Are Medicare Beneficiaries With Knee Osteoarthritis Receiving Enough Conservative Care?

By Marilynn Larkin

June 21, 2021

NEW YORK (Reuters Health) - Non-surgical care for knee osteoarthritis is uncommon among older adults, especially in regions of the U.S. where total knee arthroplasty (TKA) rates are high, a large retrospective analysis shows.

"As rheumatologists, we often think of knee arthroplasty as the last resort, after patients have tried and failed more conservative treatments, such as PT, weight loss, NSAIDs, and maybe glucocorticoid injections," Dr. Michael Ward of the US National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health in Bethesda told Reuters Health by email.

"The most surprising finding from this study is that, at the population level, many patients don't receive these more conservative treatments," he said.

"Because lack of use of these conservative treatments was more common in regions of the country where TKA was more commonly used, we think it is often being substituted for conservative care," he added.

As reported in Arthritis and Rheumatology, Dr. Ward analyzed data on close to one million U.S. Medicare beneficiaries with knee osteoarthritis in 2005 - 2010. Health care utilization for knee complaints - i.e., rates of physician visits, physical therapy, knee injections and arthroscopy - was compared among beneficiaries who lived in regions with high or low rates of TKA.

About one-third of patients (33.1%) had TKA during a median follow-up of 5.6 years. Higher rates of visits for knee complaints were associated with increased risks of arthroplasty, while use of physical therapy, specialist care, and intra-articular treatments were associated with lower risks.

The frequency of TKA varied from 26.4% in the lowest quintile region to 42.1% in the highest quintile.

Notably, rates of physician visits, physical therapy, specialist care, and use of intra-articular injections varied inversely with arthroplasty quintile. For example, physical therapy was used by 32.5% of beneficiaries in the lowest quintile region and 23.6% in the highest quintile region.

Physical therapy was associated with lower TKA rates across all quintiles.

Dr. Ward said, "The next steps are to determine if this is due to underappreciation of the role of conservative care on the part of patients or primary care providers, or lack of access to it, or referral patterns that prioritize orthopedic surgeons, particularly in those regions with high rates of TKA."

Orthopedic surgeon Dr. Timothy Gibson, Medical Director of the MemorialCare Joint Replacement Center at Orange Coast Medical Center in Fountain Valley, California commented in an email to Reuters Health, "This is a retrospective cohort study, which shows correlations, but has limitations and weaknesses inherent to such a study."

"It is surprising that this study found that physical therapy and other conservative strategies are not widely used in older adults with knee pain," he said. The American Academy of Orthopedic Surgeons clinical practice guideline on treatment of osteoarthritis of the knee "gives a strong recommendation for use of home exercise, strengthening, and low-impact exercise as part of conservative treatment," he said. (

"NSAIDs, non-narcotic pain medication and weight loss are also recommended," he noted. "The benefit of different injections is not as clear cut. There are numerous other conservative treatments that are not recommended due to lack of quality studies to measure their efficacy."

"The article refers to TKA as a 'risk' to be avoided such as cancer or heart attack, yet in the opening paragraph states that it is 'the most effective treatment for advanced knee osteoarthritis," he added. "It is one of the most successful surgeries for improvement in quality of life."

"Cost-effective care should include conservative treatments that work, and perhaps delay the need for surgery, but not to avoid the most effective treatment when it is appropriate," he said. "The article is concerned about the cost burden of TKA, yet there is cost in using ineffective conservative care, as well," Dr. Gibson concluded.

SOURCE: Arthritis and Rheumatology, online June 8, 2021.