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Background: Thumb carpometacarpal joint (CMC) osteoarthritis is the most symptomatic hand arthritis but the long-term healthcare burden for managing this condition is unknown. We sought to compare total healthcare cost and utilisation for operative and nonoperative treatments of thumb CMC arthritis. Methods: We conducted a retrospective longitudinal analysis using a large nationwide insurance claims database. A total of 18,705 patients underwent CMC arthroplasty (trapeziectomy with or without ligament reconstruction tendon interposition) or steroid injections between 1 October 2015 and 31 December 2018. Primary outcomes, healthcare utilisation and costs were measured from 1 year pre-intervention to 3 years post-intervention. Generalised linear mixed effect models adjusted for potentially confounding factors such as the Elixhauser comorbidity score with propensity score matching were applied to evaluate the association between the primary outcomes and treatment type. Results: A total of 13,646 patients underwent treatment through steroid injections, and 5,059 patients underwent CMC arthroplasty. At 1 year preoperatively, the surgery group required $635 more healthcare costs (95% CI [594.28, 675.27]; p < 0.001) and consumed 42% more healthcare utilisation (95% CI [1.38, 1.46]; p < 0.0001) than the steroid injection group. At 3 years postoperatively, the surgery group required $846 less healthcare costs (95% CI [-883.07, -808.51], p < 0.0001) and had 51% less utilisation (95% CI [0.49, 0.53]; p < 0.0001) annually. Cumulatively over 3 years, the surgical group on average was $4,204 costlier than its counterpart secondary to surgical costs. Conclusions: CMC arthritis treatment incurs high healthcare cost and utilisation independent of other medical comorbidities. At 3 years postoperatively, the annual healthcare cost and utilisation for surgical patients were less than those for patients who underwent conservative management, but this difference was insufficient to offset the initial surgical cost. Level of Evidence: Level III (Therapeutic).
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Artroplastia , Articulações Carpometacarpais , Custos de Cuidados de Saúde , Osteoartrite , Polegar , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Retrospectivos , Osteoartrite/cirurgia , Osteoartrite/economia , Articulações Carpometacarpais/cirurgia , Custos de Cuidados de Saúde/estatística & dados numéricos , Polegar/cirurgia , Artroplastia/economia , Artroplastia/estatística & dados numéricos , Idoso , Estudos Longitudinais , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Injeções Intra-Articulares/economia , AdultoRESUMO
INTRODUCTION: Shoulder pain is one of the common musculoskeletal complaints of the patients with spinal cord injury. Corticosteroid injection to the subacromial bursa is one of the confirmed therapies which can be guided by anatomic landmarks or ultrasound. This study is aimed to compare these two methods to find the one with the highest therapeutic impact. MATERIALS AND METHODS: In this study, 30 patients with paraplegic SCI suffering from shoulder pain were enrolled. They were divided into 2 groups based on 4-block randomization sampling. The first group received subacromial corticosteroid injection through anatomic landmarks; while in the second group, the injection was guided by ultrasound. VAS criterion was employed for investigation of pain severity; while the constant score was used to study the shoulder pain and function. BREF questionnaire was also applied to examine the quality of life. FINDINGS: The mean scores of VAS and Constant in both groups showed a significant improvement two months after intervention when compared with their condition before the intervention. This improvement was significantly higher in the ultrasound group. The physical, physiological and environmental health scores of BREF questionnaire as well as their total score showed a significant improvement in both groups two months after intervention. But this improvement was not significantly different between the two groups in terms of any of the items. DISCUSSION: Hence, although ultrasound-guided injection is more costly and requires higher skills in comparison with blind injection, it is significantly more effective in controlling the pain and improving the shoulder function.
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Corticosteroides/administração & dosagem , Bolsa Sinovial , Injeções Intra-Articulares , Paraplegia/complicações , Manguito Rotador , Dor de Ombro/tratamento farmacológico , Dor de Ombro/etiologia , Traumatismos da Medula Espinal/complicações , Tendinopatia/complicações , Ultrassonografia de Intervenção , Adolescente , Adulto , Humanos , Injeções Intra-Articulares/economia , Injeções Intra-Articulares/métodos , Injeções Intra-Articulares/normas , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Método Simples-Cego , Ultrassonografia de Intervenção/economia , Ultrassonografia de Intervenção/métodos , Ultrassonografia de Intervenção/normas , Adulto JovemRESUMO
PURPOSE: To examine the cost-effectiveness of a series (total of 3 injections) of intra-articular platelet-rich plasma (PRP) injections in comparison to that of hyaluronic acid (HA) viscosupplementation for the treatment of symptomatic knee osteoarthritis. METHODS: Outcome data regarding the use of PRP or HA injections for the treatment of symptomatic knee osteoarthritis were determined from the highest-quality data (Level I) available in the literature until 2015. Health utility values were then derived from these high-quality data. Costs were determined by examining typical charges for patients undergoing a series of either PRP or HA injections for the treatment of this condition at a large private orthopaedic practice. These health utility values and costs were used to create an expected-value decision analysis model. RESULTS: The results of the model revealed that the cost per quality-adjusted life-year (QALY) of a series of PRP injections was $8,635.23/QALY and that of a series of HA injections was $5,331.75/QALY. A series of PRP injections was associated with a higher initial cost than a series of HA injections (difference, $1,433.67); however, PRP was also more effective (higher utility value) than HA by 0.11 QALYs (0.69 vs 0.58, P = .0062) at 1 year. The incremental cost-effectiveness ratio of the use of PRP injections as opposed to HA was $12,628.15/QALY. CONCLUSIONS: Although a series of either PRP ($8,635.23/QALY) or HA ($5,331.75/QALY) injections for the treatment of symptomatic knee osteoarthritis would be considered cost-effective (cost per QALY < $50,000), PRP injections were not more cost-effective than HA injections. However, PRP was significantly more effective at 1 year, and being associated with an incremental cost-effectiveness ratio of $12,628.15/QALY when compared with HA, a series of PRP injections should be considered a reasonable and acceptable alternative to HA injections for the treatment of symptomatic knee osteoarthritis. LEVEL OF EVIDENCE: Level II, economic and decision analysis of Level I studies.
