title: Defining the Value of Future Research to Identify the Preferred Treatment of Meniscal Tear in the Presence of Knee Osteoarthritis.
abstract: BACKGROUND
  Arthroscopic partial meniscectomy (APM) is extensively used to relieve pain in patients with symptomatic meniscal tear (MT) and knee osteoarthritis (OA). Recent studies have failed to show the superiority of APM compared to other treatments. We aim to examine whether existing evidence is sufficient to reject use of APM as a cost-effective treatment for MT+OA.
  
  
  METHODS
  We built a patient-level microsimulation using Monte Carlo methods and evaluated three strategies: Physical therapy ('PT') alone; PT followed by APM if subjects continued to experience pain ('Delayed APM'); and 'Immediate APM'. Our subject population was US adults with symptomatic MT and knee OA over a 10 year time horizon. We assessed treatment outcomes using societal costs, quality-adjusted life years (QALYs), and calculated incremental cost-effectiveness ratios (ICERs), incorporating productivity costs as a sensitivity analysis. We also conducted a value-of-information analysis using probabilistic sensitivity analyses.
  
  
  RESULTS
  Calculated ICERs were estimated to be $12,900/QALY for Delayed APM as compared to PT and $103,200/QALY for Immediate APM as compared to Delayed APM. In sensitivity analyses, inclusion of time costs made Delayed APM cost-saving as compared to PT. Improving efficacy of Delayed APM led to higher incremental costs and lower incremental effectiveness of Immediate APM in comparison to Delayed APM. Probabilistic sensitivity analyses indicated that PT had 3.0% probability of being cost-effective at a willingness-to-pay (WTP) threshold of $50,000/QALY. Delayed APM was cost effective 57.7% of the time at WTP = $50,000/QALY and 50.2% at WTP = $100,000/QALY. The probability of Immediate APM being cost-effective did not exceed 50% unless WTP exceeded $103,000/QALY.
  
  
  CONCLUSIONS
  We conclude that current cost-effectiveness evidence does not support unqualified rejection of either Immediate or Delayed APM for the treatment of MT+OA. The amount to which society would be willing to pay for additional information on treatment outcomes greatly exceeds the cost of conducting another randomized controlled trial on APM.
authors.affiliation: Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America; Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, United States of America; Harvard Medical School, Boston, Massachusetts, United States of America; Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America.
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
authors.affiliation: Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.
authors.forename: Elizabeth E
authors.initials: EE
authors.lastname: Dervan
authors.affiliation: Yale School of Public Health and Yale School of Management, New Haven, Connecticut, United States of America.
authors.forename: A David
authors.initials: AD
authors.lastname: Paltiel
authors.affiliation: Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.
authors.forename: Yan
authors.initials: Y
authors.lastname: Dong
authors.affiliation: Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.
authors.forename: R John
authors.initials: RJ
authors.lastname: Wright
authors.affiliation: Department of Orthopaedic Surgery, Cleveland Clinic, Garfield Heights, Ohio, United States of America.
authors.forename: Kurt P
authors.initials: KP
authors.lastname: Spindler
authors.affiliation: Weill Cornell Medical College, New York, New York, United States of America; Hospital for Special Surgery, New York, New York, United States of America.
authors.forename: Lisa A
authors.initials: LA
authors.lastname: Mandl
authors.affiliation: Department of Orthopaedic Surgery, Cleveland Clinic, Garfield Heights, Ohio, United States of America.
authors.forename: Morgan H
authors.initials: MH
authors.lastname: Jones
authors.affiliation: Weill Cornell Medical College, New York, New York, United States of America; Hospital for Special Surgery, New York, New York, United States of America.
authors.forename: Robert G
authors.initials: RG
authors.lastname: Marx
authors.affiliation: Department of Rehabilitation Services, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.
authors.forename: Clare E
authors.initials: CE
authors.lastname: Safran-Norton
authors.affiliation: Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America; Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, United States of America; Harvard Medical School, Boston, Massachusetts, United States of America; Departments of Epidemiology and Environmental Health, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America.
authors.forename: Jeffrey N
authors.initials: JN
authors.lastname: Katz
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003362:Cost-Benefit Analysis; D005260:Female; D017048:Health Care Costs; D006801:Humans; D007718:Knee Injuries / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009010:Monte Carlo Method; D020370:Osteoarthritis, Knee / Q000628:therapy*; D017063:Outcome Assessment, Health Care; D019057:Quality-Adjusted Life Years; D000070600:Tibial Meniscus Injuries; D016896:Treatment Outcome