Abstract
Knee osteoarthritis is associated with an annual cost to society exceeding US$27 billion. Value-based treatment is an important consideration, and cost-benefit analyses are crucial to determine the benefits to both patients and society. The quality-adjusted life year (QALY) is a generic measure of burden including both quality and quantity. Recent studies have suggested that intra-articular injection of platelet-rich plasma (PRP) is effective treatment for knee osteoarthritis and comparable to hyaluronic acid (HA). Although the costs (dollars) per QALY were higher for PRP ($8,635) than for HA ($5,331), PRP was more cost effective at 1 year and was associated with an incremental cost-effectiveness ratio (ICER) of $12,628 QALY. Similarly, the utility value (proportion of QALY compared with perfect health) of PRP was higher by 0.11 QALY: 0.69 versus 0.58.
The United States spends approximately $3.6 trillion on health care per year, an increase from 5% of GDP in 1960 to 18% of GDP in 2018.
1
One reason is an aging population spending more on health care; another is introduction of new technology.Peter G Paterson Foundation
Why are Americans paying more for healthcare?.
Why are Americans paying more for healthcare?.
https://www.pgpf.org/blog/2020/04/why-are-americans-paying-more-for-healthcare
Date accessed: August 29, 2020
1
The Consumer Price Index (CPI) has increased by 2.1% over the past 20 years, but the CPI for health care has grown at an average rate of 3.5%.Peter G Paterson Foundation
Why are Americans paying more for healthcare?.
Why are Americans paying more for healthcare?.
https://www.pgpf.org/blog/2020/04/why-are-americans-paying-more-for-healthcare
Date accessed: August 29, 2020
2
Not surprisingly, there is a recent emphasis on value in health care.3
Money value and cost-benefit analyses take cost into consideration and assess the value of treatment.4
One way to assess a treatment’s value is to relate cost and effectiveness. Cost-utility analysis presents the consequences of these 2 variables as quality-adjusted life years (QALY)4
—in other words, “How much health benefit do we get for our money?”5
The QALY is a generic measure of burden including both quality and quantity6
; a QALY is equivalent to 1 year with quality scores ranging from 1 (perfect health) to 0 (death).6
Of course, QALY is associated with cost, and the magic number of $50,000 per QALY has become a mythical benchmark.6
,7
In modern medicine, however, a QALY value of $109,000 may be more appropriate.8
Knee osteoarthritis is associated with an annual cost of more than US$27 billion, and total knee arthroplasty in 2009 contributed to hospital expenditures of US$28.5 billion. The final stage of treating knee osteoarthritis is total knee arthroplasty, and the QALY added by this procedure has been calculated to be 14.63, with an associated cost of $49,424 per QALY.
9
Interestingly, data have suggested that the QALY for PRP injections is very similar: 14.55, with an associated cost of $49,090.9
One could argue that all other treatment options should be judged on these figures.Using this framework, the study by Samuelson, Ebel, Reynolds, Arnold, and Brown, “The Cost Effectiveness of Platelet-Rich Plasma Compared With Hyaluronic Acid Injections for the Treatment of Knee Osteoarthritis,” can be evaluated in a more objective manner.
10
The authors based their assumptions on the current Medicare and Medicaid Physicians Fee Schedules; QALY and WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) scores were derived from a systematic review published in 2016.11
They concluded that both PRP and hyaluronic acid (HA) are cost effective. Although the costs per QALY were higher for PRP (US$8,635) than for HA (US$5,331), PRP was more cost effective at 1 year. The figures in Samuelson et al. (cost per QALY US$8,635),10
however, are higher than those in Rajan et al.9
(cost per QALY US$3,373). The reason for the difference is not clear, but possibly underlines the fact that these calculations depend on the input.But the comparison is what matters, and Samuelson et al.
10
have compared PRP versus HA.11
Interestingly, the utility value (proportion of QALY compared with perfect health) of PRP was significantly higher than that of HA: 0.69 versus 0.58. This translates to 36 weeks per year of perfect health with PRP versus 30 weeks for HA. Worth it? Here you go: PRP may be superior to HA.Unfortunately this may be wishful thinking. Two recent meta-analyses
12
,13
showed that PRP provides better outcomes compared with HA, cortisone, or placebo, but 2 recent studies could not demonstrate clinically relevant improvements.14
,15
Do we at least know that it is cost-effective treatment? Rajan et al.- Korpershoek J.V.
- Vonk L.A.
- De Windt T.S.
- Admiraal J.
- Kester E.
- Van Egmond N.
- et al.
Intra-articular injection with autologous conditioned plasma does not lead to a clinically relevant improvement of knee osteoarthritis: A prospective case series of 140 patients with 1-year follow-up.
Acta Orthop. 2020; : 1-7
9
argued that unless the clinical efficacy in relieving pain and improving function is established, PRP cannot be cost effective.9
In contrast, Sanchez et al.16
reported that PRP can delay the need for total knee arthroplasty by >1.5 years, with a median delay of 5.3 years. To add further to the confusion, Ong et al.17
have calculated that the potential cost savings of HA treatment, by not undergoing arthroplasty within the first 2 years, is an estimated $20,470 per patient, or $1.54 billion to society.The debate will continue. For now, the authors are congratulated for providing an excellent article discussing a difficult topic using complex analysis models. Hopefully, further studies will add more evidence to help clinicians make value-based treatment decisions for the benefit of our patients and also society.
Supplementary Data
- ICMJE author disclosure forms
References
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- Comparison between intra-articular infiltrations of placebo, steroids, hyaluronic acid and PRP for knee osteoarthritis: A Bayesian network meta-analysis [published online July 28, 2020]. Arch Orthop Trauma Surg.(doi:)
- Platelet-rich plasma versus hyaluronic acid for the treatment of knee osteoarthritis. Results at 5 years of a double-blinded, randomized controlled trial.Am J Sports Med. 2019; 47: 347-354
- Intra-articular injection with autologous conditioned plasma does not lead to a clinically relevant improvement of knee osteoarthritis: A prospective case series of 140 patients with 1-year follow-up.Acta Orthop. 2020; : 1-7
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Footnotes
The author reports the following potential conflicts of interest or sources of funding: E.H. reports personal fees, Arthroscopy Association of North America. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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