Monday 30 June 2014 - 12am PST
One third of total knee replacements in the US are
"inappropriate" when
applied to a Spanish patient classification system, according to a study
published in Arthritis & Rheumatology, a journal of the American College of Rheumatology.
Figures from the Agency for
Healthcare Research and Quality show that more than 600,000 knee replacements are performed each
year in the US. This surgery has become increasingly more
common over the past 15 years, with studies showing a 162% annual
volume increase in Medicare-covered knee replacement surgeries during
1991-2010.
Experts are divided on the
reasons for this growth, with some maintaining it demonstrates that the procedure
is effective, while others argue the surgery is being overused. One concern of the critics who
believe total knee arthroplasties (TKA) are being overused is that the
procedure "is highly reliant on subjective criteria."
For the new study,
researchers from Virginia Commonwealth University in Richmond examined the
criteria that is used to determine appropriateness for TKA.
The authors point out that the investigated criteria have
not been studied in the US and have been developed in other countries.
"To my knowledge, ours
is the first US study to compare validated appropriateness criteria with actual
cases of knee replacement surgery," says lead author Dr. Daniel Riddle from
the Department of Physical Therapy at Virginia Commonwealth University.
Dr. Riddle examined a
modified version of an appropriateness classification system developed in Spain
and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) Pain
and Physical Function scale.
In the study, Riddle and
colleagues note that the Spanish criteria are considered by many experts in the
field to be "among the most powerful tools for improving quality of care
and controlling costs."
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The classification systems
were used to assess participants enrolled in the Osteoarthritis Initiative - a 5-year study of 4,796 people
partly funded by the National
Institutes of Health.
Looking at a sub-set of 175
people who underwent TKA surgery, Dr. Riddle's analysis found that 44% of
surgeries were classified as "appropriate," 22% were
"inconclusive," and 34% were "inappropriate."
The mean age of knee
replacement patients in the study was 67 years old, and 60% of them were female.
"Our
finding that one third of knee replacements were inappropriate was higher than
expected and linked to variation in knee pain [osteoarthritis] severity and
functional loss," says Dr. Riddle. "These data highlight the need to
develop patient selection criteria in the US."
"I agree with Riddle and
colleagues," writes Dr.
Jeffery Katz - from the Orthopedic and Arthritis Center for Outcomes
Research at Brigham and
Women's Hospital in Boston, MA - in a linked editorial.
"We should be concerned about offering total knee
replacements to subjects who endorse 'none' or 'mild' on all items of the WOMAC
pain and function scales."
The new study also highlights
that there are many
variables involved in the decision to undergo TKA surgery. Severity of symptoms
and the psychological readiness of the patient are two important factors,
but in addition to the variables examined in the study, there are a wide range
of variables specific to the patient that a surgeon will consider when making
the decision for or against TKA surgery.
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