Assuntos
Ácido Hialurônico/administração & dosagem , Osteoartrite do Joelho/terapia , Plasma Rico em Plaquetas , Viscossuplementos/administração & dosagem , Adulto , Análise Custo-Benefício , Humanos , Injeções Intra-Articulares/economia , Masculino , Anos de Vida Ajustados por Qualidade de Vida , Resultado do Tratamento , Viscossuplementação/métodosRESUMO
PURPOSE: To identify the price of treatment at which platelet-rich plasma (PRP) is cost-effective relative to hyaluronic acid (HA) and saline solution intra-articular injections. METHODS: A systemized review process of the PubMed, Embase, and MEDLINE databases was undertaken to identify randomized controlled trials comparing PRP with HA and saline solution with up to 1 year of follow-up. Level I trials that reported Western Ontario and McMaster Universities Arthritis Index Likert scores were included. These scores were converted into utility scores. Cost data were obtained from Centers for Medicare & Medicaid Services fee schedules. Total costs included the costs of the injectable, clinic appointments, and procedures. The change in utility scores from baseline to 6 months and 1 year for the PRP, HA, and saline solution groups was divided by total cost to determine utility gained per dollar and to identify the price needed for PRP to be cost-effective relative to these other injection options. RESULTS: Nine randomized controlled trials met the inclusion criteria. A total of 882 patients were included: 483 in the PRP group, 338 in the HA group, and 61 in the saline solution group. Baseline mean utility scores ranged from 0.55 to 0.57 for the PRP, HA, and saline solution groups. The 6-month gains in utility were 0.12, 0.02, and -0.06, respectively. The 12-month gains in utility from before injection were 0.14, 0.03, and 0.06, respectively. The lowest total costs for HA and saline solution were $681.93 and $516.29, respectively. For PRP to be cost-effective, the total treatment cost would have to be less than $3,703.03 and $1,192.08 for 6- and 12-month outcomes, respectively. CONCLUSIONS: For patients with symptomatic knee osteoarthritis, PRP is cost-effective, from the payer perspective, at a total price (inclusive of clinic visits, the procedure, and the injectable) of less than $1,192.08 over a 12-month period, relative to HA and saline solution. LEVEL OF EVIDENCE: Level I, systematic review.
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Análise Custo-Benefício , Injeções Intra-Articulares/economia , Osteoartrite do Joelho/economia , Osteoartrite do Joelho/terapia , Medição da Dor/métodos , Plasma Rico em Plaquetas , Comércio , Humanos , Ácido Hialurônico/administração & dosagem , Medicare , Ensaios Clínicos Controlados Aleatórios como Assunto , Índice de Gravidade de Doença , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: Intra-articular corticosteroid injections (IACI) are frequently used in the treatment of juvenile idiopathic arthritis. There is a paucity of evidence-based research describing methods of pain and anxiety control for this procedure. IACI were mostly performed under general anesthesia for children younger than 13 years old in our institution as of 2014. We started to integrate sedation services more commonly in our institution with the minimal sedation/anxiolysis (MSA) protocol outlined as an alternative to general anesthesia for IACI in 2015. The purpose of this study was to evaluate the effectiveness and cost savings of a minimal sedation protocol for intra-articular corticosteroid injections in juvenile idiopathic arthritis patients after instituting this protocol at our institution. METHODS: The MSA protocol included nitrous oxide, intranasal fentanyl, a topical numbing agent, acetaminophen, ibuprofen, ondansetron and child life intervention. A retrospective review of prospectively collected data was performed on a total of 80 consecutive patients with juvenile idiopathic arthritis who underwent joint injections using the protocol. RESULTS: The procedure was successfully completed in greater than 95% of the patients. The median pain score (measured on a verbal numeric scale of 0-10) reported by the patient was 1 (IQR 0-2.5), by the parent 1 (IQR 0-2), by the rheumatologist 1 (IQR 0-1), and by the sedationist 1 (IQR 0-1). Degree of motion during the procedure was reported by the rheumatologist and the sedationist as none in 68% of the patients, mild in 36% and moderate in 6%. Patient, parent, rheumatologist and sedationist rated satisfaction as very high in the vast majority (94%). Emesis was reported in only 2 (2.5%) patients, no significant adverse events were reported, and no patients progressed to a deeper level of sedation than intended. Financial analysis revealed a 33% cost reduction compared with the use of general anesthesia in the operating room. CONCLUSIONS: A minimal sedation/anxiolysis protocol (including nitrous oxide, intranasal fentanyl, a topical numbing agent, acetaminophen, ibuprofen, ondansetron and child life intervention), provides safe and effective analgesia for intra-articular corticosteroid injection in a subset of patients with juvenile idiopathic arthritis and offers a lower cost alternative to general anesthesia.
