Session Type: Abstract Submissions (ACR)
Background/Purpose: Arthroscopic partial meniscectomy (APM) is often offered to patients with symptomatic meniscal tear (MT). Recent trials in symptomatic patients with MT and knee OA (MT + OA) revealed similar pain relief in persons treated with APM and those treated with physical therapy (PT) and then referred for APM if pain persisted. We assessed expected costs and outcomes of alternative surgical and non-surgical strategies for patients with MT+OA. We examined the value of further research in this population and its likely impact on treatment decisions and their outcomes.
Methods: We used data from the Meniscal Tear in OA Research (MeTeOR) multicenter RCT (mean age 58, 76% Kellgren-Lawrence (KL) grade<3, 24% KL3) to estimate input parameters for a Markov state-transition computer simulation model. The model estimates long-term clinical and economic outcomes of management of MT+OA. We considered 3 strategies: 1) PT only, 2) APM, 3) PT with referral for APM, if PT did not relieve pain. We performed the analysis over a 10-year timeframe and considered short-term pain relief, subsequent pain onset (due to OA) and pain resolution. Transition probabilities were derived from MeTeOR and stratified by KL grade and time from treatment initiation. Pain relief 3 months after APM was 69% (95% CI: 59%-79%) among those with KL<3 and 51% (95% CI: 36%-66%) among those with KL3. Pain relief following APM among those who failed PT was worse (58% for KL<3 and 25% for KL3). Pain relief from PT alone was 49% (95% CI: 39%-58%) for KL<3 and 34% (95% CI 19%-50%) for KL3. Costs of PT ($680/3 month) and pain control ($215/quarter) were derived from MeTeOR and costs of APM ($2,800) from the Medicare Fee Schedule. We performed a probabilistic sensitivity analysis to examine the impact of parameter uncertainty on our finding. To estimate the value of further research, we assessed the expected value of partial perfect information (EVPPI), related to pain-based model parameters. We used willingness to pay (WTP) thresholds from $50k to $144K/QALY to denote programs as “cost-effective”.
Results: PT alone led to quality-adjusted life expectancy of 6.96 years with costs of $4,116. Delayed APM (in those who failed PT) led to 7.009 QALYs with costs of $8,130, yielding an incremental cost-effectiveness ratio (ICER) of $80,300/QALY. Immediate APM produced both higher costs ($9,556) and lower QALYs (7.008). In persons with KL<3, the estimated ICERs were $42,200/QALY for delayed APM and $106,400/QALY for immediate APM. In persons with KL3, neither APM-based strategy had favorable cost-effectiveness. Accounting for uncertainty in parameter estimates, in persons with KL<3, the probability of immediate APM being cost-effective ranged from 35% if WTP=$50K to 50% if WTP=$144K. The EVPPI that would result from reducing uncertainty in likelihood of pain relief and subsequent development and resolution of pain was estimated at $2,700/person.
Conclusion: APM-based strategies are unlikely to be cost-effective for MT+OA, even in those with less advanced OA. However, this conclusion is sensitive to assumptions regarding short- and long-term pain relief. Given the prevalence of this condition, more research on pain parameters is warranted.
A. D. Paltiel,
K. P. Spindler,
Smith & Nephew, Inc.,
L. A. Mandl,
J. N. Katz,
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ACR Meeting Abstracts - https://acrabstracts.org/abstract/value-of-arthroscopic-partial-meniscectomy-in-treatment-of-symptomatic-patients-with-meniscal-tears-and-knee-osteoarthritis-is-more-research-warranted/