Using Medicare Data to Understand Low-Value Health Care: The Case of Intra-articular Hyaluronic Acid Injections | Osteoarthritis | JAMA Internal Medicine | JAMA Network
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Figure.  Injections of Intra-articular Hyaluronic Acid in 2012 per 1000 Medicare Beneficiaries by Health Referral Region
Injections of Intra-articular Hyaluronic Acid in 2012 per 1000 Medicare Beneficiaries by Health Referral Region

Number of hyaluronic acid injections derived from 2012 Medicare Provider Utilization and Payment Data and total number of Medicare beneficiaries from the Dartmouth Atlas of Health Care.3,4,7

Table.  Association Between Physician Supply and the 0dds of Intra-articular Hyaluronic Acid Injections in a Health Referral Region
Association Between Physician Supply and the 0dds of Intra-articular Hyaluronic Acid Injections in a Health Referral Region
1.
Table 1: summary of recommendations: AAOS clinical practice guideline on the injection of osteoarthritis of the knee (non-arthroplasty), second edition. American Academy of Orthopaedic Surgeons Web site. http://www.aaos.org/news/aaosnow/jun13/cover1_t1.pdf. Accessed April 16, 2014.
2.
Rutjes  AW, Jüni  P, da Costa  BR, Trelle  S, Nüesch  E, Reichenbach  S.  Viscosupplementation for osteoarthritis of the knee: a systematic review and meta-analysis.  Ann Intern Med. 2012;157(3):180-191.PubMedGoogle ScholarCrossref
3.
The Centers for Medicare and Medicaid Services, Office of Information Products and Data Analytics. Medicare fee-for-service Provider Utilization and Payment Data Physician and Other Supplier Public Use File: a methodological overview. Centers for Medicare and Medicaid Services Web site. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Downloads/Medicare-Physician-and-Other-Supplier-PUF-Methodology.pdf. Published April 7, 2014. Updated May 13, 2014. Accessed April 16, 2014.
4.
Geographic crosswalks and boundary files: ZIP code to crosswalks: 2012. The Dartmouth Atlas of Health Care Web site. http://www.dartmouthatlas.org/tools/downloads.aspx?tab=39. Accessed April 16, 2014.
5.
Selected hospital and physician capacity measures data: 2006. The Dartmouth Atlas of Health Care Web site. http://www.dartmouthatlas.org/tools/downloads.aspx?tab=35. Accessed April 16, 2014.
6.
Zhang  Y, Baik  SH, Fendrick  AM, Baicker  K.  Comparing local and regional variation in health care spending.  N Engl J Med. 2012;367(18):1724-1731.PubMedGoogle ScholarCrossref
7.
Selected measures of primary care access and quality: 2010. The Dartmouth Atlas of Health Care Web site. http://www.dartmouthatlas.org/tools/downloads.aspx. Accessed April 16, 2014.
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    Comment on research letter Using Medicare data to understand low value healthcare: The case of intra-articular hyaluronic acid injections JAMA internal medicine August 25, 2014
    Roy Altman, Marc Hochberg | Roy D. Altman, MD Professor of Medicine University of California, Los Angeles (UCLA) Los Angeles, California, Marc C. Hochberg, MD, MPH, MACP Professor of Medicine and Epidemiology and Public Health
    We read with interest the research letter and were not surprised by either the regional variation in use of intra-articular hyaluronate injections or the correlation between the number of orthopaedic surgeons and rheumatologists and use of this therapy. We are concerned, however, with the description of intra-articular hyaluronate injections as “low value health care.” This statement appears to be based on a “cherry picked” meta-analysis and the recommendations of the American Academy of Orthopedic Surgeon’s, that are not published in a peer-reviewed journal. There is an extensive literature of systematic reviews of intra-articular hyaluronate therapy, the majority of which support statistically significant efficacy compared with placebo, including reviews of guidelines (1). It should be noted that placebo (saline) injections, often administered following joint aspiration, are significantly more efficacious than oral placebo (2). Thus, when intra-articular hyaluronate therapy is compared to oral placebo in a network meta-analysis, the effect size for efficacy is even greater than when compared to intra-articular placebo (saline) injections (3) . Furthermore, intra-articular hyaluronate therapy is “conditionally” recommended by the American College of Rheumatology in patients with knee OA who have not had an adequate response to analgesics and nonpharmacologic therapy; consistent with the FDA labeling of these products (4). While intra-articular hyaluronic acid does not provide clinically important benefit to all of those treated, some patients clearly benefit from this therapy and there is increasing evidence that knee joint replacement may be delayed in those receiving intra-articular hyaluronic acid (5). Unfortunately, at this time, we are not able to determine which patients benefit or do not from this therapy, although data suggest that patients with more severe radiographic damage, e.g., Kellgren-Lawrence grade 4 changes, are less likely to benefit. Until more effective therapies become available, intra-articular hyaluronic acid needs to continue to be part of the multimodal therapy program for people with osteoarthritis of the knee..1. Poitras S1, Avouac J, Rossignol M, Avouac B, Cedraschi C, Nordin M, et al. A critical appraisal of guidelines for the management of knee osteoarthritis using Appraisal of Guidelines Research and Evaluation criteria. Arthritis Res Ther. 2007;9(6):R126.2. Zhang W, Robertson J, Jones AC, Dieppe PA, Doherty M. The placebo effect and its determinants in osteoarthritis: meta-analysis of randomised controlled trials. Ann Rheum Dis. 2008 Dec;67(12):1716-23.3. Bannuru RR, Schmid CH, Sullivan MC, Kent DM, Wong JB, McAlindon TE. Differential response of placebo treatments in osteoarthritis trials: A systematic review and network Meta–analysis. Osteoarthritis Cartilage 2014;22 (Suppl):S24.4. Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip and knee. Arthritis Care Res 2012;64:465-74.5. Abbott T, Altman RD, Dimeff R, Fredericson, Vad V, Vitanzo P,Yadalam S, et al. Do hyaluronic acid injections delay total knee replacement surgery? American College of Rheumatology, San Diego, CA, Program Book (October):2013 (Suppl):308. Roy D. Altman, MDProfessor of MedicineUniversity of California, Los Angeles (UCLA)Los Angeles, CaliforniaMarc C. Hochberg, MD, MPH, MACPProfessor of Medicine and Epidemiology and Public HealthHead, Division of Rheumatology & Clinical ImmunologyVice Chair, Department of MedicineUniversity of Maryland School of MedicineBaltimore, Maryland
    CONFLICT OF INTEREST: Roy Altman: Consultant Ferring, DuPuy, Bioventis, RottaMarc Hochberg: none
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    Research Letter
    October 2014