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Ansiolíticos/administração & dosagem , Artrite Juvenil/tratamento farmacológico , Sedação Consciente/métodos , Redução de Custos/estatística & dados numéricos , Glucocorticoides/administração & dosagem , Adolescente , Ansiolíticos/efeitos adversos , Criança , Pré-Escolar , Sedação Consciente/efeitos adversos , Sedação Consciente/economia , Feminino , Humanos , Injeções Intra-Articulares/efeitos adversos , Injeções Intra-Articulares/economia , Injeções Intra-Articulares/métodos , Masculino , Manejo da Dor/efeitos adversos , Manejo da Dor/economia , Manejo da Dor/métodos , Medição da Dor/métodos , Satisfação do Paciente/estatística & dados numéricos , Estudos RetrospectivosRESUMO
INTRODUCTION: The use of stem cell therapy (SCT) and platelet-rich plasma (PRP) injection for knee osteoarthritis (OA) is extremely controversial and at best experimental stage. These treatments are being offered across the nation for "cash-only payments." Our objectives were to determine (1) what proportion of board-certified orthopedic surgeons in Miami-Dade County offer SCT or PRP and (2) how much do practices charge for these services. METHODS: All board-certified orthopedic surgeons' offices in Miami-Dade County were identified by their American Academy of Orthopaedic Surgeons active membership. Offices were contacted and presented a hypothetical patient with end-stage OA searching for treatment (SCT or PRP injections) before having to undergo surgery. RESULTS: Of the 96 registered American Academy of Orthopaedic Surgeons member's offices, 91 (94.7%) were contacted, 36% of offices offered PRP, and 24.5% offered SCT. However, 81% of the offices were transparent on the pricing of PRP, whereas 42% gave a price for SCT. Remaining practices stated that pricing would be "determined or discussed" during a scheduled visit. Mean cost for PRP injection was $897 (range, $350 to $1,700), and for SCT injection, it was $3,100 (range, $1,200 to $6,000). DISCUSSION: Biological injectables as treatment of knee OA have potential use in the nonsurgical management of this disease. Data on the effectiveness are lacking and are conflicting. Data should continue to be investigational. LEVEL OF EVIDENCE: Level IV.
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Osteoartrite do Joelho/economia , Osteoartrite do Joelho/terapia , Plasma Rico em Plaquetas , Padrões de Prática Médica/economia , Transplante de Células-Tronco/economia , Florida , Humanos , Injeções Intra-Articulares/economia , Cirurgiões OrtopédicosRESUMO
Platelet-rich plasma (PRP) injections are often used for the treatment of knee osteoarthritis (OA), despite clinical value and cost-effectiveness not being definitely established. PRP injections are considered as a potential means of reducing pain and improving function in patients with knee OA, in the hope of delaying or avoiding the need for surgical intervention. Centers that offer PRP injections usually charge patients out of pocket and directly market services. Therefore, the purpose of this study was to quantify the current (1) prices and (2) marketed clinical efficacy of autologous PRP injections for knee OA. A prospective cross-sectional study was performed based on 286 centers identified in the United States offering PRP injections for knee OA. A total of 179 (73.4%) centers were successfully contacted via e-mail or phone, using a simulated 52-year-old male patient with knee OA. Scripted questions were asked by the simulated patient to determine the current marketed prices and clinical efficacy, either reported as "good results" or "symptomatic improvement," claimed by each treating center. The mean price for a single unilateral knee same-day PRP injection was $714 with a standard deviation of $144 (95% confidence interval [CI]: $691-737, n = 153). The mean claim of clinical efficacy was 76% with a standard deviation of 11% (95% CI: 73.5-78.3%, n = 84). Out of the 84 clinics, 10 claimed "90 to 100% efficacy," 27 claimed "80 to 90%," 29 claimed "70 to 80%," 9 claimed "60 to 70%," 8 claimed "50 to 60%," and 1 claimed "40 to 60%." These findings provide a unique perspective on the PRP market for the treatment of knee OA that is valuable to physicians and health care providers in providing better education to patients on the associated costs and purported clinical benefits of PRP injections.
