Few older patients with knee OA receive conservative care prior to knee replacement
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Just 23% of Medicare beneficiaries with osteoarthritis who eventually underwent knee replacement ever had a physical therapy visit, according to data published in Arthritis & Rheumatology.
Among those who avoided knee replacement, that figure is only slightly higher, at 28.9%.
“This is the first population-based study of the types of care received by older patients with knee osteoarthritis, and the first to examine if the use of different types of care varies across the country along with rates of knee replacement,” Michael M. Ward, MD, MPH, of the NIH National Institute of Arthritis and Musculoskeletal and Skin Diseases, in Bethesda, Maryland, told Healio Rheumatology.
According to Ward, the frequency of nonsurgical care use in patients with knee OA in the United States is unknown.
“It is not clear how often patients are seen for knee complaints, how commonly specialists such as rheumatologists or physiatrists are consulted, and how commonly physical therapy and intra-articular medications are used,” Ward wrote in Arthritis & Rheumatology. “If non-operative measures are infrequently used, particularly among patients who later have TKA, it could suggest opportunities to improve the health status in patients with knee OA and potentially lessen the need for [total knee arthroplasty (TKA)].”
To analyze health care use among older patients with knee OA and determine whether said use differs in regions with high and low rates of total knee replacement, Ward conducted a retrospective cohort study of U.S. Medicare beneficiaries from 2005 to 2010. The analysis included a total of 988,570 beneficiaries with knee OA, among whom 33.1% received total knee arthroplasty during a median 5.6 years of follow-up.
Ward reviewed the health care use for knee complaints, including rates of physician visits, physical therapy, knee injections and arthroscopy, using Medicare claims files for all patients until knee replacement or 2015, when the study ended. He then compared health care use among beneficiaries who lived in regions with high or low rates of total knee arthroplasty.
According to the researchers, higher rates of visits for knee complaints were associated with an increased risk for knee replacement, while the use of physical therapy, specialist care and intra-articular injections were associated with a lower risk. The frequency of knee replacement surgery varied from 26.4% in the lowest quintile region to 42.1% in the highest quintile, Ward wrote.
Rates of physician visits, physical therapy, specialist care and the use of intra-articular injections varied inversely with arthroplasty quintile, with physical therapy used by 32.5% of beneficiaries in the lowest quintile region and by 23.6% in the highest quintile region. In addition, physical therapy was associated with lower rates of knee replacement in all quintiles.
“Many aspects of conservative care were not used often, even among patients with subsequently went on to have a knee replacement,” Ward said. “For example, only 28.9% of those who did not have a knee replacement, and only 23% of those who later had a knee replacement, had any physical therapy visit. Visits to physiatrists and rheumatologists were similarly low. Intra-articular corticosteroids were used in only 40% of patients. These results suggest that there is room to expand the use of conservative care, which may impact the need for knee replacement.”
“In addition, rates of many types of conservative care were lower in regions of the country with the highest rates of knee replacement, suggesting that knee replacement was substituting for more reliance on conservative care in the high-surgery regions,” he added. “Patients with knee OA and their primary care providers should consider whether conservative treatments are appropriate before having a referral to an orthopedic surgeon. Some patients may benefit and avoid or postpone the need for arthroplasty.”
Perspective
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Tien-I Karleen Su, MD
Knee osteoarthritis (KOA) affects approximately 14 million people in the U.S. with increasing prevalence. The cost of caring for these patients in the U.S. puts a high burden on our health care system (about $27 billion annually), with a significant portion of the cost from care related to total knee arthroplasties (TKA).
The study by Ward and colleagues explores important questions regarding utilization of non-operative vs. operative care among Medicare beneficiaries with KOA in different regions of the U.S. and whether there is opportunity for physicians to optimize non-operative care in order to reduce the need for TKA.
This study found that 33% of Medicare beneficiaries in the study period underwent TKA. The rate of TKA varied among different regions, and across all regions, higher rate of visits related to KOA was associated with higher rates of TKA, suggesting these patients had more severe KOA. However, at every visit frequency, quintile 5 had higher rates of TKA compared to quintile 1. This difference was more marked in the lower visit rates, suggesting that patients in quintile 5 with less severe KOA may be undergoing more TKA compared to those in quintile 1.
Higher use of nonsurgical care such as physical therapy (PT) and visits to specialists such as rheumatologists were associated with lower rates of TKA in all regions, indicating less advanced KOA in these patients. Quintile 1 had more PT visits and specialist visits whereas quintile 5 had the lowest. These results suggest that patients in quintile 5 may be underutilizing conservative treatment before TKA. It was surprising that regardless of region, there was an overall low use of conservative management (27% for PT) and few patients sought care from specialists like us, therefore decreasing the opportunity for us to maximize conservative care before recommending TKA.
The results of this study raise several questions that future studies can address: Are there barriers to the use of non-operative care in this country? Are these barriers amplified in regions with high rates of TKA? Per this study, this underutilization of PT or specialists was not due to undersupply of these services in quintile 5. Is there a difference in attitude towards nonsurgical and surgical care across these regions among the patients and physicians that lead to a reluctance in conservative care?
Additionally, will increasing patient education on the benefits of nonsurgical care encourage patients to consider these options more favorably? Are there specific obstacles that older patients may encounter that prevent them from seeking conservative management? In my clinic, older patients without access to transportation are unable to attend PT sessions. A simple cost-effective solution in this case would be to provide transportation for these patients.
These are just some of the questions that may elucidate further on why there are regional differences in the care of KOA across these regions, which will allow us to better target efforts in increasing the use of nonsurgical care for our KOA patients to reduce the need for TKA in appropriate cases.
Perspective
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David A. McLain, MD, MACR, FACP, FRCP
Total knee arthroplasty (TKA) is a major cost to the health care system, with about 50% of the population developing OA of the knee. In fact, TKA is the second most common non-obstetric operation performed in America.
This single-authored big database study examined the care that patients with knee OA received up to 2015 (the last date available) and under what circumstances they progressed to TKA. The cost of care of knee OA was estimated to be $34 billion in 2014.
It was “satisfying” to see that progression to TKA was lower in patients who had seen rheumatologists (or physiatrists or pain specialists), had physical therapy, were treated with opiates or had intra-articular therapies. It turned out that most patients had not seen rheumatologists, had not received physical therapy and had not received intra-articular therapies, either corticosteroids or hyaluronic acid.
From this analysis, it appears that conservative treatment of knee OA is beneficial to the patient and the health care system as it delays TKA. In this vein, conservative treatment of knee OA patients with comorbidities or advanced age that precludes TKA, is also likely helpful.
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