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Figure.
Knee Arthroscopy and Arthroplasty Procedures in Florida From 2002 to 2015
Knee Arthroscopy and Arthroplasty Procedures in Florida From 2002 to 2015

Data are from the Florida State Ambulatory Surgery and State Inpatient Databases for 2002 to 2015.

1.
Khan  M, Evaniew  N, Bedi  A, Ayeni  OR, Bhandari  M.  Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis.  CMAJ. 2014;186(14):1057-1064. doi:10.1503/cmaj.140433PubMedGoogle ScholarCrossref
2.
Thorlund  JB, Juhl  CB, Roos  EM, Lohmander  LS.  Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms.  BMJ. 2015;350:h2747. doi:10.1136/bmj.h2747PubMedGoogle ScholarCrossref
3.
Barlow  T, Plant  CE.  Why we still perform arthroscopy in knee osteoarthritis: a multi-methods study.  BMC Musculoskelet Disord. 2015;16:85. doi:10.1186/s12891-015-0537-yPubMedGoogle ScholarCrossref
4.
Howard  D, Brophy  R, Howell  S.  Evidence of no benefit from knee surgery for osteoarthritis led to coverage changes and is linked to decline in procedures.  Health Aff (Millwood). 2012;31(10):2242-2249. doi:10.1377/hlthaff.2012.0644PubMedGoogle ScholarCrossref
5.
Kirkley  A, Birmingham  TB, Litchfield  RB,  et al.  A randomized trial of arthroscopic surgery for osteoarthritis of the knee.  N Engl J Med. 2008;359(11):1097-1107. doi:10.1056/NEJMoa0708333PubMedGoogle ScholarCrossref
6.
Park  J, Mendy  A, Vieira  ER.  Various types of arthritis in the United States: prevalence and age-related trends from 1999 to 2014.  Am J Public Health. 2018;108(2):256-258. doi:10.2105/AJPH.2017.304179PubMedGoogle ScholarCrossref
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    1 Comment for this article
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    Trends in the use of knee arthroscopy in adults
    Robin Holtedahl, MD | Specialist in Physical Medicine and Rehabilitation
    David H. Howard recently described reduced rates of knee arthroscopy in Florida, starting around 2008. I collaborated in a project under the South-East Regional Health Authority (HSE RHA) in Norway analyzing Norwegian rates of arthroscopic knee surgery, and we published the results in BMJ Open (2018 Jun 15;8(6):e021199. doi: 10.1136/bmjopen-2017-021199.) Compared to the present study, we found about twice as large rate reductions in the period 2012-16 in this RHA, from 325 to 171 per 100 000, but hardly any change in the remaining RHAs. This difference we attributed to a more proactive, "hands-on" administrative and professional approach towards the involved surgical departments, starting in 2012. We concluded that professional attitudes in the surgical community probably played a relatively lesser role in explaining the reductions, though more local traditions and beliefs could not be excluded.

    Concerning the age distribution, our group found that there was only a small reduction in proportion of patients 50 years or older in the study period, with almost 50% being in this age group in 2016. Howard's results, though using 65 as cutoff age, add to the evidence indicating that far too many elderly patients are been subjected to knee arthroscopy. There is irrefutable evidence that the vast majority in this age group have chronic degenerative knee conditions that do not respond to surgical interventions, or at least do no better than less invasive alternatives. It also seems likely that the risk of iatrogenic harm is substantially increased in this age group. I therefore think the author has been unduly cautious in his conclusion, and could have placed more emphasis on the dubious ethics of continuing to perform knee arthroscopy, especially in middle-aged and elderly patients. In my opinion, from a public health perspective it is imperative that these rates be brought down substantially, without undue delay, both in the public and private sector.
    CONFLICT OF INTEREST: None Reported
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    Research Letter
    Less Is More
    November 2018

    Trends in the Use of Knee Arthroscopy in Adults

    Author Affiliations
    • 1Department of Health Policy and Management, Emory University, Atlanta, Georgia
    JAMA Intern Med. 2018;178(11):1557-1558. doi:10.1001/jamainternmed.2018.4175

    Multiple clinical trials have shown that knee arthroscopy, compared with medical management, does not result in clinically significant benefits for patients with osteoarthritis, meniscal tears, and knee pain.1,2 It is unclear whether these trials have affected clinical practice. Reimbursement incentives favor surgery, and surgeons’ and patients’ beliefs may not reflect the evidence.3 In this article, I document the trends in the use of knee arthroscopy in Florida from January 1, 2002, to December 31, 2015.

    Methods

    I evaluated trends in outpatient arthroscopic knee procedures among patients aged 18 years or older using the Florida State Ambulatory Surgery and State Inpatient Databases for 2000 to 2015. The all-payer data included 100% of ambulatory and inpatient surgical procedures in the state. I selected Florida because of the availability of data for that state and because it has a large, diverse population. Following a previous study,4 I measured receipt of arthroscopic knee surgery using Current Procedural Terminology codes and International Classification of Diseases, Ninth Revision and Tenth Revision procedure codes to identify arthroscopic knee operations.