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Osteoartrite do Joelho/terapia , Plasma Rico em Plaquetas , Comércio/estatística & dados numéricos , Análise Custo-Benefício , Estudos Transversais , Humanos , Injeções Intra-Articulares/economia , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/economia , Dor , Estudos Prospectivos , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: Evidence on the effectiveness of intra-articular corticosteroid injection for hip osteoarthritis is limited and conflicting. The primary objective of the Hip Injection Trial (HIT) is to compare pain intensity over 6 months, in people with hip OA between those receiving an ultrasound-guided intra-articular hip injection of corticosteroid with 1% lidocaine hydrochloride plus best current treatment with those receiving best current treatment alone. Secondary objectives are to determine specified comparative clinical and cost-effectiveness outcomes, and to explore, in a linked qualitative study, the lived experiences of patients with hip OA and experiences and impact of, ultrasound-guided intra-articular hip injection. METHODS: The HIT trial is a pragmatic, three-parallel group, single-blind, superiority, randomised controlled trial in patients with painful hip OA with a linked qualitative study. The current protocol is described, in addition to details and rationale for amendments since trial registration. 204 patients with moderate-to-severe hip OA will be recruited. Participants are randomised on an equal basis (1:1:1 ratio) to one of three interventions: (1) best current treatment, (2) best current treatment plus ultrasound-guided intra-articular hip injection of corticosteroid (triamcinolone acetonide 40 mg) with 1% lidocaine hydrochloride, or (3) best current treatment plus an ultrasound-guided intra-articular hip injection of 1% lidocaine hydrochloride alone. The primary endpoint is patient-reported hip pain intensity across 2 weeks, 2 months, 4 months and 6 months post-randomisation. Recruitment is over 29 months with a 6-month follow-up period. To address the primary objective, the analysis will compare participants' 'average' follow-up pain NRS scores, based on a random effects linear repeated-measures model. Data on adverse events are collected and reported in accordance with national guidance and reviewed by external monitoring committees. Individual semi-structured interviews are being conducted with up to 30 trial participants across all three arms of the trial. DISCUSSION: To ensure healthcare services improve outcomes for patients, we need to ensure there is a robust and appropriate evidence-base to support clinical decision making. The HIT trial will answer important questions regarding the clinical and cost-effectiveness of intra-articular corticosteroid injections. TRIAL REGISTRATION: ISRCTN: 50550256 , 28th July 2015.
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Anestésicos Locais/economia , Análise Custo-Benefício/métodos , Glucocorticoides/economia , Osteoartrite do Quadril/tratamento farmacológico , Osteoartrite do Quadril/economia , Ultrassonografia de Intervenção/economia , Corticosteroides/administração & dosagem , Corticosteroides/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestésicos Locais/administração & dosagem , Feminino , Seguimentos , Glucocorticoides/administração & dosagem , Humanos , Injeções Intra-Articulares/economia , Injeções Intra-Articulares/métodos , Lidocaína/administração & dosagem , Lidocaína/economia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Osteoartrite do Quadril/diagnóstico por imagem , Medição da Dor/efeitos dos fármacos , Medição da Dor/economia , Medição da Dor/métodos , Método Simples-Cego , Resultado do Tratamento , Triancinolona Acetonida/administração & dosagem , Triancinolona Acetonida/economia , Ultrassonografia de Intervenção/métodosRESUMO
OBJECTIVE: The purpose of this study was to determine the cost-effectiveness of landmark-based and image-guided intraarticular steroid injections for the initial treatment of a population with adhesive capsulitis. MATERIALS AND METHODS: A decision analytic model from the health care system perspective over a 6-month time frame for 50-year-old patients with clinical findings consistent with adhesive capsulitis was used to evaluate the incremental cost-effectiveness of three techniques for administering intraarticular steroid to the glenohumeral joint: landmark based (also called blind), ultrasound guided, and fluoroscopy guided. Input data on cost, probability, and utility estimates were obtained through a comprehensive literature search and from expert opinion. The primary effectiveness outcome was quality-adjusted life years (QALY). Costs were estimated in 2017 U.S. dollars. RESULTS: Ultrasound-guided injections were the dominant strategy for the base case, because it was the least expensive ($1280) and most effective (0.4096 QALY) strategy of the three options overall. The model was sensitive to the probabilities of getting the steroid into the joint by means of blind, ultrasound-guided, and fluoroscopy-guided techniques and to the costs of the ultrasound-guided and blind techniques. Two-way sensitivity analyses showed that ultrasound-guided injections were favored over blind and fluoroscopy-guided injections over a range of reasonable probabilities and costs. Probabilistic sensitivity analysis showed that ultrasound-guided injections were cost-effective in 44% of simulations, compared with 34% for blind injections and 22% for fluoroscopy-guided injections and over a wide range of willingness-to-pay thresholds. CONCLUSION: Ultrasound-guided injections are the most cost-effective option for the initial steroid-based treatment of patients with adhesive capsulitis. Blind and fluoroscopy-guided injections can also be cost-effective when performed by a clinician likely to accurately administer the medication into the correct location.
