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Cost-effectiveness analysis of arthroscopic surgery compared with non-operative management for osteoarthritis of the knee
  1. Jacquelyn D Marsh1,
  2. Trevor B Birmingham2,
  3. J Robert Giffin3,
  4. Wanrudee Isaranuwatchai4,
  5. Jeffrey S Hoch5,
  6. Brian G Feagan6,
  7. Robert Litchfield3,
  8. Kevin Willits3,
  9. Peter Fowler3
  1. 1Faculty of Health Sciences; Bone and Joint Institute; Western University, London, Ontario, Canada
  2. 2School of Physical Therapy, Faculty of Health Sciences; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada
  3. 3Department of Surgery, Schulich School of Medicine and Dentistry; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada
  4. 4Centre for Excellence in Economic Analysis Research (CLEAR), St. Michael's Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  5. 5Department of Public Health Sciences, University of California, Davis (UCD); Center for Healthcare Policy and Research, UCD; Centre for Excellence in Economic Analysis Research (CLEAR), St. Michael's Hospital; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario Canada
  6. 6Departments of Medicine, and Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry; Robarts Clinical Trials, Robarts Research Institute; Western University, London, Ontario, Canada
  1. Correspondence to Dr Trevor B Birmingham; tbirming{at}uwo.ca and J Robert Giffin; rgiffin@uwo.ca

Abstract

Objective To determine the cost-effectiveness of arthroscopic surgery in addition to non-operative treatments compared with non-operative treatments alone in patients with knee osteoarthritis (OA).

Design, setting and participants We conducted an economic evaluation alongside a single-centre, randomised trial among patients with symptomatic, radiographic knee OA (KL grade ≥2).

Interventions Patients received arthroscopic debridement and partial resection of degenerative knee tissues in addition to optimised non-operative therapy, or optimised non-operative therapy only.

Main outcome measures Direct and indirect costs were collected prospectively over the 2-year study period. The effectiveness outcomes were the Western Ontario McMaster Osteoarthritis Index (WOMAC) and quality-adjusted life years (QALYs). Cost-effectiveness was estimated using the net benefit regression framework considering a range of willingness-to-pay values from the Canadian public payer and societal perspectives. We calculated incremental cost-effectiveness ratios and conducted sensitivity analyses using the extremes of the 95% CIs surrounding mean differences in effect between groups.

Results 168 patients were included. Patients allocated to arthroscopy received partial resection and debridement of degenerative meniscal tears (81%) and/or articular cartilage (97%). There were no significant differences between groups in use of non-operative treatments. The incremental net benefit was negative for all willingness-to-pay values. Uncertainty estimates suggest that even if willing to pay $400 000 to achieve a clinically important improvement in WOMAC score, or ≥$50 000 for an additional QALY, there is <20% probability that the addition of arthroscopy is cost-effective compared with non-operative therapies only. Our sensitivity analysis suggests that even when assuming the largest treatment effect, the addition of arthroscopic surgery is not economically attractive compared with non-operative treatments only.

Conclusions Arthroscopic debridement of degenerative articular cartilage and resection of degenerative meniscal tears in addition to non-operative treatments for knee OA is not an economically attractive treatment option compared with non-operative treatment only, regardless of willingness-to-pay value.

Trial registration number NCT00158431.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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