Cost-effectiveness of total knee replacement in addition to non-surgical treatment: a 2-year outcome from a randomised trial in secondary care in Denmark

Abstract

ObjectiveTo assess the 24-month cost-effectiveness of total knee replacement (TKR) plus non-surgical treatment compared with non-surgical treatment with the option of later TKR if needed.Methods100 adults with moderate-to-severe knee osteoarthritis found eligible for TKR by an orthopaedic surgeon in secondary care were randomised to TKR plus 12 weeks of supervised non-surgical treatment (exercise, education, diet, insoles and pain medication) or to supervised non-surgical treatment alone. Including quality-adjusted life years (QALYs) data from baseline, 3, 6, 12 and 24 months, effectiveness was measured as change at 24 months. Healthcare costs and transfer payments were derived from national registries. Incremental healthcare costs, and incremental cost-effectiveness ratios (ICERs) were calculated. A probabilistic sensitivity analysis was conducted and the probability of cost-effectiveness was estimated at the 22 665 Euros/QALY threshold defined by the National Institute for Health and Care Excellence.ResultsTKR plus non-surgical treatment was more expensive (mean of 23 076 vs 14 514 Euros) but also more effective than non-surgical treatment (mean 24-month improvement in QALY of 0.195 vs 0.056). While cost-effective in the unadjusted scenario (ICER of 18 497 Euros/QALY), TKR plus non-surgical treatment was not cost-effective compared with non-surgical treatment with the option of later TKR if needed in the adjusted (age, sex and baseline values), base-case scenario (ICER of 32 611 Euros/QALY) with a probability of cost-effectiveness of 23.2%. Including deaths, TKR plus non-surgical treatment was still not cost-effective (ICERs of 46 277 to 64 208 Euros/QALY).ConclusionsFrom a 24-month perspective, TKR plus non-surgical treatment does not appear to be cost-effective compared with non-surgical treatment with the option of later TKR if needed in patients with moderate-to-severe knee osteoarthritis and moderate intensity pain in secondary care in Denmark. Results were sensitive to changes, highlighting the need for further confirmatory research also assessing the long-term cost-effectiveness of TKR.Trial registration numberClinicalTrials.gov (NCT01410409).

Are education, exercise and diet interventions a cost-effective treatment to manage hip and knee osteoarthritis? A systematic review

“…A recent trialbased economic evaluation of total knee arthroplasty observed 68% of surgical candidates randomized to an exercise therapy intervention have not proceeded to surgery 2 years after the study period. 53 This exercise and education program would pay for itself if 8% of people with knee OA avoided a total joint replacement. 54 An integrated pathway aligning with OA clinical guidelines would be cost-effective in multiple health systems but could be cost saving if total joint replacement were avoided.…”

Effects of acupuncture at acupoints with lower versus higher pain threshold for knee osteoarthritis: a multicenter randomized controlled trial

“…The management of KOA usually starts with non-drug treatment (e.g., education and exercise) and medications (e.g., nonsteroidal anti-inflammatory drugs, NSAIDs), and ends up with joint replacement surgery [ 4 – 6 ]. Due to undesirable side effects of long-term pharmacological treatments and knee surgery [ 7 – 9 ], complementary and alternative medical (CAM) therapies are increasingly used [ 10 ]. Acupuncture treatment represents the most popular CAM therapy [ 11 , 12 ], evidence from clinical trials and systemic reviews has suggested that acupuncture can be effective in treating pain and dysfunction in patients with KOA [ 9 , 13 – 15 ].…”

Knee-extensor strength, symptoms, and need for surgery after two, four, or six exercise sessions/week using a home-based one-exercise program: A randomized dose-response trial of knee-extensor resistance exercise in patients eligible for knee replacement (the QUADX-1 trial)

“…A care pathway in which exercise therapy is employed prior to knee replacement complies with guideline recommendations while also being cost-effective. [5][6][7][8][9][10]64 We have previously argued that the premise for exercise therapy before potential surgery to enhance postoperative outcomes in patients eligible for knee replacement should be questioned 33 as several systematic reviews conclude no clinically relevant effect. 33,[65][66][67][68][69][70][71][72][73][74] In line with this and based on the results from the QUADX-1 trial, we suggest the use of exercise therapy within the ERAS concept is to "pre-evaluate" to promote shared decision-making in an enhanced care pathway for patients with severe knee OA rather than to "prepare" patients for surgery.…”

“…49,[74][75][76][77][78][79][80][81][82][83] Instead of being a predetermined care pathway (leading to surgery), exercise therapy before potential surgery could be used to inform the shared decision-making process when planning a care pathway, 8,17,18 which complies with guideline recommendations while being costeffective. [5][6][7][8][9][10]84 Based on the results from the QUADX-1 trial, we suggest using simple (one exercise) homebased resistance exercise therapy within the ERAS concept to "pre-evaluate" the need for surgery in patients with severe knee OA rather than to "prepare" patients for surgery.…”