Jones
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Mohan AV, Fazel R, Huang PH, Shen YC, Howard D. Changes in Geographic Variation in the Use of Percutaneous Coronary Intervention for Stable Ischemic Heart Disease After Publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) Trial. Circ Cardiovasc Qual Outcomes 2014; 7:125-30. [DOI: 10.1161/circoutcomes.113.000282] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Clinical uncertainty is cited as a cause of geographic variation. However, little is known about the effect of comparative effectiveness research on variation. We examined whether geographic variation in the use of percutaneous coronary intervention (PCI) for stable ischemic heart disease (SIHD) declined after publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial.
Methods and Results—
We examined changes in utilization and geographic variation in 67 hospital referral regions using the State Inpatient Databases. We compared age- and sex-adjusted rates of PCI for SIHD before (2006) and after (2008) publication of the COURAGE trial and compared those with contemporaneous changes in PCI volume for acute coronary syndrome. A total of 272 659 PCIs for SIHD from 526 hospitals were included in the analysis. After the publication of the COURAGE trial, PCI volume for SIHD declined by 25% (
P
<0.001) and decreased by 12% for acute coronary syndrome (
P
<0.001). This was predominantly attributable to changes in hospital referral regions with the highest levels of utilization pre-COURAGE trial (35% decline in the highest tertile versus 18% in the lowest). As measured by the systematic component of variation, there was substantial geographic variation in the use of PCI for SIHD preceding the publication of the COURAGE trial. Variation declined by 28% (0.53 versus 0.40) after publication, but geographic variation remained higher for SIHD than acute coronary syndrome (0.40 versus 0.17).
Conclusions—
There was a substantial decline in the use of and geographic variation in PCI for SIHD after the publication of the COURAGE trial. However, geographic variation in the use of PCI for SIHD remained high.
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Affiliation(s)
- Arun V. Mohan
- From the Department of Medicine, Divisions of Hospital Medicine (A.M.) and Cardiology (R.F.), Emory University School of Medicine, Atlanta, GA; Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (P.-H.H.); Department of Economics, Naval Postgraduate School, Monterey, CA (Y.-C.S.); Associate Professor of Economics, Department of Economics, Naval Postgraduate School, Monterrey, CA (Y.-C.S.); Faculty Research Fellow, National Bureau of Economic Research, Cambridge, MA (Y.-C.S
| | - Reza Fazel
- From the Department of Medicine, Divisions of Hospital Medicine (A.M.) and Cardiology (R.F.), Emory University School of Medicine, Atlanta, GA; Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (P.-H.H.); Department of Economics, Naval Postgraduate School, Monterey, CA (Y.-C.S.); Associate Professor of Economics, Department of Economics, Naval Postgraduate School, Monterrey, CA (Y.-C.S.); Faculty Research Fellow, National Bureau of Economic Research, Cambridge, MA (Y.-C.S
| | - Pei-Hsiu Huang
- From the Department of Medicine, Divisions of Hospital Medicine (A.M.) and Cardiology (R.F.), Emory University School of Medicine, Atlanta, GA; Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (P.-H.H.); Department of Economics, Naval Postgraduate School, Monterey, CA (Y.-C.S.); Associate Professor of Economics, Department of Economics, Naval Postgraduate School, Monterrey, CA (Y.-C.S.); Faculty Research Fellow, National Bureau of Economic Research, Cambridge, MA (Y.-C.S
| | - Yu-Chu Shen
- From the Department of Medicine, Divisions of Hospital Medicine (A.M.) and Cardiology (R.F.), Emory University School of Medicine, Atlanta, GA; Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (P.-H.H.); Department of Economics, Naval Postgraduate School, Monterey, CA (Y.-C.S.); Associate Professor of Economics, Department of Economics, Naval Postgraduate School, Monterrey, CA (Y.-C.S.); Faculty Research Fellow, National Bureau of Economic Research, Cambridge, MA (Y.-C.S
| | - David Howard
- From the Department of Medicine, Divisions of Hospital Medicine (A.M.) and Cardiology (R.F.), Emory University School of Medicine, Atlanta, GA; Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (P.-H.H.); Department of Economics, Naval Postgraduate School, Monterey, CA (Y.-C.S.); Associate Professor of Economics, Department of Economics, Naval Postgraduate School, Monterrey, CA (Y.-C.S.); Faculty Research Fellow, National Bureau of Economic Research, Cambridge, MA (Y.-C.S
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Howard DH, Shen YC. Trends in PCI volume after negative results from the COURAGE trial. Health Serv Res 2013; 49:153-70. [PMID: 23829189 DOI: 10.1111/1475-6773.12082] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To describe trends in the use of percutaneous coronary intervention (PCI) following the COURAGE trial, which found that medical therapy is as effective as PCI for patients with stable angina. DATA SOURCES We used the National Hospital Discharge Survey; inpatient and outpatient discharge data from Florida, Maryland, and New Jersey; and the English Hospital Episode Statistics database. STUDY DESIGN We report trends in PCI volume by diagnosis (stable angina vs. unstable angina or AMI) before and after publication of the COURAGE trial. PRINCIPAL FINDINGS The number of PCIs in patients without a diagnosis of AMI or unstable angina in Florida, Maryland, and New Jersey declined from 48,000 in 2006 to 40,000 in 2008 (-17 percent). There was no change in the number of PCIs in patients with a diagnosis of AMI. We observed similar patterns in U.S. community hospitals. PCI volume did not decline in England. CONCLUSIONS PCI volume declined after publication of the COURAGE trial. The experience of the COURAGE trial suggests that comparative effectiveness research can lead to cost-saving changes in medical practice patterns. However, there are many patients with stable coronary disease who continue to receive PCI post-COURAGE.
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Affiliation(s)
- David H Howard
- Department of Health Policy and Management, Emory University, Atlanta, GA
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Can major systematic reviews influence practice patterns? A case study of episiotomy trends. Arch Gynecol Obstet 2013; 288:1285-93. [DOI: 10.1007/s00404-013-2904-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 05/16/2013] [Indexed: 10/26/2022]
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