The effect of negative randomized trials and surgeon volume on the rates of arthroscopy for patients with knee OA

Publication of 2 (negative) randomized clinical trials (RCTs) in 2002 and 2008 demonstrating inefficacy of arthroscopic debridement of the knee (ADK) for osteoarthritis, and a 2004 national non-coverage Medicare determination, have decreased overall ADK utilization. However, because of potentially favorable outcomes associated with high volume, surgeons performing high arthroscopy volume may be slower to abandon performing ADK than would low volume surgeons. We examined the trends in ADKs performed by high and low volume surgeons before and after these 2 trials and the Medicare determination. New York state residents 40 years and older undergoing outpatient ADK from 1997 to 2010 were identified from a statewide database, and monthly population-based age and sex-adjusted ADK rates were calculated. We estimated the change in utilization trends over time, stratified by surgeon annual arthroscopy volume, for Medicare and non-Medicare patients. 1386 surgeons performed 29,658 ADKs during the study period, with the proportion performed by high volume surgeons increasing from 22% in 1997 to 66% in 2010. Overall monthly ADK rates declined from 2.4 to 1.3 per 100,000 population (45%) over the study period. Rates of ADK performed by high volume surgeons increased after the first RCT in the non-Medicare population and after the CMS decision in the Medicare population, and decreased after the second RCT. With more definitive evidence from the second negative trial, high volume surgeons performed less ADKs, suggesting that multiple RCTs with consistently negative results are needed to change practice of high volume surgeons.