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BRIEF REPORT
Ahead of print publication  

Factors influencing the utilization of total knee replacement in osteoarthritis knee: A web-based survey of treating doctors


1 Department of Rheumatology, Manipal Hospitals, Bengaluru, Karnataka, India
2 Division of Clinical Immunology and Rheumatology, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand; Department of Orthopaedics, Manipal Hospitals, Bengaluru, Karnataka, India
3 Department of Orthopaedics, Manipal Hospitals, Bengaluru, Karnataka, India

Date of Submission26-Dec-2021
Date of Acceptance01-May-2022
Date of Web Publication06-Jul-2022

Correspondence Address:
Yogesh Preet Singh,
Division of Clinical Immunology and Rheumatology, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Jolly Grant, Dehradun - 248 140, Uttarakhand

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injr.injr_289_21

  Abstract 


Background: India, with its aging population is going to face a major health-care burden due to osteoarthritis (OA) knee in the coming decades. Total knee replacement (TKR) is the most effective way of treating severe OA knee and has a wide variation in its utilization.
Objective: The objective of this survey was to gain insight into the factors that influence the treating doctor in considering TKR for a patient and barriers to its utilization.
Methods: Rheumatologists, orthopedicians, and physicians were invited to complete a 14-item web-based survey.
Results: A total of 217 variable responses were received. The majority were rheumatologists (n = 143; 67.45%). Most felt that TKR was underutilized (n = 134; 62.9%). Functional demands of the patient were the most important patient factor which influenced TKR referral (84%; n = 178). Annual income and availability of health insurance were important socioeconomic factors influencing TKR referral by 105 (50.5%) and 73 (35.1%) respondents, respectively. Financial status (n = 76; 35.8%) was an important patient-related factor influencing TKR decision. High cost was considered the biggest barrier for the underutilization of TKR by 117 (55.5%). Price regulation on knee implants had mixed views, with 94 (46.3%) saying that it had improved access of TKR to a larger population and 90 (44.3%) saying it had not had any impact.
Conclusion: High cost and the nonaffordable population remain the biggest barrier to utilization of TKR in OA knee.

Keywords: Epidemiology, knee osteoarthritis, surgery, survey, therapeutic use, therapy, total knee replacement



How to cite this URL:
Jain N, Singh YP, Yathish G C, Veerappa L, Mallinath G, Kalyan H, Shah I, Velangi V. Factors influencing the utilization of total knee replacement in osteoarthritis knee: A web-based survey of treating doctors. Indian J Rheumatol [Epub ahead of print] [cited 2022 Dec 5]. Available from: https://www.indianjrheumatol.com/preprintarticle.asp?id=350023




  Introduction Top


Knee osteoarthritis (OA) is the most common degenerative joint disease and one of the leading causes of disability worldwide. Its prevalence in India is 28.7%.[1] Framingham OA study showed that radiographic knee OA increases with age, 27% in subjects aged ≤70 years to 44% in subjects aged ≥80 years.[2] Total knee replacement (TKR) is a safe and effective procedure for severe knee OA. A meta-analysis from >15 countries and 1.5 million TKR showed that 30- and 90-day postoperative mortality rate was 0.2%.[3] Despite being safe and effective, marked disparities exist in the utilization of TKR. As per Medicare data, the annual rate of TKR was 4.84 per 1000 among African American women, compared to 5.97 per 1000 among Caucasian women. The rate for African American men (1.84 per 1000) was also lower than that for white men (4.82 per 1000).[4]

India, with its aging population, is going to face a major health-care burden due to OA knee in the coming decades. In developed countries and countries with well-developed health infrastructure, utilization rates of TKR are increasing rapidly as compared to low to middle-income countries. There are no data available from India regarding the utilization of TKR and barriers to its utilization.

Objective

The objective of this survey is to gain insight into the factors influencing treating doctors in referring a patient to TKR and understand the barriers to its utilization.


  Methods Top


Doctors of various specialties (rheumatologists, orthopedician, and general physicians) who manage patients with OA were invited to complete an e-survey between July 20, 2019, and August 3, 2019. SurveyMonkey® platform was used for recording the survey. Survey cover letter included team introduction, objective, and a link to the survey questionnaire. Informed consent was obtained at the beginning of the survey. Survey dissemination was by E-mail, text messages, and Whatsapp®.

