Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
Department of Surgery & Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas.
J Bone Joint Surg Am. 2018 May 16;100(10):827-834. doi: 10.2106/JBJS.17.01045.
The efficacy of corticosteroid and hyaluronic acid injections for knee osteoarthritis has been questioned. The purpose of this study was to determine the impact of the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines on the use of these injections in the United States and determine if utilization differed by provider specialty.
Patients with knee osteoarthritis were identified within the Humana database from 2007 to 2015, and the percentage of patients receiving a knee injection relative to the number of patients having an encounter for knee osteoarthritis was calculated and was trended for the study period. The impact of each edition of the AAOS clinical practice guidelines on injection use was evaluated with segmented regression analysis. Injection trends were also analyzed relative to the specialty of the provider performing the injection.
Of 1,065,175 patients with knee osteoarthritis, 405,101 (38.0%) received a corticosteroid injection and 137,005 (12.9%) received a hyaluronic acid injection. The rate of increase in hyaluronic acid use, per 100 patients with knee osteoarthritis, decreased from 0.15 to 0.07 injection per quarter year (p = 0.02) after the first clinical practice guideline, and the increase changed to a decrease at a rate of -0.12 injection per quarter (p < 0.001) after the second clinical practice guideline. After the first clinical practice guideline, the rate of increase in utilization of corticosteroids, per 100 patients with knee osteoarthritis, significantly lessened to 0.12 injection per quarter (p < 0.001), and after the second clinical practice guideline, corticosteroid injection use plateaued (p = 0.72). The trend in use of hyaluronic acid injections by orthopaedic surgeons and pain specialists decreased with time following the second-edition clinical practice guideline but did not change for primary care physicians or nonoperative musculoskeletal providers.
Subtle but significant changes in hyaluronic acid and corticosteroid injections occurred following the publication of both clinical practice guidelines. Although the clinical practice guidelines did impact injection use, given the high costs of these injections and their questionable clinical efficacy, further interventions beyond publishing clinical practice guidelines are needed to encourage higher-value care for patients with knee osteoarthritis.
皮质类固醇和透明质酸注射治疗膝骨关节炎的疗效一直受到质疑。本研究旨在确定美国矫形外科医师学会（AAOS）临床实践指南对这些注射在美国的使用的影响，并确定是否因提供者专业的不同而有所不同。
在 2007 年至 2015 年期间，在 Humana 数据库中确定了患有膝骨关节炎的患者，并计算了接受膝关节注射的患者百分比相对于因膝骨关节炎就诊的患者百分比，并对研究期间的趋势进行了分析。使用分段回归分析评估了每版 AAOS 临床实践指南对注射使用的影响。还分析了注射趋势与进行注射的提供者的专业之间的关系。
在 1065175 例膝骨关节炎患者中，405101 例（38.0%）接受了皮质类固醇注射，137005 例（12.9%）接受了透明质酸注射。每 100 例膝骨关节炎患者中，透明质酸使用量的增加率从每季度 0.15 次注射减少到 0.07 次（p = 0.02），在第一个临床实践指南之后，增加率变为每季度减少 0.12 次（p < 0.001）。在第一个临床实践指南之后，每 100 例膝骨关节炎患者中皮质类固醇使用率的增加显著减少到每季度 0.12 次注射（p < 0.001），在第二个临床实践指南之后，皮质类固醇注射使用率趋于平稳（p = 0.72）。随着第二个版本临床实践指南的发布，骨科医生和疼痛专家使用透明质酸注射的趋势随着时间的推移而减少，但对于初级保健医生或非手术肌肉骨骼提供者而言，这种趋势并未改变。
在发布了这两个临床实践指南后，透明质酸和皮质类固醇注射的使用发生了微妙但显著的变化。尽管临床实践指南确实影响了注射的使用，但鉴于这些注射的高成本及其临床疗效的可疑性，除了发布临床实践指南之外，还需要采取进一步的干预措施，以鼓励为膝骨关节炎患者提供更高价值的治疗。