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Bursite/tratamento farmacológico , Análise Custo-Benefício , Fluoroscopia/economia , Injeções Intra-Articulares/economia , Dor de Ombro/tratamento farmacológico , Esteroides/administração & dosagem , Esteroides/economia , Ultrassonografia de Intervenção/economia , Pontos de Referência Anatômicos , Bursite/diagnóstico por imagem , Técnicas de Apoio para a Decisão , Feminino , Humanos , Masculino , Anos de Vida Ajustados por Qualidade de Vida , Dor de Ombro/diagnóstico por imagem , Resultado do Tratamento , Estados UnidosAssuntos
Injeções Intra-Articulares/economia , Injeções Intra-Articulares/métodos , Injeções Intramusculares/economia , Injeções Intramusculares/métodos , Ultrassonografia de Intervenção/economia , Ultrassonografia de Intervenção/métodos , Humanos , Injeções Intra-Articulares/instrumentação , Injeções Intramusculares/instrumentação , Ultrassonografia de Intervenção/instrumentaçãoRESUMO
BACKGROUND: This study investigated preoperative interventions and their costs in the 2-year period before a patient undergoing a unicompartmental knee arthroplasty (UKA). METHODS: A retrospective cohort analysis of patients undergoing UKA between 2009 and 2011 was conducted using the PearlDiver Patient Record Database to track inpatient and outpatient billing records. RESULTS: One thousand eight hundred forty-one patients from Medicare and 4704 patients from United Healthcare underwent UKA between 2009 and 2011. In the 2 years before UKA, the per patient average charge was $3919.96 for Medicare patients and $5219.14 for United Healthcare patients, with 21.7% of Medicare-associated charges and 28.2% of United Healthcare-associated charges occurring within 3 months of surgery. In the 2-year period before surgery, 65.5% of Medicare patients and 53.6% of United Healthcare patients received an intra-articular injection, with 29.1% (Medicare) and 46.0% (United Healthcare) of these injections occurring within 3 months of surgery. In addition, 15.1% of Medicare patients and 20.7% of United Healthcare patients underwent an arthroscopy, with between 32.4% and 43.8% of these occurring in the final 6 months before UKA. CONCLUSION: Preoperative interventions (ie, imaging, procedures, physical therapy, and injections) occur at a high frequency in close proximity to UKA resulting in substantial costs. The development of algorithms to guide management of these patients is critical in reducing costs before UKA.
Assuntos
Artroplastia do Joelho/economia , Artroscopia/economia , Osteoartrite do Joelho/economia , Osteoartrite do Joelho/terapia , Cuidados Pré-Operatórios/economia , Idoso , Artroscopia/estatística & dados numéricos , Bases de Dados Factuais , Honorários e Preços/estatística & dados numéricos , Humanos , Injeções Intra-Articulares/economia , Injeções Intra-Articulares/estatística & dados numéricos , Articulação do Joelho/cirurgia , Imageamento por Ressonância Magnética/estatística & dados numéricos , Medicare/economia , Pessoa de Meia-Idade , Visita a Consultório Médico/economia , Osteoartrite do Joelho/diagnóstico por imagem , Modalidades de Fisioterapia/economia , Estudos Retrospectivos , Estados UnidosRESUMO
Given the wide difference in price per vial between various presentations of hyaluronic acid, this study seeks to compare the effectiveness and treatment cost of stabilized hyaluronic acid (NASHA) in a single injection with standard preparations of hyaluronic acid (HA) in five injections in osteoarthritis (OA) of the knee. Fifty-four patients with knee osteoarthritis (Kellgren-Lawrence Grade II and III) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain score greater than 7, with a homogeneous distribution of age, sex, BMI, and duration of disease, were included in this study. Patients were randomized into two groups: Group I was treated with NASHA (Durolane®) and Group II with HA (Go-ON®). Patient's evolution was followed up at the 1st, 2nd, 4th, 8th, 12th, and 26th week after treatment. A statistically significant improvement in WOMAC score was observed for patients treated with NASHA versus those who received HA at Week 26. In addition, the need for analgesia was significantly reduced at Week 26 in the NASHA-treated group. Finally, the economic analysis showed an increased cost of overall treatment with HA injections. Our data support the use of the NASHA class of products in the treatment of knee OA.