    Using Medicare Data to Understand Low-Value Health Care: The Case of Intra-articular Hyaluronic Acid Injections

    Author Affiliations
    • 1Department of Medicine and Rheumatology, University of California, San Francisco
    • 2San Francisco Veterans Affairs Medical Center, San Francisco, California
    • 3Department of Orthopedic Surgery, University of California, San Francisco
    • 4Philip R. Lee Institute for Health Policy Studies, San Francisco, California
    JAMA Intern Med. 2014;174(10):1702-1704. doi:10.1001/jamainternmed.2014.3926

    The US Food and Drug Administration first approved intra-articular hyaluronic acid injections (also known as viscosupplementation) in 1997 to treat patients with severe knee osteoarthritis. The effectiveness of these injections, however, has recently been questioned. In 2013, the American Academy of Orthopedic Surgeons issued a clinical practice guideline that stated, “We cannot recommend using hyaluronic acid for patients with symptomatic [osteoarthritis] of the knee,” with a “strong” rating.1 The rating was based on high-quality evidence that hyaluronic acid injections were not associated with clinically meaningful improvement in symptoms compared with placebo injections. A meta-analysis published in 2012 reported similar findings.2 Using recent Medicare Part B claims data, we examined patterns of use for intra-articular hyaluronic acid injections across the United States.

    Methods

    We analyzed 2012 Medicare Provider Utilization and Payment Data, which is available for public use. The data file contains all Part B claims for the Medicare fee-for-service population, aggregated by provider, with certain exclusions.3 We tabulated injections (“bene-days”) with all formulations of hyaluronic acid (Healthcare Common Procedure Coding System codes J7321, J7323, J7324, J7325, and J7326) according to health referral region (HRR; large regionalized health care markets defined by patients’ travel for tertiary care).4 We calculated total payments by Medicare from reported payments to each provider for (1) hyaluronic acid products and (2) the associated Current Procedural Terminology code for large-joint injections (20610). If multiple injections were given on the same day to a single patient, only 1 was counted.

    Using data from the Dartmouth Atlas of Health Care, we divided the raw totals for the number of hyaluronic acid injections by the total number of Medicare beneficiaries in each HRR.4 We used logistic regression to correlate the number of procedures performed in each HRR (per 1000 beneficiaries) with the number of physicians per capita.5 We applied previously described methods to assess clustering among high-use regions.6

    Aggregated records derived from 10 or fewer beneficiaries were excluded from this public use file. The data set also did not contain information on individual patients, including indications for treatment. The institutional review boards at our institutions exempted the study from review.

