Increased Prevalence and Associated Costs of Psychiatric Comorbidities in Patients Undergoing Sports Medicine Operative Procedures.

PURPOSE: To evaluate the prevalence of preoperatively diagnosed psychiatric comorbidities and the impact of these comorbidities on the healthcare costs of ten common orthopaedic sports medicine procedures. METHODS: Patients undergoing 10 common sports medicine procedures from 2007 to 2017q1 were identified using the Humana claims database. These procedures included anterior cruciate ligament reconstruction; posterior cruciate ligament reconstruction; medial collateral ligament repair/reconstruction; Achilles repair/reconstruction; Rotator cuff repair; meniscectomy/meniscus repair; hip arthroscopy; arthroscopic shoulder labral repair; patellofemoral instability procedures; and shoulder instability repair. Patients were stratified by preoperative diagnoses of depression, anxiety, bipolar disorder, or schizophrenia. Cohorts included patients with ≥1 psychiatric comorbidity (psychiatric) versus those without psychiatric comorbidities (no psychiatric). Differences in costs across groups were compared using Mann-Whitney U tests, with significance defined as P < .05. Linear regression analysis was used to assess rates of procedures per year from 2006 to 2016. RESULTS: In total, 226,402 patients (57.7% male) from 2007 to 2017q1 were assessed. The prevalence of ≥1 psychiatric comorbidity within the entire database was 10.31% (reference) versus 21.21% in those patients undergoing the 10 investigated procedures. Patients with psychiatric comorbidity most frequently underwent rotator cuff repair (28%), hip labral repair (26.3%) and meniscectomy/meniscus repair (25.0%%) had ≥1 psychiatric comorbidity. Compared with the no psychiatric cohort, diagnosis of ≥1 psychiatric comorbidity was associated with increased health care costs for all 10 sports medicine procedures ($9678.81 vs $6436.20, P < .0001). CONCLUSIONS: The prevalence of preoperatively diagnosed psychiatric comorbidities among patients undergoing orthopaedic sports medicine procedures is high. The presence of psychiatric comorbidities preoperatively was associated with increased postoperative costs following all investigated orthopaedic sports medicine procedures. LEVEL OF EVIDENCE: Level III; retrospective comparative study.

Comparing Meniscectomy and Meniscal Repair: A Matched Cohort Analysis Utilizing a National Insurance Database.

BACKGROUND: Meniscal repair leads to improved patient outcomes compared with meniscectomy in small case series. PURPOSE: To compare the reoperation rates, 30-day complication rates, and cost differences between meniscectomy and meniscal repair in a large insurance database. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A national insurance database was queried for patients who underwent meniscectomy (Current Procedural Terminology [CPT] code 29880 or 29881) or meniscal repair (CPT code 29882 or 29883) in the outpatient setting and who had a minimum 2-year follow-up. Patients without confirmed laterality and patients who underwent concomitant ligament reconstruction were excluded. Reoperation was defined by ipsilateral knee procedure after the index surgery. The 30-day postoperative complication rates were assessed using the International Classification of Diseases, 9th Revision, Clinical Modification codes. The cost of the procedures per patient was calculated. Propensity score matching was utilized to create matched cohorts with similar characteristics. Statistical comparisons of cohort characteristics, reoperations, postoperative complications, and payments were made. All P values were reported with significance set at P < .05. RESULTS: A total of 27,580 patients (22,064 meniscectomy and 5516 meniscal repair; mean age, 29.9 ± 15.1 years; 41.2% female) were included in this study with a mean follow-up of 45.6 ± 21.0 months. The matched groups were similar with regard to characteristics and comorbidities. There were significantly more patients who required reoperation after index meniscectomy compared with meniscal repair postoperatively (5.3% vs 2.1%; P < .001). Patients undergoing meniscectomy were also significantly more likely to undergo any ipsilateral meniscal surgery (P < .001), meniscal transplantation (P = .005), or total knee arthroplasty (P = .001) postoperatively. There was a significantly higher overall 30-day complication rate after meniscal repair (1.2%) compared with meniscectomy (0.82%; P = .011). The total day-of-surgery payments was significantly higher in the repair group compared with the meniscectomy group ($7094 vs $5423; P < .001). CONCLUSION: Meniscal repair leads to significantly lower rates of reoperation and higher rates of early complications with a higher total cost compared with meniscectomy in a large database study.

