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Stahel PF, Wang P, Hutfless S, et al. Surgeon Practice Patterns of Arthroscopic Partial Meniscectomy for Degenerative Disease in the United States: A Measure of Low-Value Care. JAMA Surg. 2018;153(5):494–496. doi:10.1001/jamasurg.2017.6235
Arthroscopic partial meniscectomy (APM) is one of the most common surgical procedures in the world. However, the value of APM has come under intense scrutiny.1 Multiple randomized clinical trials, including the sham surgery–controlled Finnish Degenerative Meniscal Lesion Study (FIDELITY),2 revealed no benefit from the procedure in patients with degenerative meniscal tears compared with exercise and physical therapy.3,4 Evidence that may support an APM-only procedure (APM not associated with a ligament, cartilage, or meniscus repair) is for a small subset of patients with an acute traumatic meniscal tear, but these typically occur in younger, non-Medicare patients. Despite this, APM-only procedures continue to be common among Medicare beneficiaries.1 To better understand the disparity between the medical evidence and current orthopedic practice, we designed this study to measure surgeon practice patterns of APM-only procedures.
Using 2016 Centers for Medicare and Medicaid Services data, we evaluated the prevalence of APM-only procedures as a proportion of all knee arthroscopies (Current Procedural Terminology [CPT] codes 29866-29889) performed by a surgeon. We excluded patients with septic knee lavage and drainage (CPT code 29871). Arthroscopic partial meniscectomy–only procedures were identified by CPT codes 29880 (medial and lateral meniscus) and 29881 (medial or lateral meniscus). We defined low-volume surgeons as those performing 10 or fewer arthroscopies annually in the Medicare population (Johns Hopkins University institutional review board approval 00085313). Informed consent was waived for this study due to it being a database study.
We identified 121 624 knee arthroscopies in the Medicare population performed by 12 504 surgeons. We found wide practice variation in the national distribution of surgeons by the proportion of knee arthroscopies they performed that were APM-only procedures, regardless of the indication (Figure). Arthroscopic partial meniscectomy–only procedures comprised 66.7% (81 102 of 121 624) knee arthroscopies for both the 8366 low-volume surgeons (24 521 of 36 776 procedures) and the 4138 high-volume surgeons (56 581 of 84 848 procedures). Among high-volume arthroscopic knee surgeons, 286 (6.9%) never performed the APM-only procedure while 518 (12.5%) exclusively performed the APM-only procedure as their only knee arthroscopy procedure in Medicare beneficiaries.
These data suggest a significant and troubling disparity between evidence and practice for one of the most common operations performed in the United States. There may be a few reasons for this disparity. First, a consumerist culture may be demanding the procedure (also referred to by patients as a “knee washout” or “meniscus shaving”). Patients may perceive a clinical improvement despite unequivocal scientific evidence to the contrary in middle-aged patients with degenerative meniscal lesions.5 Second, the evidence may be in the slow-adoption phase because of the publication of multiple randomized clinical trials on this topic in recent years.2 This delay may have 3 contributors: (1) a lack of knowledge about the evidence, (2) knowledge of the evidence but disagreement about the interpretation of findings, or (3) knowledge of the evidence but disregard of the findings. The high safety of this routine procedure may further propagate its overuse. Notably, this study was performed in Medicare patients, suggesting that it underestimates the true magnitude of overuse in the United States. One limitation is coding accuracy. Some surgeons may code for an APM-only procedure when a chondroplasty is actually performed (CPT codes 29877 and 29879). Similarly, surgeons may be coding for an acute meniscal tear in older patients when they really have degenerative disease.
Finally, in observing the mass overuse of APM, it is important that we not make absolute conclusions for all patients. The clear lack of benefits from APM in the literature reviewed was exclusively demonstrated in middle-aged and older patients who had developed degenerative meniscal tears.3,4 Arthroscopic partial meniscectomies may benefit a very small subset of acute traumatic meniscal tears in younger patients, a distinct entity that is different from degenerative meniscal lesions that are common in older patients. Interestingly, a secondary post hoc analysis with 2-year follow-up of the FIDELITY trial2 rejected the conventional notion that the presence of mechanical symptoms that are associated with unstable meniscal tears represents an absolute indication for surgery, as this sham surgery–controlled randomized clinical trial revealed no benefit from APM over conservative treatments in this selected subgroup.6
We propose that the annual proportion of knee arthroscopy procedures that are APM-only in patients with degenerative disease is a surgeon-level measure of appropriateness in surgical care. At best, APM represents low-value care that is common in the Medicare population. In considering this quality measure, we believe that a distinction should be made between interventions that lack supporting evidence and practices like APM for degenerative disease that are contrary to ample level 1A evidence.
Corresponding Author: Martin A. Makary, MD, MPH, Johns Hopkins Hospital, Johns Hopkins University School of Public Health, 600 N Wolfe St, Halsted 610, Baltimore, MD 21287 (firstname.lastname@example.org).
Accepted for Publication: December 10, 2017.
Published Online: February 28, 2018. doi:10.1001/jamasurg.2017.6235
Author Contributions: Drs Wang and Hutfless had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Stahel, Makary
Acquisition, analysis, or interpretation of data: Wang, Hutfless, McCarty, Mehler, Osgood, Makary.
Drafting of the manuscript: Stahel, Wang.
Critical revision of the manuscript for important intellectual content: Hutfless, McCarty, Mehler, Osgood, Makary.
Statistical analysis: Wang, Hutfless.
Administrative, technical, or material support: Stahel, Mehler.
Supervision: Mehler, Makary.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study is partially funded by grant 73417 from the Robert Wood Johnson Foundation.
Role of the Funder/Sponsor: The Robert Wood Johnson Foundation 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.