Impact of total knee replacement practice: cost effectiveness analysis of data from the Osteoarthritis Initiative

Abstract

ObjeCtivesTo evaluate the impact of total knee replacement on quality of life in people with knee osteoarthritis and to estimate associated differences in lifetime costs and quality adjusted life years (QALYs) according to use by level of symptoms. DesignMarginal structural modeling and cost effectiveness analysis based on lifetime predictions for total knee replacement and death from population based cohort data.setting Data from two studies-Osteoarthritis Initiative (OAI) and the Multicenter Osteoarthritis Study (MOST)-within the US health system. PartiCiPants 4498 participants with or at high risk for knee osteoarthritis aged 45-79 from the OAI with no previous knee replacement (confirmed by baseline radiography) followed up for nine years. Validation cohort comprised 2907 patients from MOST with two year follow-up.interventiOn Scenarios ranging from current practice, defined as total knee replacement practice as performed in the OAI (with procedural rates estimated by a prediction model), to practice limited to patients with severe symptoms to no surgery. Main OutCOMe MeasuresGeneric (SF-12) and osteoarthritis specific quality of life measured over 96 months, model based QALYs, costs, and incremental cost effectiveness ratios over a lifetime horizon. resultsIn the OAI, total knee replacement showed improvements in quality of life with small absolute changes when averaged across levels of confounding variables: 1.70 (95% uncertainty interval 0.26 to 3.57) for SF-12 physical component summary (PCS); −10.69 (−13.39 to −8.01) for Western Ontario and McMaster Universities arthritis index (WOMAC); and 9.16 (6.35 to 12.49) for knee injury and osteoarthritis outcome score (KOOS) quality of life subscale. These improvements became larger with decreasing functional status at baseline. Provision of total knee replacement to patients with SF-12 PCS scores <35 was the optimal scenario given a cost effectiveness threshold of $200 000/QALY, with cost savings of $6974 ($5789 to $8269) and a minimal loss of 0.008 (−0.056 to 0.043) QALYs compared with current practice. These findings were reproduced among patients with knee osteoarthritis from the MOST cohort and were robust against various scenarios including increased rates of total knee replacement and mortality and inclusion of non-healthcare costs but were sensitive to increased deterioration in quality of life without surgery. In a threshold analysis, total knee replacement would become cost effective in patients with SF-12 PCS scores ≤40 if the associated hospital admission costs fell below $14 000 given a cost effectiveness threshold of $200 000/QALY. COnClusiOn Current practice of total knee replacement as performed in a recent US cohort of patients with knee osteoarthritis had minimal effects on quality of life and QALYs at the group level. If the procedure were restricted to more severely affected patients, its effectiveness would rise, with practice becoming economically more attractive than its current use.

Protective effects of quercetin against inflammation and oxidative stress in a rabbit model of knee osteoarthritis

“…The prevalence of OA is on the rise and it is expected to be continuing increase in the coming decades due to the longevity and the growing prevalence of obesity (Wirth et al, ). A number of risk factors attribute to the development of OA, such as genetic factors, diabetes, obesity, joint infections, and damages from mechanical stress (Ferket et al, ). The management of OA includes weight control, physical activity, medications, joint replacement surgery, and a variety of other techniques (Groen, Diloksumpan, van Weeren, Levato, & Malda, ).…”

“…A number of risk factors attribute to the development of OA, such as genetic factors, diabetes, obesity, joint infections, and damages from mechanical stress (Ferket et al, 2017). The management of OA includes weight control, physical activity, medications, joint replacement surgery, and a variety of other techniques (Groen, Diloksumpan, van Weeren, Levato, & Malda, 2017).…”

Effect of preoperative psychological interventions on elective orthopaedic surgery outcomes: a systematic review and meta‐analysis

“…This in turn impacts the cost effectiveness and clinical impact of these procedures. 6 The role of psychological factors with regard to successful surgical outcomes has been highlighted previously. 7 For example, patients undergoing TKA with preoperative psychological distress are more likely to be more dissatisfied and have worse pain postoperatively.…”

“…With the increasing numbers of procedures, the burden of patients with poor outcomes will also continue to increase. This in turn impacts the cost effectiveness and clinical impact of these procedures …”

Intra-articular Injections for Management of Knee Osteoarthritis

“…Younger patients undergoing primary TKR are also far more likely to require revision surgery in the future due to increased demands and expectations following surgery [6]. Furthermore, a recent analysis performed by Ferket et al found that current practice on TKR operations leads to minimal changes in quality of life and quality adjusted life years, and is only cost-effective in older patients with severe symptoms [7]. For these reasons TKR should ideally be delayed for as long as reasonably possible and initially managed conservatively.…”