Direct treatment cost outcomes among patients with medial meniscus deficiency: results from a 24-month surveillance study.

Objective: Meniscus deficiency is highly prevalent in the United States and represents a substantial societal cost burden. The objective of this case series was to evaluate and compare direct costs associated with treatment for acute or degenerative medial meniscus deficiency.Methods: Case series patients (n = 50) received either non-surgical therapy or an operative partial meniscectomy based on clinical assessment by the principal study investigator which included physical examination and MRI. Cumulative 24-month direct treatment costs were compared between non-surgical and operative cohorts. Direct treatment costs were calculated using billing record reimbursements for all medical services administered by the treating institution, and imputed for medical services prescribed by the treating physician but provided external to the treating institution.Results: At study initiation, 33 patients (67%) were treated with non-surgical care, and 17 patients (33%) received a partial medial meniscectomy. By 24 months, average direct treatment costs were highest for patients who received a partial medial meniscectomy at study initiation ($4488 ± $1265) compared to patients who received non-surgical care at study initiation ($4092 ± $7466), although differences in average direct treatment costs were not statistically significant across treatment cohorts (p = .830). Average direct treatment costs were highest for the subgroup of patients who initiated non-surgical therapy but received a subsequent total knee arthroplasty during the study period (n = 2; $32,197 ± $169).Conclusion: Findings from this case series suggests that patients with acute or degenerative meniscus deficiency incur substantial direct treatment costs related to their knee pathology, particularly for patients receiving total knee arthroplasty.

How do the costs of physical therapy and arthroscopic partial meniscectomy compare? A trial-based economic evaluation of two treatments in patients with meniscal tears alongside the ESCAPE study.

OBJECTIVES: To examine whether physical therapy (PT) is cost-effective compared with arthroscopic partial meniscectomy (APM) in patients with a non-obstructive meniscal tear, we performed a full trial-based economic evaluation from a societal perspective. In a secondary analysis-this paper-we examined whether PT is non-inferior to APM. METHODS: We recruited patients aged 45-70 years with a non-obstructive meniscal tear in nine Dutch hospitals. Resource use was measured using web-based questionnaires. Measures of effectiveness included knee function using the International Knee Documentation Committee (IKDC) and quality-adjusted life-years (QALYs). Follow-up was 24 months. Uncertainty was assessed using bootstrapping techniques. The non-inferiority margins for societal costs, the IKDC and QALYs, were €670, 8 points and 0.057 points, respectively. RESULTS: We randomly assigned 321 patients to PT (n=162) or APM (n=159). PT was associated with significantly lower costs after 24 months compared with APM (-€1803; 95% CI -€3008 to -€838). The probability of PT being cost-effective compared with APM was 1.00 at a willingness to pay of €0/unit of effect for the IKDC (knee function) and QALYs (quality of life) and decreased with increasing values of willingness to pay. The probability that PT is non-inferior to APM was 0.97 for all non-inferiority margins for the IKDC and 0.89 for QALYs. CONCLUSIONS: The probability of PT being cost-effective compared with APM was relatively high at reasonable values of willingness to pay for the IKDC and QALYs. Also, PT had a relatively high probability of being non-inferior to APM for both outcomes. This warrants further deimplementation of APM in patients with non-obstructive meniscal tears. TRIAL REGISTRATION NUMBERS: NCT01850719 and NTR3908.

A Cost-Effectiveness Analysis of Isolated Meniscal Repair Versus Partial Meniscectomy for Red-Red Zone, Vertical Meniscal Tears in the Young Adult.

