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Knee Osteoarthritis Treatment That Doesn’t Follow Guidelines Comes at a Price

If health care providers treated patients with knee osteoarthritis (OA) according to established guidelines that include physical therapy, researchers say costs of treatment could drop by as much as 45%. Yet too many physicians are prescribing interventions that are not supported by evidence and may even carry extra risk.

An award-winning study published in The Journal of Arthroplasty queried the Humana claims database to determine the prevalence of eight nonsurgical treatment modalities—hyaluronic acid (HA) injections, corticosteroid (CS) injections, physical therapy, knee brace, wedge insole, opioids, NSAIDs, and tramadol—used to treat 86,081 patients with knee OA. The patients were receiving conservative treatment in the year prior to total knee arthroplasty (TKA).

Of all eight modalities, only physical therapy, NSAIDs, and tramadol are strongly recommended by the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for nonsurgical management of knee OA. However, authors found the three most frequent interventions to be CS injections (46%), HA injections (18%), and opioids (15.5%). Physical therapy was utilized by only 13.6% of patients.

More than one-half of the total cost of knee OA treatment was for noninpatient care, with HA injections accounting for 29.2%, which AAOS classifies as “cannot recommend—strong.” The per-patient cost for physical therapy was one-half that of HA injections. Researchers found that the AAOS-recommended interventions represented only 12.2% of the cost of noninpatient care, with physical therapy at 10.9%, NSAIDs at 1.2%, and tramadol at 0.1%.

The study shines a bright light on the “high prevalence of low-value interventions in the management of knee OA symptoms in the year prior to TKA,” according to the authors, who also expressed concern about the risk of infection associated with injections. Preoperative use of opioids, they note, has a higher risk for complications and “a more painful recovery” after TKA.

While experts acknowledge they have no data on the interventions’ effectiveness, “given that all patients in this study underwent TKA within a year or less … it seems likely that the treatments were not overly successful in alleviating symptoms.”

— Source: The Journal of Arthroplasty