Costs of physical therapy in comparison to arthroscopic partial meniscectomy
Worldwide around 2 million arthroscopic knee operations are performed. These are accompanied by $ 4 billion in direct medical costs. Although a clinically important benefit of surgery over conservative treatment has not been demonstrated, the number of arthroscopic operations is decreasing more slowly than expected. An economic evaluation comparing conservative treatment with surgery can therefore confirm the findings of previous research and support the implementation of changes in clinical care. A recent model-based economic evaluation found that arthroscopic partial meniscectomy (APM) was not cost-effective in patients with or at risk for osteoarthritis compared to a group of matched controls that received no treatment.
Since no treatment at all is not a common alternative to surgical treatment in clinical practice, this model should be interpreted with caution. With treatment alternatives such as physical therapy (PT), painkillers or injections, the actual difference in costs is probably smaller. To close this gap in the literature, an economic evaluation was performed in addition to a multi-center randomized controlled trial (RCT) comparing PT and APM in patients between 45 and 70 years with a non-obstructive meniscus tear (ie no knee joint locking).
To investigate whether physiotherapy (PT) is cost-effective compared to arthroscopic partial meniscectomy (APM) in patients with a non-obstructive meniscus tear, a fully trial-based economic evaluation was conducted from a social perspective. A secondary analysis - this article - investigated whether PT is not inferior to APM.
Patients aged 45-70 were recruited with a non-obstructive meniscal tear in nine Dutch hospitals. The use of resources was measured using web-based questionnaires. Measures for effectiveness include knee function with the help of 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 social costs, the IKDC and QALYs, were € 670, 8 points and 0.057 points respectively.
They randomly assigned 321 patients to PT (n = 162) or APM (n = 159). After 24 months PT was associated with considerably lower costs compared to APM (- € 1803; 95% CI - € 3008 to - € 838). The probability that PT is cost-effective compared to APM was 1.00 with 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.
The probability that PT is cost effective compared to APM was relatively high with reasonable values of willingness to pay for the IKDC and QALYs. PT also had a relatively high chance of being non-inferior to APM for both outcomes. This justifies a further deimplementation of APM in patients with non-obstructive meniscus tears.
Br J Sports Med 2019