    Results

    In 2012, Medicare Part B reimbursed for 1 161 924 injections with intra-articular hyaluronic acid among 423 669 patients by 12 761 physicians or other clinicians. Most formulations of hyaluronic acid consist of 3 injections given 1 week apart. Medicare paid $207 million for the hyaluronic acid product and $80 million for the associated large-joint injection (identified by the Current Procedural Terminology code). Thus, the average cost per injection paid by Medicare was $179 for the drug and $69 for the injection. The clinicians most likely to give intra-articular hyaluronic acid were orthopedic surgeons (59%), primary care physicians (11%, including family, general, internal, and geriatric medicines), physician assistants (10%), and rheumatologists (8%). An analysis by HRRs showed that rates of intra-articular hyaluronic acid injections varied from 1 to 115 injections per 1000 Medicare beneficiaries (mean, 39/1000 Medicare beneficiaries; coefficient of variation, 56% [Figure]). These HRRs were clustered (P < .001). Higher rates of injection of intra-articular hyaluronic acid in an HRR were associated with higher numbers of physicians, surgeons, and rheumatologists (adjusted for population size) but were not correlated with the number of orthopedists (Table).

    Discussion

    In the United States in 2012, intra-articular hyaluronic acid was given frequently to Medicare beneficiaries despite strong evidence that this treatment is of low value for its approved indication of severe knee osteoarthritis. The injections are costly and have limited clinical benefit. We also found that the frequency of use varied widely and was correlated with the number of physicians, but not the number of orthopedic surgeons, in a region. One limitation of our study is that we could not determine the indications for treatment, such as the percentage of injections given to patients with severe knee osteoarthritis. We also could not determine if any patients developed infections or other complications.

    Based on recent guidelines and studies, intra-articular hyaluronic acid injections represent low-value care and an inefficient use of health care resources.2,3 Medicare beneficiaries and society would be better served if physicians and others involved in delivering and paying for health care worked together to minimize the use of such low-value care.

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    Article Information

    Corresponding Author: Gabriela Schmajuk, MD, MS, Department of Medicine and Rheumatology, San Francisco Veterans Affairs Medical Center, 4150 Clement St, Mail Stop 111R, San Francisco, CA 94121 (gabriela.schmajuk@ucsf.edu).

    Published Online: August 25, 2014. doi:10.1001/jamainternmed.2014.3926.

    Author Contributions: Dr Schmajuk had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Study concept and design: All authors.

    Acquisition, analysis, or interpretation of data: Schmajuk, Yazdany.

    Drafting of the manuscript: All authors.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Schmajuk.

    Administrative, technical, or material support: Bozic.

    Study supervision: Bozic, Yazdany.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This study was supported by grants K23 AR063770 (Dr Schmajuk) and K23 AR060259 (Dr Yazdany) from the National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases.

    Role of the Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.

    References
    1.
    Table 1: summary of recommendations: AAOS clinical practice guideline on the injection of osteoarthritis of the knee (non-arthroplasty), second edition. American Academy of Orthopaedic Surgeons Web site. http://www.aaos.org/news/aaosnow/jun13/cover1_t1.pdf. Accessed April 16, 2014.
    2.
    Rutjes  AW, Jüni  P, da Costa  BR, Trelle  S, Nüesch  E, Reichenbach  S.  Viscosupplementation for osteoarthritis of the knee: a systematic review and meta-analysis.  Ann Intern Med. 2012;157(3):180-191.PubMedGoogle ScholarCrossref
    3.
    The Centers for Medicare and Medicaid Services, Office of Information Products and Data Analytics. Medicare fee-for-service Provider Utilization and Payment Data Physician and Other Supplier Public Use File: a methodological overview. Centers for Medicare and Medicaid Services Web site. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Downloads/Medicare-Physician-and-Other-Supplier-PUF-Methodology.pdf. Published April 7, 2014. Updated May 13, 2014. Accessed April 16, 2014.
    4.
    Geographic crosswalks and boundary files: ZIP code to crosswalks: 2012. The Dartmouth Atlas of Health Care Web site. http://www.dartmouthatlas.org/tools/downloads.aspx?tab=39. Accessed April 16, 2014.
    5.
    Selected hospital and physician capacity measures data: 2006. The Dartmouth Atlas of Health Care Web site. http://www.dartmouthatlas.org/tools/downloads.aspx?tab=35. Accessed April 16, 2014.
    6.
    Zhang  Y, Baik  SH, Fendrick  AM, Baicker  K.  Comparing local and regional variation in health care spending.  N Engl J Med. 2012;367(18):1724-1731.PubMedGoogle ScholarCrossref
    7.
    Selected measures of primary care access and quality: 2010. The Dartmouth Atlas of Health Care Web site. http://www.dartmouthatlas.org/tools/downloads.aspx. Accessed April 16, 2014.
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