PURPOSE: To evaluate the cost-effectiveness of treating isolated red-red zone, vertical meniscal tears with either isolated meniscal repair (IMR) or partial meniscectomy (PM) in the young adult using conservative modeling. METHODS: A decision-analytic Markov disease progression model with a 40-year horizon was created simulating outcomes after IMR or PM for an isolated meniscal tear. Event probabilities, costs, and utilities were used for the index procedures, and the development of osteoarthritis (OA) and subsequent need for knee arthroplasty were calculated or selected from the published literature. Differences in cost, difference in quality-adjusted life years (QALYs), and the incremental cost effect ratio were calculated to determine which index procedure is most cost effective. RESULTS: Total direct costs from PM were modeled at $38,648, and the total direct costs of IMR were $23,948, resulting in a projected cost savings of $14,700 with IMR. There was a modeled gain in QALYs of 17 for PM and 21 for IMR, resulting in an increase in 4 QALYs for the IMR treatment group. This results in an incremental cost effect ratio of $3,935 per QALY, favoring IMR as the dominant procedure. CONCLUSIONS: Meniscal repair for isolated red-red zone, vertical meniscal tears was predicted to have lower direct costs and improve QALYs compared with partial meniscectomy over 40-year modeling, indicating isolated meniscal repair to be the cost-effective procedure in the treatment of an isolated meniscal tear in the young adult population. LEVEL OF EVIDENCE: Level 3: economic and decision analysis.

Increased rates of knee arthroplasty and cost of patients with meniscal tears treated with arthroscopic partial meniscectomy versus non-operative management.

PURPOSE: The purpose of this study was to determine the cost of arthroscopic partial meniscectomy (APM), one of the most common surgeries performed by orthopaedic surgeons, and the associated rate of progression to knee arthroplasty (KA) compared to patients treated non-operatively after diagnosis of meniscal tear. METHODS: Utilizing data mining software (PearlDiver, Colorado Springs, CO), a national insurance database of approximately 23.5 million orthopaedic patients was queried for patients diagnosed with a meniscal tear. Patients were classified by treatment: non-operative and arthroscopic partial meniscectomy and were followed after initial diagnosis for cost and progression to knee arthroplasty. RESULTS: There were 176,407 subjects in the non-op group and 114,194 subjects in the arthroscopic partial meniscectomy group. Arthroscopic partial meniscectomy generated more cost than non-operative ($3842.57 versus $411.05, P < 0.001). Arthroscopic partial meniscectomy demonstrated greater propensity to need future knee arthroplasty (11.4% at 676 days) than those treated non-operatively (9.5% at 402 days) (P < 0.001). Female patients demonstrated a higher rate of progression to knee arthroplasty in the arthroscopic partial meniscectomy and non-operative groups (P < 0.001). CONCLUSION: Compared to non-operative treatment for meniscal tears, arthroscopic partial meniscectomy is more expensive and does not appear to decrease the rate of progression to knee arthroplasty. Patients undergoing arthroscopic partial meniscectomy yielded on average a delay of only 9 months (274 days) before undergoing knee arthroplasty. Female patients experienced a significantly higher rate of progression to knee arthroplasty. The authors recognize the limitations of this type of study including its retrospective nature, reliance upon accurate coding and billing information, and the inability to determine whether symptoms including mechanical locking played a role in the decision to perform an APM. LEVEL OF EVIDENCE: IV.

Meniscus Root Repair vs Meniscectomy or Nonoperative Management to Prevent Knee Osteoarthritis After Medial Meniscus Root Tears: Clinical and Economic Effectiveness.

BACKGROUND: Medial meniscus root tears are a common knee injury and can lead to accelerated osteoarthritis, which might ultimately result in a total knee replacement. PURPOSE: To compare meniscus repair, meniscectomy, and nonoperative treatment approaches among middle-aged patients in terms of osteoarthritis development, total knee replacement rates (clinical effectiveness), and cost-effectiveness. STUDY DESIGN: Meta-analysis and cost-effectiveness analysis. METHODS: A systematic literature search was conducted. Progression to osteoarthritis was pooled and meta-analyzed. A Markov model projected strategy-specific costs and disutilities in a cohort of 55-year-old patients presenting with a meniscus root tear without osteoarthritis at baseline. Failure rates of repair and meniscectomy procedures and disutilities associated with osteoarthritis, total knee replacement, and revision total knee replacement were accounted for. Utilities, costs, and event rates were based on literature and public databases. Analyses considered a time frame between 5 years and lifetime and explored the effects of parameter uncertainty. RESULTS: Over 10 years, meniscus repair, meniscectomy, and nonoperative treatment led to 53.0%, 99.3%, and 95.1% rates of osteoarthritis and 33.5%, 51.5%, and 45.5% rates of total knee replacement, respectively. Meta-analysis confirmed lower osteoarthritis and total knee replacement rates for meniscus repair versus meniscectomy and nonoperative treatment. Discounted 10-year costs were $22,590 for meniscus repair, as opposed to $31,528 and $25,006 for meniscectomy and nonoperative treatment, respectively; projected quality-adjusted life years were 6.892, 6.533, and 6.693, respectively, yielding meniscus repair to be an economically dominant strategy. Repair was either cost-effective or dominant when compared with meniscectomy and nonoperative treatment across a broad range of assumptions starting from 5 years after surgery. CONCLUSION: Repair of medial meniscus root tears, as compared with total meniscectomy and nonsurgical treatment, leads to less osteoarthritis and is a cost-saving intervention. While small confirmatory randomized clinical head-to-head trials are warranted, the presented evidence seems to point relatively clearly toward adopting meniscus repair as the preferred initial intervention for medial meniscus root tears.

