Friday, February 24, 2017 Study: Knee OA Treatment That Doesn't Follow Guidelines Comes at a Price In brief: Current orthopedic surgeon guidelines recommend use of physical therapy, tramadol, and NSAIDs for nonsurgical treatment of knee OA, and against use of injections and opioids other than tramadol. Analysis of claims utilization data found that the top 3 interventions were corticosteroid injections (46.0%), hyaluronic acid injections (18.0%), and opioids other than tramadol (15.5%), none of which are recommended in the guidelines. Physical therapy was prescribed for only 13.6% patients. Adhering to AAOS treatment guidelines for knee OA could decrease cost of care by 45%. 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 (abstract only available for free) queried the Humana claims database to determine the prevalence of 8 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 8 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 3 most frequent interventions to be CS injections (46.0%), HA injections (18.0%), and opioids (15.5%). Physical therapy was utilized by only 13.6% of patients. More than half of the total cost of knee OA treatment was for noninpatient care, with 29.2% accounted for by HA injections, which AAOS classifies as “Cannot recommend – strong.” The per-patient cost for physical therapy was half that of HA injections. Researchers found that the AAOS-recommended interventions represented only 12.2% of the cost of noninpatient care: 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,” say authors, who also express concern about 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.” Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.