There is a rise in knee osteoarthritis, particularly in the aging U.S. population. A practice known as hyaluronic acid (HA) injections is used for the treatment of knee osteoarthritis; however, its efficacy and cost-effectiveness are being debated. In this study, the utilization and costs of HA injections were evaluated during the 12 months preceding total knee arthroplasty (TKA) and the usage of HA injections in end-stage knee osteoarthitis management in relation to other treatments was also evaluated. Truven Health Analytics databases (MarketScan Commercial Claims and Encounters and Medicare Supplemental and Cooridination of Benefits) were reviewed in order to find patients who underwent TKA from 2005 to 2012. All patient-specific osteoarthritis-related health care, including medications, corticosteroid injections, HA injections, imaging, and office visits, as well as payment information were analyzed during the 12 months before TKA.
244,059 patients met the inclusion criteria, and 35,935 (14.7%) of them had > 1 HA injections in the 12-month period. HA accounted for 16.4% of all payments related to osteoarthritis, coming in second only to imaging studies (18.2%). In terms of treatment-specific payments, HA injections accounted for 25.2%, a rate higher than that of any other treatment. Compared with patients who did not receive HA injections, patients who had the injections were significantly more likely to receive additional knee osteoarthritis-related treatment.
HA injections are still frequently used to treat osteoarthritis of the knee even though there have been numerous studies that question their efficacy and cost-effectiveness for that purpose. Based on the results and a lack of data supporting the effectiveness of HA injections in the current cost-conscious health-care climate, the authors of this study concluded that decreasing the use of HA injections for patients with end-stage knee osteoarthritis may substantially reduce cost without adversely affecting the quality of care.
An interesting article, but a lack of perspective of a joint replacement surgeon. We care for the patient at the end of their non-surgical care of the arthritic knee, but are constrained by Medicare and private insurance requirements for an additional 3 to 6 month period of nonsurgical care, i.e. injections, physical therapy, non-narcotic medication and narcotics.
This in spite of prior similar treatments and the absurdity of forcing patients into PT, which only increases their pain at this stage of their arthritis. Many of these patients are already on a home exercise program and PT offers them nothing. The 244,059 patients all came to TKA regardless of these add-on treatments, including HA, which only added to the cost burden. How long must we continue to “check off a box” before the needed TKA is allowed to proceed? How many narcotics must be given before the TKA is allowed to proceed?
This article is interesting in that the inclusion criteria is basically failed nonsurgical management of knee osteoarthritis. I suspect that any study that looks at only patients who have failed conservative treatment prior to any surgery (HNP, THR, etc.) might conclude that this nonsurgical management is wasteful. The author should be careful in making broad conclusions regarding the use of viscosupplements and other conservative treatments in all patients based upon the failure of efficacy in select patients.
Perhaps a study that includes only those patients receiving viscosupplementation that did not go on to need total knee replacement (the successes) would yield different conclusions? I treat many patients who are too young, too old, too sick, fearful, or just not interested in joint replacement. Viscosupplementation is a useful modality, not a cure, and should remain in our armamentarium, in my opinion.