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Arthroscopy of the knee assessed in Switzerland
Within the framework of the Federal HTA program, the benefits currently paid under the compulsory health insurance are being reevaluated. On the 4th of September, 2019, the health technology assessment of arthroscopy of the knee, developed by the Swiss Medical Board on behalf of the Federal Ofice for Public Health, has been published.
This HTA report aimed to assess the clinical effectiveness and safety of therapeutic knee arthroscopy compared to any other treatment in patients with degenerative changes of the knee – irrespective of whether they are primarily due to meniscal damage, osteoarthritis of the knee or a mix of both. Furthermore, its goal was also to evaluate the budget impact of knee arthroscopy in patients with degenerative changes of the knee primarily due to meniscal damage and the inpatient compared to outpatient therapeutic knee arthroscopy.
Risk of bias was assessed according to the Cochrane Handbook, and the quality of evidence was evaluated according to GRADE for short-term and intermediate follow-up. When possible, clinical outcome results were summarised quantitatively in a meta-analysis by using inverse variance models assuming random effects.
Clinical effectiveness and safety
There were 21 RCTs (n>2000 patients) identified for the assessment of clinical effectiveness and safety of arthroscopy in patients with degenerative knee symptoms.
The following data were extracted (for short-term follow-up and intermediate follow-up): outcomes of pain, function, global assessment (combined pain, function and/or stiffness), joint stiffness, the occurrence of total knee replacement, QoL, adverse events and serious adverse event. There was no statistically significant difference between arthroscopy, and the comparator found for the outcomes of function, global assessment, joint stiffness, total knee replacement and quality of life at short-term (≤6 months) or intermediate follow-up (>6 months and <7 years). There was a small statistically significant effect in favor of arthroscopy in the outcome of pain at short-term follow-up (SMD -0.16, 95% CI [-0.31, -0.01]), while no statistically significant difference was found at intermediate follow-up. None of the included RCTs reported outcomes at long-term follow-up. The evidence of harms reported by the RCTs was limited; Thus, it was difficult to assess the overall clinical effectiveness with regards to benefits and harms of arthroscopy.
The authors judged the overall quality of evidence to be very low for short-term follow up, and low, for intermediate follow-up.
In conclusion, there is no evidence that arthroscopic knee interventions in patients with degenerative changes of the knee have any benefit on outcomes measured at short or intermediate follow-up, with the exception of a small effect on the reduction of pain at short follow-up. Therefore, it remains unclear whether knee arthroscopy has an impact on the assessed outcomes.
The authors identified four cost-effectiveness studies. Two compared knee arthroscopy to non-operative treatment and showed conflicting results: one suggested that knee arthroscopy was more expensive and less effective than non-operative interventions alone (from both the societal and healthcare payer perspective). The other indicated that knee arthroscopy was more costly and more effective (incremental cost-effectiveness ratio (ICER) better than CHF 30,000 per quality-adjusted life-year (QALY) gained) from a healthcare payer perspective or even cost-saving from a societal perspective if compared to physical therapy alone. The other two studies comparing preoperative status with postoperative status suggested that knee arthroscopy may be cost-effective with ICERs of CHF 7,200 to 7,300 per QALY gained.
The identified health economic evidence was very limited. Thus, it was difficult to draw reliable conclusions on the cost-effectiveness of arthroscopic surgery in patients with degenerative changes of the knee. Although three of four identified studies reported arthroscopy to be cost-effective, the authors were not convinced as the flaws were identified in the methodology, as well as the low quality of evidence.
Two analytical strategies were used to assess the budget impact. In the first, only patients who reported at the same time a relevant DRG code, at least one related diagnosis (ICD-10 code), and at least one appropriate treatment (CHOP code) were included. In the second strategy, all patients who had at the same time at least one proper diagnosis (ICD-10 code) and one appropriate treatment (CHOP code), irrespective of the reported DRG codes, were included.
The results of the budget impact analysis (first strategy) suggested that the total expenditure for knee/meniscus derangement in Switzerland ranged from CHF 53.52 Mio. to CHF 71.93 Mio. in 2013 and from CHF 52.30 Mio. to CHF 67.73 Mio. in 2014. Outpatient costs accounted for 20-28% of the total costs.
The authors believe that the second strategy brought more realistic results. It suggests total inpatient costs of CHF 58.10 Mio. in 2010, CHF 55.87 Mio. in 2011, CHF 58.44 Mio. in 2012, CHF 57.20 Mio. in 2013 and CHF 54.47 Mio. in 2014. Total outpatient costs were estimated to be CHF 14.73 Mio. in 2013 and CHF 13.26 Mio. in 2014.
Inpatient vs. outpatient setting
One RCT (n=100 patients) that assessed the clinical effectiveness and safety of arthroscopy in the inpatient and outpatient settings was identified. This RCT reported only on pain within a week of discharge, and no difference is demonstrated. The overall quality of evidence was judged to be very low by the authors.
This HTA report can be found in English (with summaries in German, French and Italian) here.
More info about the Federal HTA program can be seen here.
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