Survey design and validity

A search was conducted using PubMed using the combination of the keywords “Knee osteoarthritis” AND “total knee arthroplasty” AND “Barriers to utilization” AND “referral” AND “Indications.” Totally, 31 articles were identified and included observational studies and reviews. Relevant articles were reviewed and used to formulate the survey questionnaire. Initially, 11 questions were generated. One question was added to understand the opinion of treating doctors regarding the impact of price capping of knee implants on the utilization of TKR in India. Two questions were added which were case scenarios to understand the referral indications for TKR. There were a total of 14 questions. The questionnaire included questions on demographics of respondents; medical specialty; frequency of knee OA patients consultations and referral for TKR; referral indications for TKR; barriers to utilization (social and economic); and the impact of price capping on TKR utilization. Four questions were open-ended and the rest were multiple-choice questions. The survey was designed by YGC, reviewed by YPS. To maintain anonymity, personal details such as name and contact details were not recorded. The survey is enclosed as [Supplementary File 1]. Two rheumatologists (YGC and YPS) and three orthopedic surgeons (HK, LV, and MG) reviewed the questions and confirmed them to be representative of the content and face validity. The questionnaire underwent pilot testing with five rheumatologists to evaluate face validity and identify errors in grammar and syntax. The average survey time was 3 min. It was not mandatory to attempt all the questions and respondents could skip the questions.



Statistical analysis

A total of 217 doctors responded to the survey. As it was not mandatory to answer all the questions, the responses were nonuniform as some respondents did not answer all the questions. Due to heterogeneous responses, individual question responses were analyzed for their statistical significance. SPSS software version 20.0 IBM SPSS Statistics Client 64-bit 27.0 Microsoft Windows Multilingual Standard Edition (IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp) was used for statistical analysis. Continuous variables were expressed as mean ± standard deviation. Statistical significance was assessed using the Pearson's Chi-square test and P < 0.05 was considered as significant.


  Results Top


Males were more in number (n = 168; 78.9%.). Majority were rheumatologists (n = 143; 67.45%) followed by others (orthopedic surgeons –51 [24.05%] and physicians –18 [8.5%]) [Table 1]. The majority felt that TKR is underutilized in OA knee treatment (n = 134; 62.9%).
Table 1: Showing baseline demographics of the respondents, factors influencing TKR utilization and Impact of price capping on knee implants

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Factors influencing referral for total knee replacement

Functional demands of the patient were the most important clinical factor which influenced the decision of referral for TKR (n = 178, 84%) (P = 0.004). The annual income of the patient/relative and the availability of health insurance were socioeconomic factors influencing referral for TKR (n = 105 [50.5%]; n = 73 [35.1%]). Financial status (n = 76; 35.8%, P = 0.026) was one of the important patient-related factors influencing the decision of TKR. Overall, the high cost of TKR was considered as the biggest barrier for the underutilization of TKR (n = 117 [55.5%]). Poor financial status and previous bad experiences of patient's relatives or friends were one of the major patient-related reasons for underutilization of TKR (n = 76 [35.8%]; n = 69 [32.5%]).

Impact of price regulation on knee implants

Impact of price capping by governing agencies on knee implants had mixed views, with 94 (46.39%) saying that it has improved access to TKR to a larger population and 90 (44.3%) saying it has not had any impact.

Two hypothetical clinical scenarios were given to respondents to assess the clinical and socioeconomic factors which can affect TKR referral by the respondents. Responses were similar by the majority of doctors. In the first clinical scenario, impaired functional status along with daily NSAID requirement and availability of health insurance were the important factors for referral (n = 191, 90.9%), and in the second clinical scenario, impaired functional status was the predominant factor governing the referral (n = 168, 80.4%).


  Discussion Top


TKR is a safe, effective, and cost-effective surgical intervention in the treatment of knee OA. Despite this, its utilization is variable around the globe. Data from India regarding utilization and factors influencing TKR are nonexistent. We have attempted to fill this gap in understanding the utilization of TKR, factors influencing referral, and barriers to its effective usage. To our knowledge, this is the only study from India which has attempted to address this knowledge gap.

The majority of the respondents felt that TKR is underutilized (62.9%). Globally, utilization rate for TKR has significantly increased over the years. Data from European countries in 2011 observed a nearly 27-fold rise in TKR utilization rates.[5] The annual utilization of TKR in the United States is also increasing. Till 2010, >6 lakhs/year TKR were being performed, which has doubled from 1991 to 2010 (from 31 to 62 per 10000 annually among Medicare enrollees)[6] and it is expected to rise by 143% by 2050 compared to 2015.[7] No such epidemiological data are available which have assessed utilization rates of TKR in India.

The utilization is influenced by various clinical, socioeconomic factors. The functional status of the patient was the main clinical factor responsible for considering TKR (84%). This is consistent with guidelines on the treatment of OA knees. American Academy of Orthopedic Surgeons guidelines recommend TKR for patients with persistent pain and functional disability despite conventional treatment.[8] However, there is a lack of uniformity among various guidelines for referral characteristics of TKR.