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Custos de Cuidados de Saúde , Ácido Hialurônico/administração & dosagem , Osteoartrite do Joelho/tratamento farmacológico , Viscossuplementação/economia , Adulto , Idoso , Feminino , Humanos , Ácido Hialurônico/economia , Injeções Intra-Articulares/economia , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/economia , Distribuição Aleatória , Viscossuplementação/métodosRESUMO
Objective This paper discusses the potential for horizon scanning to identify low-value, inappropriate clinical practices that deliver minimal benefit to patients and represent a considerable financial burden on the health system. Methods Platelet-rich plasma (PRP) was identified by routine horizon scanning as a potentially innovative treatment alternative for osteoarthritis of the knee. A rapid, non-systematic assessment of the evidence pertaining to the safety and effectiveness of PRP compared with nonsteroidal anti-inflammatory drugs (NSAIDs) for the treatment of osteoarthritis of the knee was conducted. Results The evidence base supporting the use of PRP for the treatment of osteoarthritis was poor. No comparative studies were identified that compared the use of PRP to NSAIDs, the current treatment option for osteoarthritis of the knee in Australia. Despite the lack of effectiveness evidence, the use of PRP injections was rapidly increasing in the private sector using an inappropriate Medicare Benefits Schedule item number. Conclusions This assessment highlights the potential of using established horizon scanning methodologies to identify targets for full or partial disinvestment of ineffective, inefficient or harmful clinical practices. What is known about the topic? PRP is rapidly diffusing in the private health system in Australia, however the use of a Medicare Benefits Schedule item number meant that this practice was being subsidised by the public reimbursement of treatment fees. What does this paper add? Traditional horizon scanning tends to identify technologies for health systems to invest in. The evidence on the effectiveness of PRP was examined with the purpose of exploring investment in an innovative treatment that may have reduced the number of invasive procedures being performed in the public hospital system. The current evidence base does not support the use of PRP injections for the treatment of osteoarthritis. It does, however, support the use of horizon scanning as an inexpensive methodology to identify possible disinvestment targets associated with potential patient harm and high health service expenditure. What are the implications for practitioners? Practitioners should be aware that public funding for the injection of PRP should not be used for the treatment of osteoarthritis.
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Medicina Baseada em Evidências , Osteoartrite do Joelho/terapia , Plasma Rico em Plaquetas , Procedimentos Desnecessários , Anti-Inflamatórios não Esteroides/economia , Anti-Inflamatórios não Esteroides/uso terapêutico , Austrália , Difusão de Inovações , Humanos , Injeções Intra-Articulares/economia , Medição de Risco , Resultado do Tratamento , Procedimentos Desnecessários/economiaRESUMO
BACKGROUND: The prevalence of knee osteoarthritis is increasing in the aging U.S. POPULATION: The efficacy and cost-effectiveness of the use of hyaluronic acid (HA) injections for the treatment of knee osteoarthritis are debated. In this study, we assessed the utilization and costs of HA injections in the 12 months preceding total knee arthroplasty (TKA) and evaluated the usage of HA injections in end-stage knee osteoarthritis management in relation to other treatments. METHODS: MarketScan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits databases (Truven Health Analytics) were reviewed to identify patients who underwent TKA from 2005 to 2012. The utilization of patient-specific osteoarthritis-related health care (including medications, corticosteroid injections, HA injections, imaging, and office visits) and payment information were analyzed for the 12 months preceding TKA. RESULTS: A total of 244,059 patients met the inclusion criteria. Of those, 35,935 (14.7%) had ≥1 HA injection in the 12 months preceding TKA. HA injections were responsible for 16.4% of all knee osteoarthritis-related payments, trailing only imaging studies (18.2%), and HA injections accounted for 25.2% of treatment-specific payments, a rate that was higher than that of any other treatment. Patients receiving HA injections were significantly more likely to receive additional knee osteoarthritis-related treatments compared with patients who did not receive HA injections. CONCLUSIONS: Despite numerous studies questioning the efficacy and cost-effectiveness of HA injections for osteoarthritis of the knee, HA injections are still utilized for a substantial percentage of patients. Given the paucity of data supporting the effectiveness of HA injections and the current cost-conscious health-care climate, decreasing their use among patients with end-stage knee osteoarthritis may represent a substantial cost reduction that likely does not adversely impact the quality of care.
Assuntos
Ácido Hialurônico/uso terapêutico , Injeções Intra-Articulares/estatística & dados numéricos , Osteoartrite do Joelho/tratamento farmacológico , Viscossuplementos/uso terapêutico , Idoso , Artroplastia do Joelho/economia , Análise Custo-Benefício , Feminino , Custos de Cuidados de Saúde , Humanos , Ácido Hialurônico/administração & dosagem , Ácido Hialurônico/economia , Injeções Intra-Articulares/economia , Articulação do Joelho/cirurgia , Masculino , Medicare , Pessoa de Meia-Idade , Osteoartrite do Joelho/economia , Estados Unidos , Viscossuplementos/administração & dosagem , Viscossuplementos/economiaRESUMO
INTRODUCTION: Osteoarthritis (OA), as one of the leading causes of disability, decreases the quality of life for those suffering from the disease and creates a substantial financial burden. Intra-articular hyaluronic acid (HA) can provide relief from the symptoms of OA and multiple HA products are prescribed. The purpose of this study is to examine the single payer cost-effectiveness of various HA products in the treatment of knee OA. METHODS: A single payer economic evaluation was conducted comparing Synvisc(®) (Sanofi, USA), Durolane(®) (Bioventus, USA), Hyalgan(®) (Fidia Pharma Inc., USA), Supartz™ (Bioventus, USA), and Euflexxa(®) (Ferring Pharmaceuticals Inc., USA). Utility scores for HA products were obtained by extracting Western Ontario and McMaster Universities Arthritis Index pain, stiffness and function from randomized controlled trials and converting them to health utilities index mark 3 scores. The cost of a treatment included the cost of the HA injection, cost of a knee injection procedure and cost of a doctor's visit for each required injection. Cost-utility in 2015 USD per quality-adjusted life years (QALY) saved was calculated for each HA product, and incremental cost-effectiveness ratios were calculated to compare the effectiveness of HA products to one another and to conventional care. RESULTS: When compared to conventional care, all investigated HA products were cost-effective, assuming a willingness-to-pay threshold of $50,000/QALY gained. The HA product Euflexxa had the most favorable cost-utility ratio ($5785.52/QALY) when compared to all other HA brands. CONCLUSION: The present study showed several HA products to be cost-effective in comparison to conventional care, with Euflexxa having the most favorable cost/QALY gained ratio compared to the other HA products. FUNDING: Ferring Pharmaceutics Inc.