The Cost-Effectiveness of Meniscal Repair Versus Partial Meniscectomy in the Setting of Anterior Cruciate Ligament Reconstruction.

PURPOSE: To compare the cost-effectiveness of anterior cruciate ligament (ACL) reconstruction with meniscal repair to ACL reconstruction with partial meniscectomy. METHODS: A decision-analytic Markov disease progression model with a 40-year horizon was created simulating outcomes after both meniscal repair and partial meniscectomy at the time of ACL reconstruction. Event probabilities, costs, and utilities were used for the index procedures. The development of osteoarthritis and subsequent knee replacement were either calculated or selected from published literature. Difference in cost, difference in quality-adjusted life-years (QALYs), and incremental cost-effective ratio were calculated to determine which index procedure is most cost-effective. RESULTS: There is total direct cost from ACL reconstruction with meniscus repair of $17,898 compared with that with partial meniscectomy of $24,768 (cost savings of $6,870). There was an estimated gain of 18.00 QALYs after ACL reconstruction with meniscus repair compared with 17.16 QALYs with partial meniscectomy (increase of 0.84 QALYs). In this scenario, meniscus repair is the dominant index procedure at the time of ACL reconstruction. CONCLUSIONS: Meniscal repair at the time of ACL reconstruction is more cost-effective than partial meniscectomy. LEVEL OF EVIDENCE: Level IV, economic and decision analysis.

Arthroscopic meniscectomy for degenerative meniscal tears reduces knee pain but is not cost-effective in a routine health care setting: a multi-center longitudinal observational study using data from the osteoarthritis initiative.

OBJECTIVES: It is disputed whether arthroscopic meniscectomy is an (cost-) effective treatment for degenerative meniscus tears in day-to-day clinical practice. The objective of this study was to assess the cost-effectiveness of arthroscopic meniscectomy in subjects with knee osteoarthritis, in routine clinical practice, while taking into account the increased risk for future knee replacement surgery. We compared cost-effectiveness of arthroscopic meniscectomy compared to no surgery. DESIGN: We used a state transition (Markov) simulation model to evaluate the cost-effectiveness of arthroscopic meniscectomy compared to no surgery in subjects with knee osteoarthritis (age range 45-79 years). Data used in the preparation of the current study were obtained from the Osteoarthritis Initiative (AOI) database. We applied a 9 years' time horizon (which is equal to the current OAI study follow up period), and evaluated cost-effectiveness from a societal perspective. The main outcome measure was the incremental cost-effectiveness ratio (Euros per quality adjusted life-year (QALY) gained). RESULTS: Arthroscopic meniscectomy was associated with 8.09 (SD ± 0.07) QALYs at a cost of € 21,345 (SD ± 841), whereas the no surgery was associated with 8.05 (SD ± 0.07) QALYs at a cost of € 16,284 (SD ± 855). For arthroscopic meniscectomy, the incremental cost per QALY gained was € 150,754. CONCLUSIONS: In day-to-day clinical practice, arthroscopic meniscectomy in subjects with knee osteoarthritis is associated with € 150,754 per QALY gained, which exceeds the generally accepted willingness to pay (WTP) (range € 20,000-€ 80,000).