The high cost of the TKR, poor financial status, and lack of health insurance were the common socioeconomic factors influencing referral for TKR. Socioeconomic status and health-care access in a country play a major role in TKR utilization.[4] There are no similar epidemiological data for the Indian population. In countries like India, health-care utilization is largely impacted by financial constraints. Peters DH (2002)[9] demonstrated that the poorest quintile of Indians is 2.6 times more likely than the richest to forgo medical treatment in the event of illness. Approximately 10% of India's population is estimated to be covered under private health insurance.[10]

To improve health-care access and achieve universal health coverage (UHC), India has launched Ayushman Bharat to achieve UHC.[11] This approach has improved health-care access to the population below the poverty line, but still, citizens belonging to the middle class have to either depend on health insurance by private companies or by spending their savings/loans/selling their assets. Recent reforms by the government of India like the inclusion of TKR in the Ayushman Bharat scheme and price capping on knee implants reduce the cost of the procedure and increase health-care access.[12],[13] Doctors had mixed opinions regarding the impact of price regulation on the utilization of TKR.

Our survey has various advantages. First, to the best of our knowledge, this is the only study that has tried to look for the factors influencing referral for TKR and utilization, and the impact of price capping on knee implants. Second, it includes experts dealing with such patients; hence, the validity and generalization are better.

There are various limitations of our study. There are limitations inherent to the web-based survey including the absence of an interviewer prevents us from gaining clarification on responses to open-ended questions, they are also prone to survey fraud by erroneous reporting.[14] In addition, this study is likely to have selection bias and response bias. Other limitations were it does no't include the direct patient data or epidemiological data regarding TKR utilization and factors affecting it. It also does not have follow-up questions concerning reasons for the mixed opinion regarding price capping, which would have given us more insights.


  Conclusion Top


Socioeconomic factors affect referral for TKR. The high cost of TKR is the biggest barrier influencing the referral. Epidemiological studies are needed for a better understanding of TKR utilization rates and barriers to its usage in India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Felson DT, Naimark A, Anderson J, Kazis L, Castelli W, Meenan RF. The prevalence of knee osteoarthritis in the elderly. The Framingham Osteoarthritis Study. Arthritis Rheum 1987;30:914-8.  Back to cited text no. 1
    
2.
Pal CP, Singh P, Chaturvedi S, Pruthi KK, Vij A. Epidemiology of knee osteoarthritis in India and related factors. Indian J Orthop 2016;50:518-22.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Berstock JR, Beswick AD, López-López JA, Whitehouse MR, Blom AW. Mortality after total knee arthroplasty: A systematic review of incidence, temporal trends, and risk factors. J Bone Joint Surg Am 2018;100:1064-70.  Back to cited text no. 3
    
4.
Skinner J, Weinstein JN, Sporer SM, Wennberg JE. Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medicare patients. N Engl J Med 2003;349:1350-9.  Back to cited text no. 4
    
5.
Kurtz S, Ong K, Lau E, Widmer M, Maravic M, Gómez-Barrena E, et al. International survey of primary and revision total knee replacement. Int Orthop 2011;35:1783-9.  Back to cited text no. 5
    
6.
Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991-2010. JAMA 2012;308:1227-36.  Back to cited text no. 6
    
7.
Inacio MC, Paxton EW, Graves SE, Namba RS, Nemes S. Projected increase in total knee arthroplasty in the United States – An alternative projection model. Osteoarthritis Cartilage 2017;25:1797-803.  Back to cited text no. 7
    
8.
Osteoarthritis of the Knee – Clinical Practice Guideline (CPG) | American Academy of Orthopaedic Surgeons; 2020. Available from: https://www.aaos.org/quality/quality-programs/lower-extremity-programs/osteoarthritis-of-the-knee/. [Last accessed on 2020 Dec 11].  Back to cited text no. 8
    
9.
Peters DH, editor. Better health systems for India's poor: findings, analysis, and options. World Bank Publications; 2002.  Back to cited text no. 9
    
10.
Federation of Indian Chambers of Commerce & Industry: Health Insurance Companies Should Focus More on Disease-Specific Policies – Member, IRDAI, Insurance News, August 20, 2020; 2020. Available from: http://ficci.in/ficci-in-news-page.asp?nid=24999. [Last accessed on 2020 Dec 27].  Back to cited text no. 10
    
11.
Press Information Bureau, Government of India. Cabinet Approves Ayushman Bharat-National Health Protection Mission; 2018. Available from: http://www.pib.nic.in/newsite/PrintRelease.aspx?relid=177816. [Last accessed on 2018 Mar 27].  Back to cited text no. 11
    
12.
Top Tertiary Care Procedures under Ayushman Bharat-PMJAY; 2020. Available from: https://pib.gov.in/Pressreleaseshare.aspx?PRID=1594640. [Last accessed on 2020 Dec 11].  Back to cited text no. 12
    
13.
Deyl S. Knee Implants to Cost up to 69% Less as Government Caps Prices. Available from: https://timesofindia.indiatimes.com/india/knee-implants-to-cost-up-to-69-less-as-government-caps-prices/articleshow/60094167.cms. [Last accessed on 2017 Dec 27].  Back to cited text no. 13
    
14.
Gaur PS, Zimba O, Agarwal V, Gupta L. Reporting survey based studies – A primer for authors. J Korean Med Sci 2020;35:e398.  Back to cited text no. 14
    



 
 
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