Assuntos
Ácido Hialurônico , Injeções Intra-Articulares , Osteoartrite do Joelho , Análise Custo-Benefício , Humanos , Ácido Hialurônico/economia , Ácido Hialurônico/uso terapêutico , Injeções Intra-Articulares/economia , Injeções Intra-Articulares/métodos , Injeções Intra-Articulares/estatística & dados numéricos , Osteoartrite do Joelho/tratamento farmacológico , Osteoartrite do Joelho/economia , Anos de Vida Ajustados por Qualidade de Vida , Resultado do Tratamento , Estados Unidos , Revisão da Utilização de Recursos de Saúde , Viscossuplementos/classificação , Viscossuplementos/economia , Viscossuplementos/uso terapêuticoRESUMO
BACKGROUND: Complaints of knee pain secondary to early osteoarthritis may account for up to 30% of visits to primary care physicians. Due to the proposed inflammatory changes in early osteoarthritis, intra-articular injections of corticosteroids (IACS) have been considered as an option for disease progression modification, pain control, and improvement of function. However, some studies have suggested poor accuracy rates of IA injections depending on the entry site chosen. It is therefore the aim of this study to evaluate the efficacy of IA knee corticosteroid injection in reducing pain and improving function in patients with early osteoarthritis and whether the low accuracy rates reported with the Anterolateral joint line injection site translate to worse functional and pain outcome measures as compared to Suprapatellar lateral injections. MATERIALS AND METHODS: The study was carried out as an open-label, randomized controlled trial with 60 sequential patients recruited. Simple randomization separated groups into anterolateral joint line or suprapatellar lateral injection sites. Improvements were measured with WOMAC and VAS scores after injection of Lidocaine and steroid solution. RESULTS: Patients receiving IACS injections had a measurable improvement in self-reported outcomes as evidenced by standard deviation change in WOMAC and VAS scores. The majority of patients had a clinically significant improvement in VAS scores as compared to their initial measures with a notable amount of patients improving significantly as well on their WOMAC scores, irrespective of the injection site chosen. CONCLUSIONS: We have therefore continued the use of palpation-guided intra-articular knee injections in an effort to reduce costs as compared to other injection modalities with positive results in our osteoarthritis patients.
Assuntos
Anti-Inflamatórios/administração & dosagem , Artralgia/tratamento farmacológico , Injeções Intra-Articulares/métodos , Osteoartrite do Joelho/tratamento farmacológico , Triancinolona Acetonida/administração & dosagem , Anestésicos Locais/administração & dosagem , Anti-Inflamatórios/uso terapêutico , Artralgia/etiologia , Redução de Custos , Seguimentos , Humanos , Injeções Intra-Articulares/economia , Lidocaína/administração & dosagem , Osteoartrite do Joelho/fisiopatologia , Medição da Dor , Palpação , Recuperação de Função Fisiológica , Índice de Gravidade de Doença , Resultado do Tratamento , Triancinolona Acetonida/uso terapêuticoRESUMO
Liposomal bupivacaine periarticular injection (PAI) offers sustained bupivacaine release after TKA, but few prospective independent studies exist. In this prospective, blinded study, liposomal bupivacaine was randomized against bupivacaine and incorporated into a comprehensive multimodal pain management protocol. 111 primary TKAs were randomized to receive PAI: 58 patients received 266 mg (20cc) liposomal bupivacaine mixed with 75 mg (30cc) 0.25% bupivacaine, and 53 patients received 150 mg (60cc) 0.25% bupivacaine. Visual analog pain scores and narcotic use were determined. No pain score differences occurred between study and control patients: Day 1: 4.5/4.6 (P=0.73); Day 2: 4.4/4.8 (P=0.27); or Day 3: 3.5/3.7 (P=0.58). Narcotic use was similar during hospitalization, 51.8/54.2 (P=0.34). The study medication costs $285, and the control medication costs $2.80. This finding does not justify the routine use of liposomal bupivacaine.