    In addition, I identified trends in the use of total knee arthroplasties to gauge the possible substitution between knee arthroplasty and arthroscopy. I separately examined the trends in arthroscopic knee procedures by age group.

    I report the surgical rate per 100 000 population aged 18 years or older, standardized by age and sex to the 2002 Florida population, using the direct method. I evaluated the significance of trends using least squares regression with a time trend variable. The study was exempt from institutional review board review under federal regulation 45 CFR §46.101 because the data were previously collected and deidentified.

    Results

    In total, 868 482 arthroscopic knee procedures were performed in Florida between 2002 and 2015. Of the 868 482 procedures, 704 563 (81.1%) were meniscectomies. The knee arthroscopy rate declined over the study period, from 449 procedures per 100 000 population aged 18 years or older in 2002 to 345 in 2015 (change, 23%; P < .001) (Figure, A). The meniscectomy rate declined from 349 in 2002 to 291 in 2015 (change, 17%; P = .002), and the adjusted knee arthroplasty rate increased from 170 in 2002 to 244 in 2015 (change, 44%; P < .001).

    The adjusted knee arthroscopy rate in the population aged 18 to 64 years declined from 447 in 2002 to 339 in 2015 (change, −24%; P < .001). The rate in the population aged 65 years or older declined from 454 in 2002 to 368 in 2015 (change, −19%; P = .01) (Figure, B).

    Discussion

    Knee arthroscopy rates in Florida declined by 23% between 2002 and 2015. The decline in arthroscopy rates was especially pronounced after 2008. The trial by Kirkley et al5 was published in 2008, which was the second major trial that failed to detect a difference between arthroscopy and medical management in the treatment of osteoarthritis of the knee. The knee arthroplasty rate increased, but most of the increase preceded the decline in arthroscopy rates.

    Between 1999 and 2014, the prevalence of osteoarthritis in the US adult population more than doubled from 6.6% to 14.3%.6 Trends in per capita knee surgical procedures, which are not adjusted for the increase in the prevalence of osteoarthritis, likely understate the degree to which use of arthroscopic surgery as a treatment for knee pain has declined.

    Some private insurers have started to require physicians to obtain authorization before an arthroscopic knee procedure. The fee-for-service Medicare program does not require prior authorization. Private insurers covered 72% of knee arthroscopies in patients younger than 65 years, and Medicare covered 83% of these procedures in patients aged 65 years or older. I could not observe the impact of prior authorization requirements directly, but trends in arthroscopy rates in these age groups were similar, indicating that the requirements may not be a major factor behind the decline in rates.

    The results suggest that the accumulating evidence on the lack of benefit associated with knee arthroscopy, compared with medical management, has altered treatment decisions. Despite the lower use rates, knee arthroscopy is still a common procedure. There may be additional opportunities to reduce the use of knee arthroscopy without adversely affecting patient outcomes.

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    Article Information

    Accepted for Publication: June 16, 2018.

    Corresponding Author: David H. Howard, PhD, Department of Health Policy and Management, Emory University, 1518 Clifton Rd NE, Atlanta, GA 30322 (david.howard@emory.edu).

    Published Online: September 24, 2018. doi:10.1001/jamainternmed.2018.4175

    Conflict of Interest Disclosures: None reported.

    References
    1.
    Khan  M, Evaniew  N, Bedi  A, Ayeni  OR, Bhandari  M.  Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis.  CMAJ. 2014;186(14):1057-1064. doi:10.1503/cmaj.140433PubMedGoogle ScholarCrossref
    2.
    Thorlund  JB, Juhl  CB, Roos  EM, Lohmander  LS.  Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms.  BMJ. 2015;350:h2747. doi:10.1136/bmj.h2747PubMedGoogle ScholarCrossref
    3.
    Barlow  T, Plant  CE.  Why we still perform arthroscopy in knee osteoarthritis: a multi-methods study.  BMC Musculoskelet Disord. 2015;16:85. doi:10.1186/s12891-015-0537-yPubMedGoogle ScholarCrossref
    4.
    Howard  D, Brophy  R, Howell  S.  Evidence of no benefit from knee surgery for osteoarthritis led to coverage changes and is linked to decline in procedures.  Health Aff (Millwood). 2012;31(10):2242-2249. doi:10.1377/hlthaff.2012.0644PubMedGoogle ScholarCrossref
    5.
    Kirkley  A, Birmingham  TB, Litchfield  RB,  et al.  A randomized trial of arthroscopic surgery for osteoarthritis of the knee.  N Engl J Med. 2008;359(11):1097-1107. doi:10.1056/NEJMoa0708333PubMedGoogle ScholarCrossref
    6.
    Park  J, Mendy  A, Vieira  ER.  Various types of arthritis in the United States: prevalence and age-related trends from 1999 to 2014.  Am J Public Health. 2018;108(2):256-258. doi:10.2105/AJPH.2017.304179PubMedGoogle ScholarCrossref
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