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Knee Injections for OA Remain Common, Despite Guideline Updates

Clinical practice guideline updates issued by the American Academy of Orthopedic Surgeons led to “subtle but significant changes” in the use of hyaluronic acid and corticosteroid injections for the treatment of knee osteoarthritis (OA), according to findings from a new study.
However, these interventions have remained in common use, despite the updates.
For their study, the researchers evaluated 1,065,175 patients with knee OA with available data in the Humana database from 2007 to 2015.
Segmented regression analysis was used to assess the impact of each edition of the AAOS clinical practice guidelines on injection use.
In addition, trends in injection use were examined with respect to the specialty of the provider administering the injection.
A total of 405,101 (38.0%) patients received a corticosteroid injection and 137,005 (12.9%) received a hyaluronic acid injection.
Results showed that, for each 100 patients with knee OA, the rate of increase in hyaluronic acid use decreased from 0.15 to 0.07 injection per quarter year after the first guideline, published in 2008. Following the release of the second guideline, published in 2013, this increase changed to a decrease of -0.12 injection per quarter.
Furthermore, for every 100 patients with knee OA, the rate of increase in utilization of corticosteroids decreased significantly to 0.12 injection per quarter. Corticosteroid injection use was found to plateau after the second guideline was issued.
The researchers noted that the trend in hyaluronic acid injection use by orthopedic surgeons and pain specialists decreased with time after the second guideline was released. However, this trend did not change for primary care physicians or nonoperative musculoskeletal providers.
“In conclusion, this study demonstrates that there have been subtle but significant changes in the use of hyaluronic acid and corticosteroid injections in response to published clinical practice guidelines,” the researchers wrote. “Despite formal recommendations against hyaluronic acid injections and inconclusive recommendations for corticosteroid injections in the most recent edition of the clinical practice guideline, these interventions remain in common use.”
“Given the relatively high costs of these injections and their questionable clinically efficacy, further interventions beyond publishing clinical practice guidelines are needed to change practice patterns and to encourage the provision of higher-value care for patients with knee osteoarthritis,” they added.

REFERENCE:
Bedard NA, DeMik DE, Glass NA, Burnett RA, Bozic KJ, Callaghan JJ. Impact of clinical practice guidelines on use of intra-articular hyaluronic acid and corticosteroid injections for knee osteoarthritis. J Bone Joint Surg. 2018;100(10):827-834. doi:10.2106/JBJS.17.01045