Assuntos
Anestésicos Locais/administração & dosagem , Artroplastia do Joelho , Bupivacaína/administração & dosagem , Lipossomos/administração & dosagem , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Bupivacaína/economia , Preparações de Ação Retardada/administração & dosagem , Feminino , Humanos , Injeções Intra-Articulares/economia , Lipossomos/economia , Masculino , Pessoa de Meia-Idade , Manejo da Dor/economia , Medição da Dor , Estudos Prospectivos , Método Simples-CegoRESUMO
The objective of this study was to analyse healthcare and productivity costs in patients with trapeziometacarpal osteoarthritis. We included 161 patients who received surgery or steroid injection and calculated their healthcare costs in Euro () over 1 year. Patients filled out the Work Productivity and Activity Impairment Questionnaire to assess loss of productivity at baseline, and after 3, and 12 months. In the surgical group, loss of productivity among employed patients first increased and then decreased (50%, 64%, and 25% at 0, 3, and 12 months). Productivity was more stable over time in the injection group (52%, 38%, and 48%). In the surgical group, estimated total annual healthcare and productivity costs were 5770 and 5548, respectively. In the injection group, healthcare and productivity costs were 348 and 3503. These findings highlight the need for assessing productivity costs to get a comprehensive view of the costs associated with a treatment.Level of Evidence III.
Assuntos
Eficiência Organizacional , Articulações dos Dedos , Glucocorticoides/economia , Procedimentos Ortopédicos/economia , Osteoartrite/economia , Absenteísmo , Estudos de Coortes , Custos e Análise de Custo , Emprego/economia , Europa (Continente) , Feminino , Articulações dos Dedos/cirurgia , Glucocorticoides/administração & dosagem , Humanos , Injeções Intra-Articulares/economia , Masculino , Ossos Metacarpais/cirurgia , Pessoa de Meia-Idade , Osteoartrite/terapia , Inquéritos e Questionários , Polegar/cirurgia , Trapézio/cirurgiaRESUMO
BACKGROUND: The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilisation is by non-radiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases and hydrodissections. OBJECTIVE: Critically review the literature related to the accuracy, efficacy and cost-effectiveness of ultrasound-guided injections (USGIs) in major, intermediate and small joints; and soft tissues. DESIGN: Systematic review of the literature. RESULTS: USGIs are more accurate than landmark-guided injections (LMGIs; strength of recommendation taxonomy (SORT) Evidence Rating=A). USGIs are more efficacious than LMGIs (SORT Evidence Rating=B). USGIs are more cost-effective than LMGIs (SORT Evidence Rating=B). Ultrasound guidance is required to perform many new procedures (SORT Evidence Rating=C). CONCLUSIONS: The findings of this position statement indicate there is strong evidence that USGIs are more accurate than LMGI, moderate evidence that they are more efficacious and preliminary evidence that they are more cost-effective. Furthermore, ultrasound-guided (USG) is required to perform many new, advanced procedures and will likely enable the development of innovative USG surgical techniques in the future.
Assuntos
Sistema Musculoesquelético/diagnóstico por imagem , Medicina Esportiva/normas , Ultrassonografia de Intervenção/normas , Tecido Conjuntivo/diagnóstico por imagem , Consenso , Análise Custo-Benefício , Previsões , Humanos , Injeções/economia , Injeções/normas , Injeções Intra-Articulares/economia , Injeções Intra-Articulares/normas , Articulações/diagnóstico por imagem , Lesões dos Tecidos Moles/diagnóstico por imagem , Medicina Esportiva/economia , Medicina Esportiva/tendências , Ultrassonografia de Intervenção/economiaRESUMO
OBJECTIVE: Community-based outpatient clinics (CBOCs) have been established by the Department of Veterans Affairs (VA) to provide primary care services to veterans living in remote and rural regions. The objective of this study was to evaluate the cost effectiveness of training rural primary care providers to perform knee injections in CBOCs, thereby avoiding referring the patient to an urban medical center for an injection by rheumatology or orthopedic specialists. METHODS: We developed a decision-analysis model to compare costs and outcomes between rural providers who are trained to perform knee injections versus those who are not trained, therefore requiring a referral to a specialist to provide the injections. The model was run separately using costs from the perspective of the VA as well from the patient's perspective. The effectiveness outcome was quality-adjusted life years (QALYs). Probabilistic sensitivity analyses were performed using 10,000 second-order Monte Carlo simulations. RESULTS: In our base-case analyses, the incremental cost-effectiveness ratio for trained rural providers was $21,190/QALY using costs from the perspective of the VA and $205/QALY using costs from the patient's perspective. Training rural providers was cost effective in 74.4% and 93.6% of 10,000 Monte Carlo simulations at a willingness-to-pay threshold of $50,000/QALY from the perspectives of the VA and the patient, respectively. CONCLUSION: Training rural providers to perform knee injections for patients with knee pain secondary to osteoarthritis appears cost effective using the commonly used threshold of $50,000/QALY if more than 20 such patients per year are seen at rural primary care clinics. These results provide support for our ongoing efforts to implement such a training program.