Though 59 patients in therapy group “crossed over” to the surgery group in the first year, five patients in the surgery group subsequently underwent total knee replacement compared with just three in the therapy group. Patients in both groups registered similar scores on the standard physical-function test that is used to measure the outcome of such treatments, the study authors reported.
“These results should change practice,” Rachelle Buchbinder, an epidemiologist at Monash University's School of Public Health and Preventive Medicine in Melbourne, Australia, wrote in an accompanying editorial. The study failed to show an advantage for patients who underwent surgery, she noted.
This latest study adds to the growing body of evidence suggesting arthroscopic surgery is overused in the U.S. and a major contributor to rising healthcare costs. A September 2011 Health Affairs study on physician pay singled out orthopedic surgeons' fees for hip and knee replacements as a key reason why the U.S. spends more than other nations on healthcare. New efforts to rein in those costs using this latest study could have a major financial impact on hospitals, surgical centers and orthopedic physician practices that specialize in arthroscopic surgery.
More than 9 million people in the U.S. have osteoarthritis of the knee, and about 35% of Americans over 50 have population has torn the meniscus cartilage of their knee, according to the study. While two-thirds of these tears are asymptomatic, they result in more than 465,000 arthroscopic partial menisectomies being performed each year.
The report could lead more patients to choose the more conservative path, according to Dr. Jeffrey Katz, director of the Orthopaedic and Arthritis Center for Outcomes Research at Brigham and Women's Hospital, and the study's lead author. The study's main message was that for patients with a torn meniscus, there are two paths leading to the same outcome.
“This is about shared decisionmaking,” said Katz, who presented his findings at the American Academy of Orthopaedic Surgeons annual meeting last week in Chicago. However, he cautioned “there is no right answer” since surgery may lead to quicker results, and that may be preferred by some patients, while others would prefer not to have any surgery at all. “This is a perfect example of where shared decision making is part of high-quality care,” Katz said.
Yet the fact that nearly a third of patients in the physical therapy-only arm eventually got surgery suggested to one co-author of the NEJM study, Dr. Matthew Matava, a professor of orthopedic surgery at the Washington University School of Medicine in St. Louis, that some patients with more severe injuries may be misled by the findings. “A key part is that there was a significant amount of patients who crossed over,” he said. “I don't know if the lay public understands that.”
Still, the latest findings are certain to stoke the debate that arthroscopic knee surgeries are being overused in the U.S. “To surgeons, that's a threatening message,” Katz said.
Orthopedic surgeons do feel under siege. In his speech at the AAOS meeting, incoming president Dr. Joshua Jacobs, chairman of the orthopedic surgery department at Rush University in Chicago, said “the specialty of orthopedic surgery has been a particular target of the government, in part due to the cost of implants and the creative history of orthopedic surgeons as innovators and inventors.”
That history has included deep financial ties between many surgeons and manufacturers of orthopedic devices, which has attracted the attention of the U.S. Justice Department and Medicare recovery audit contractors. Government investigators have sought to “claw back” payments made for hip and knee replacement surgeries.
“The procedures we do are under intense scrutiny,” Jacobs said. He cited a Journal of the American Medical Association study that reported a doubling of the per capita rate of total knee replacements in the Medicare population between 1991 and 2010.
“A steady stream of scientific papers, editorials, op-ed pieces, media reports and coverage decisions have been released addressing the so-called overutilization of joint replacement procedures,” Jacobs said. “However, instead of framing this increased utilization as a marker of the success of this procedure and the value it provides to patients and society, many media outlets focused on the role that total knee replacement demand will play in driving up healthcare costs, hinting that the procedure is being over-utilized and that limiting access to knee replacement may be necessary.”
Jacobs told the assembled surgeons they have to become advocates of quality and be part of efforts to develop clinical practice guidelines and appropriate use criteria.
There are other factors besides surgeons being quick to prescribe the procedure driving increased use, other experts said. As the operations have become more common, word-of-mouth and advertising have led to increased demand from patients. Dr. Mark Olson, a trauma surgeon in private practice working mostly out of Providence Sacred Heart Medical Center in Spokane, Wash., said the message of the NEJM study needed to get out to patients who sometimes see surgery as their first and only option.
“The attitude we have to change is, 'I have insurance, I should have it done,'” Olson said. “As time goes on, we'll have more studies like this, and I'll be able to say the preponderance of evidence shows that this surgery doesn't need to be done at this time. There are things in the body that aren't perfect, but they still work well.”
He acknowledged that this message just might send the patient to another surgeon, who—incentivized by money rather than the patient's best interests—would be happy to do it.
Ort, whose decision to wait had good results, said surgeons need to educate patients who push for quick surgeries. “It can be tough,” he said. “But you have to be part of the solution.”