title: Cost-effectiveness analysis of arthroscopic surgery compared with non-operative management for osteoarthritis of the knee.
abstract: OBJECTIVE
  To determine the cost-effectiveness of arthroscopic surgery in addition to non-operative treatments compared with non-operative treatments alone in patients with knee osteoarthritis (OA).
  
  
  METHODS
  We conducted an economic evaluation alongside a single-centre, randomised trial among patients with symptomatic, radiographic knee OA (KL grade ≥ 2).
  
  
  METHODS
  Patients received arthroscopic debridement and partial resection of degenerative knee tissues in addition to optimised non-operative therapy, or optimised non-operative therapy only.
  
  
  METHODS
  Direct and indirect costs were collected prospectively over the 2-year study period. The effectiveness outcomes were the Western Ontario McMaster Osteoarthritis Index (WOMAC) and quality-adjusted life years (QALYs). Cost-effectiveness was estimated using the net benefit regression framework considering a range of willingness-to-pay values from the Canadian public payer and societal perspectives. We calculated incremental cost-effectiveness ratios and conducted sensitivity analyses using the extremes of the 95% CIs surrounding mean differences in effect between groups.
  
  
  RESULTS
  168 patients were included. Patients allocated to arthroscopy received partial resection and debridement of degenerative meniscal tears (81%) and/or articular cartilage (97%). There were no significant differences between groups in use of non-operative treatments. The incremental net benefit was negative for all willingness-to-pay values. Uncertainty estimates suggest that even if willing to pay $400,000 to achieve a clinically important improvement in WOMAC score, or ≥$50,000 for an additional QALY, there is <20% probability that the addition of arthroscopy is cost-effective compared with non-operative therapies only. Our sensitivity analysis suggests that even when assuming the largest treatment effect, the addition of arthroscopic surgery is not economically attractive compared with non-operative treatments only.
  
  
  CONCLUSIONS
  Arthroscopic debridement of degenerative articular cartilage and resection of degenerative meniscal tears in addition to non-operative treatments for knee OA is not an economically attractive treatment option compared with non-operative treatment only, regardless of willingness-to-pay value.
  
  
  BACKGROUND
  NCT00158431.
authors.affiliation: Faculty of Health Sciences; Bone and Joint Institute; Western University, London, Ontario, Canada.
authors.forename: Jacquelyn D
authors.initials: JD
authors.lastname: Marsh
authors.affiliation: School of Physical Therapy, Faculty of Health Sciences; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada.
authors.forename: Trevor B
authors.initials: TB
authors.lastname: Birmingham
authors.affiliation: Department of Surgery, Schulich School of Medicine and Dentistry; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada.
authors.forename: J Robert
authors.initials: JR
authors.lastname: Giffin
authors.affiliation: Centre for Excellence in Economic Analysis Research (CLEAR), St. Michael's Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Wanrudee
authors.initials: W
authors.lastname: Isaranuwatchai
authors.affiliation: Department of Public Health Sciences, University of California, Davis (UCD); Center for Healthcare Policy and Research, UCD; Centre for Excellence in Economic Analysis Research (CLEAR), St. Michael's Hospital; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario Canada.
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Hoch
authors.affiliation: Departments of Medicine, and Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry; Robarts Clinical Trials, Robarts Research Institute; Western University, London, Ontario, Canada.
authors.forename: Brian G
authors.initials: BG
authors.lastname: Feagan
authors.affiliation: Department of Surgery, Schulich School of Medicine and Dentistry; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada.
authors.forename: Robert
authors.initials: R
authors.lastname: Litchfield
authors.affiliation: Department of Surgery, Schulich School of Medicine and Dentistry; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada.
authors.forename: Kevin
authors.initials: K
authors.lastname: Willits
authors.affiliation: Department of Surgery, Schulich School of Medicine and Dentistry; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Fowler
mesh_terms: D000700:Analgesics / Q000191:economics / Q000627:therapeutic use; D000893:Anti-Inflammatory Agents / Q000191:economics / Q000627:therapeutic use; D001182:Arthroscopy / Q000191:economics* / Q000379:methods; D003362:Cost-Benefit Analysis; D003646:Debridement / Q000191:economics; D005260:Female; D006801:Humans; D006820:Hyaluronic Acid / Q000191:economics / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009864:Ontario; D020370:Osteoarthritis, Knee / Q000601:surgery / Q000628:therapy*; D026741:Physical Therapy Modalities / Q000191:economics; D011446:Prospective Studies; D019057:Quality-Adjusted Life Years; D055675:Viscosupplements / Q000191:economics / Q000627:therapeutic use
chemical_list: D000700:Analgesics; D000893:Anti-Inflammatory Agents; D055675:Viscosupplements; D006820:Hyaluronic Acid