An article, just published in the NEJM, caught my attention not only for the study results, but because of what is says in a between-the-lines kind of way about the American health care system. The study looks at arthroscopic surgery for a torn meniscus in people over the age of 45 who also have arthritis of the knee. The meniscus is a rubbery disc on each end of the two bones that make up the knee (I’m a GYN, so go to WebMD for a better description of a meniscus, if you need one). A torn meniscus can contribute to knee pain for some people.
A lot of people have arthritis of the knee (we know this because of all the knee MRIs that we do in this country at $1200 or so a pop). According to the NEJM study, 9 million Americans have osteoarthritis of the knee confirmed by x-ray or MRI and 35% of people over the age of 50 will have a meniscus tear on MRI. A torn meniscus itself doesn’t necessarily identify the cause of the pain because 2/3 of meniscus tears are totally asymptomatic. MRIs are so sensitive they identify tons of things that are not causative as far as pain is concerned.
Because we have an aging population, because we MRI everyone, because we have a problem with obesity (a major co-factor in osteoarthritis), and because surgery is highly reimbursed almost 500,000 people get their partially torn meniscus trimmed by a minimally invasive surgery called arthroscopy (using a surgical telescope) each year in the United States.
However, recent studies have called into question the value of arthroscopic knee surgery. For example, we know that arthroscopic surgery for osteoarthritis (OA) alone is no better than sham surgery. Yup. Put a patient to sleep, nick the skin with a scalpel. squirt water on his leg or stick a telescope into it and fix what you think needs to be fixed… the outcomes are identical.
OK, fine, for arthritis, but what about a meniscal tear? Well, this new study in the NEJM looks at that issue and tells a similar story. Patients over 45 with OA and a meniscus tear were randomized to typical arthroscopic surgery (which included post operative physical therapy) or physical therapy (PT). They were allowed to cross over to the other group if they so desired. At 6 months and at 12 months those who had surgery were no better off pain or function wise than those who stuck with the physical therapy regimen (30% of people decided to switch from PT to surgery).
While this study is well done, it does have flaws. Studies randomizing patients to surgery or supportive/other non surgical care are simply hard to do. Only 26% of eligible patients were randomized, the most common reason was a strong preference for one intervention over the other. There also may have been a selection bias from enrolling surgeons and the study wasn’t blinded as people knew whether they’d had surgery or not. There was also no sham surgery arm.
What this study tells us that at least 70% of people will improve with PT alone. This is probably not a surprising fact to any physical therapist, but will it change the standard of care?
We practice medicine in a country where physical therapy (PT) is often harder to get than surgery. Many health plans have limited PT coverage or have $80 or higher PT co payments. People think they’re getting a better bang for the buck with surgery, although wIth many surgeries for pain that just isn’t the case. And how screwed up are we that getting the MRI for knee pain is almost always a snap, yet that $1,200 (or more) could probably pay for most of the PT visits needed to treat the condition in the first place? (the study group received an average of 8.4 visits). It’s simply fucked up when the diagnosis of a torn meniscus is more expensive and easier to get than non-invasive and effective treatment. Why can’t someone evaluate the knee, suspect a meniscal tear, and then just prescribe PT and reserve the MRI for the person who fails the physical therapy?
We manage knee pain with MRIs because the public demands imaging studies. They do. I get asked over and over again for imaging by my pain patients when it just isn’t indicated. Many patients ask because they have been imaged so many times they can’t possibly believe it isn’t useful. Others are holding out hope that this time something will show up. Some doctors with 9 minutes to see a patient don’t have the time or the clinical skills to explain the limitations of imaging. Some don’t know the limitations. And of course there are doctors who order imaging to satisfy their patients and others with the belief that a scan will reduce medico legal concerns.
We also manage knee pain in a world where a surgeon is reimbursed very well for surgery and much less for chatting about why surgery isn’t the best option. Surgeons don’t know everything about non-surgical care. They can’t. When chronic pain is the problem surgeons should be part of the team, not the only member. I’m a surgeon who manages chronic pain, but I have a multidisciplinary clinic with physical therapy, a psychologist, and a pharmacist and the more I rely on my non-phsyician team members the less I find surgery is the right option. Having a whole tool kit is much better than only owning a hammer.
As patients we all want to get better now. Every day I have someone ask for surgery when it isn’t indicated for their pain condition. The common phrase is, “But I have to do something.” Whether we want to accept it or not, medication, mind-body techniques, diet, weight loss, and physical therapy, the medical treatments that are often most effective for pain are viewed as fringe or not being aggressive enough. In America the scalpel reigns supreme. Some patients accept that surgery isn’t for them and gladly follow the non surgical recommendations, but others go from surgeon to surgeon until they get the surgery they think they need.
And what about diet and lifestyle? Obesity is a major co-factor in osteoarthritis of the knee. Not only because the knee is load bearing, but the fat pad in the knee is metabolically active like the fat around the belly and contributes to the inflammatory changes of arthritis. The average body mass index in the NEJM study was 30. That means that obesity was the norm.
This study doesn’t surprise me. Back surgery isn’t very effective for back pain, but it’s popular and the only randomized study looking comparing surgery to a multidisciplinary program for pelvis pain (my speciality), showed better outcomes and fewer surgeries when the initial approach was non surgical. But what about your friend who had surgery for his/her back/pelvis/knee pain who is better? Surgery has a remarkably high placebo response rate for chronic pain, over 27% in many studies.
So will insurers step up to the plate and make PT more accessible and affordable? I have to believe that 9 PT sessions are far less expensive than surgery and MRIs once you factor in all the costs. And what about multidisciplinary programs that work on lifestyle, stress, mind-body, diet, exercise and weight loss? Since these things overlap so much with other medical conditions the cost savings for insurers could be dramatic, but it would take a paradigm shift to get there.
How will family doctors, internists, and sports medicine doctors help? Are they willing to do a through exam, discuss lifestyle and recommend physical therapy instead of falling into the get-your-MRI-and-go-straight-to-surgery routine?
What about surgeons? Will they step up to the plate with statements like, “Outcomes can be as good with physical therapy as surgery. Let’s start noninvasively and see where we get. I’ve set you up to see a dietician, the physical therapist, and here are some names of local pools with great aquatic based programs, which are wonderful for people with sore knees?” Or perhaps the surgeons will be too worried about their Press Ganey scores and if the patient pushes for surgery they will simply agree?
And the American Medical Association? Change the fucking coding system. We should be reimbursing orthopedic surgeons handsomely for fixing fractures, I have no issue with that, but the cost of doing a surgery for a condition that can be treated just as well noninvasively should be the same in the OR as in the office. Only when a patient has failed the recommended therapies should pre-authorization be granted and the surgical fee rise. Trust me, if the surgical fee for arthroscopic meniscus surgery in a patient who hadn’t tried PT were $40 the procedure will rapidly become obsolete.
And finally, what about patients? We need to turn the mirror on ourselves. If you have knee pain and a suspected partial meniscus tear, are you willing to accept physical therapy and lifestyle modifications knowing they work? Are we willing to give up out dysfunctional love affair with the scalpel?
Hospitals, the AMA, insurance companies, doctors, and patients all revolve around the concept that with chronic pain conditions to cut is to cure. But it often isn’t. Cold surgical steel is the right treatment for many acute infections, injuries, and cancers, but this equating surgery and, while we’re at it, MRIs as doing something constructive for chronic painful conditions when at best it’s no better (but more expensive) than a non invasive approach and at worst doing harm, has got to stop. It’s bankrupting all of us in more ways than one.
These are some pretty simple fixes. Who’s brave enough to actually do it?