Healthcare Utilization and Costs of Knee or Hip Replacements versus Pain-Relief Injections

From 1999 to 2008, the utilization rate of total knee replacement procedures in the United States more than doubled for the overall population, and tripled for individuals aged 45 to 64 years.1 Additional research has shown an increase in the rate of primary and revision knee replacement surgeries, as well as hip replacements.1,2 These studies indicate a growing trend for total knee and total hip replacement procedures among the US population aged 45 to 64 years and those aged ≥65 years, with the trend being more pronounced for those who underwent total knee replacement. Although studies have shown that knee and hip replacements generally result in improvement in pain and functionality for patients who undergo these procedures,3,4 the dramatic increase in number and high cost of such surgeries has garnered much attention nationally. As demonstrated by Losina and colleagues, increases in population size and in obesity rates can only partially explain this increase.1 Furthermore, their study begs the question of whether all joint replacement procedures are clinically necessary, and whether alternative conservative treatments have been explored before joint replacement is considered. Two earlier studies focused on viscosupplementation as a viable alternative to knee and hip replacements from a managed care perspective. Arnold and colleagues suggested “its use…may generate savings in hospitalizations and other costs,”5 whereas Waddell and Bricker suggested that in candidates for total knee replacement, the need for the procedure can be delayed with hylan G-F 20 (a type of viscosupplementation) when used for the treatment of osteoarthritis (OA) knee pain.6 Until recently, the American Academy of Orthopaedic Surgeons (AAOS) was inconclusive regarding viscosupplementation as a treatment modality for patients with OA of the knee. However, in May 2013, the AAOS recommended against viscosupplementation based on the lack of evidence showing benefit.7 Given the dramatic increase in the rate of knee and hip replacement procedures, and the controversy surrounding the effectiveness of viscosupplementation, there is a need to compare the downstream healthcare utilization and costs between patients who undergo a knee or hip replacement and those who receive intraarticular injections to relieve pain and improve functionality. To examine differences between these 2 groups, lower OA-related healthcare utilization and costs were assumed to be reasonable proxies of better outcomes, consistent with lesser need for ongoing interaction with the healthcare provider. The aim of this longitudinal study—which focused on Medicare members who underwent joint replacement or received intraarticular injections for pain—was to determine which approach resulted in fewer OA-related physician office visits and OA-related treatments, as well as lower OA-related healthcare costs, after recovery.