Background/Purpose: Knee osteoarthritis (KOA) and meniscal tear (MT) are highly prevalent and often concomitant. Treatments for MT in the presence of KOA include physical therapy (PT; non-surgical) and arthroscopic partial meniscectomy (APM; surgical). Several randomized controlled trials (RCTs) suggest APM yields similar or only slightly better outcomes than PT for MT patients, but many of these trials have ~30% crossover from PT to APM, limiting their ability to isolate treatment benefits. Whether APM is cost-effective for those with KOA and MT has received little study.

Methods: We evaluated quality-adjusted life-years (QALYs), cumulative medical costs over five and 10 years, and incremental cost-effectiveness ratios (ICERs) of three treatment strategies: (1) PT Only, (2) PT + Optional APM, for those whose pain persists after a 3-month PT program, and (3) APM Only. Subjects whose pain persisted were offered total knee replacement (TKR) as a final treatment. We used the OAPol Model, a validated Monte Carlo state-transition simulation of KOA. We used a cohort with baseline KOA, MT, and demographics derived from the Meniscal Tear in Osteoarthritis Research (MeTeOR) RCT of APM vs. PT (mean age: 58; KOOS pain: 47 (0-100); KL1: 45%, KL2: 26%, KL3: 29%). We used previously published estimates of quality-of-life utilities and background medical costs based on pain, comorbidities, age, and BMI. Using published data, we estimated the risks and costs of APM complications and modeled KOA progression, with heightened progression among subjects treated with APM (relative risk: 1.62). We used MeTeOR data to estimate mean reductions in pain for subjects with low or high baseline pain (PT, low pain: 8 points; PT, high pain: 17; APM, low pain: 15; APM, high pain: 30), treatment costs (PT: $804; APM: $4,301), and utilization rates of Optional APM over one year (35%) and TKR over five years (2% for subjects treated non-surgically; 10% for those treated surgically). In sensitivity analyses we varied: indirect costs from productivity losses, Optional APM and TKR uptake rates, baseline pain, relative risk of KOA progression post-APM, duration of crossover period when subjects who failed PT are eligible for Optional APM, and efficacy of Optional APM. We discounted costs and QALYs at 3%/year and calculated ICERs as ratios of change in medical costs (2019 USD) to change in QALYs between strategies.

Results: Relative to PT Only, PT + Optional APM added 0.065 QALYs and $2,001 in costs over five years (ICER: $30,800/QALY). Relative to PT + Optional APM, APM Only added 0.0066 QALYs and $3,071 (ICER: $465,300/QALY). The 10-year analysis produced similar ICERs. Results were sensitive to reducing the efficacy of APM in the PT + Optional APM strategy compared to the APM Only strategy.

Conclusion: At a willingness-to-pay threshold of $50,000/QALY, PT followed by APM, if pain persists post-PT, is a cost-effective treatment for those with KOA and MT. Immediate APM is not cost-effective. These findings are robust despite base case assumptions that favor non-surgical approaches but are sensitive to reductions in Optional APM efficacy.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/cost-effectiveness-of-treatment-strategies-involving-arthroscopic-partial-meniscectomy-and-physical-therapy-for-degenerative-meniscal-tear/