Common Knee Procedure in Older Patients Constitutes Low-Value Care, Study Concludes
A new Medicare records study by researchers from Johns Hopkins University has added to the mounting evidence that arthroscopic partial meniscectomy (APM) offers little or no benefit to patients over age of 65, despite accounting for an estimated two-thirds of all orthopaedic knee arthroscopy procedures in older patients in 2016.
Published in JAMA Surgery, the study highlights 1 of a number of low-value, avoidable operations being performed in the US, the researchers said. An estimated 750,000 APMs are performed annually in the US, and it is one of the most common operations in the world.
Multiple clinical trials, Dr. Makary said, have shown that compared with regular exercise and physical therapy, APM provides no additional benefit in older patients with meniscal tears linked to aging and everyday wear and tear. Studies do show benefit from APM in patients with an acute, traumatic meniscal tear, an injury typically seen in younger people and athletes, Dr. Makary added.
For the study, Dr. Makary and his team first established the overall prevalence of APM-only procedures as a proportion of orthopaedic surgeons’ overall knee arthroscopy surgeries. To do this, they analyzed 2016 data on knee arthroscopies gathered by the Centers for Medicare and Medicaid Services.
APM-only procedures accounted for 66.7% (81,102) of the 121,624 knee arthroscopies performed in the Medicare population by 12,504 surgeons. Among high-volume arthroscopic knee surgeons, 6.9% (286 surgeons) never performed APM-only procedures, while 12.5% (518 surgeons) exclusively performed APM-only surgery.
“The practice is not consistent with the evidence,” said Greg Osgood, MD, assistant professor of orthopaedic surgery at the Johns Hopkins University School of Medicine and co-author of the paper.
In other words, Dr. Osgood said, too many orthopaedic surgeons are performing too many APM procedures done only to remove joint tissue, despite evidence that it offers no benefit.
Dr. Makary and Dr. Osgood said the persistence of the procedures could be due to either physicians’ lack of knowledge about the evidence, disagreement with it, or disregard for it. Dr. Makary said that their study was limited by potential coding inaccuracies by physicians and that it is important for surgeons to not dismiss APM-only entirely, as it may help a small subset of young patients.
The authors point out that the high prevalence of the procedure (also referred to by some patients as a washout or a shaving) is sometimes driven by patient demand, given a growing consumerist culture. The procedure costs anywhere from $2,000 to $10,000 and is often paid for by insurance. The authors advise patients offered the procedure for degenerative disease to ask about non-surgical alternatives and to seek a second opinion.
“In light of a recent national physician survey we conducted suggesting that 21% of all medical care may be unnecessary, better metrics of appropriateness in medicine are needed. The proportion of a surgeon’s arthroscopies that are APM-only procedures in older patients is a telling metric of low-value care,” Dr. Makary said.
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. Published online ahead of print on February 28, 2018. doi: 10.1001/jamasurg.2017.6235.