Reducing TKR surgery

Inspired by Gang et al 2020.[1]

Photo by Ketut Subiyanto on

OA – osteoarthritis
NHIS – National Health Insurance Service (Korea)
CCI – Charlson comorbidity index
HR – hazard ratio
TKR – total knee replacement

key to acronyms

This week we have another big retrospective observational study. This makes number 14 on my list of similar papers published over the last few years. We had the first from Taiwan in 2017,[2] then a second from Taiwan in 2018.[3] In 2019 we saw 6 published: 3 from Taiwan;[4–6] 2 from Korea;[7,8] and one from the US.[9] In 2020, so far, we have seen a further 6 including this Gang et al: 3 from Taiwan;[10–12] 2 from Korea;[1,13] and one from Thailand.[14]

This study used the cohort data from the National Health Insurance Service (NHIS) of Korea that was published in 2014. They found all new cases of osteoarthritis (OA) of the knee diagnosed over a 7-year period from the beginning of 2004. These were divided into an acupuncture group (AG) and a control group (CG). The CG had no record of acupuncture treatment and initially comprised 88 341 people. The AG were made up of those with newly diagnosed OA knee who had received at least two acupuncture sessions within 6 weeks of diagnosis, and they came to a total of 8 623 people. Next we have the matching process to ensure the comparison is fair, and this time a 1:3 ratio was performed so that the CG was 3 times as big as the AG. Propensity score matching used gender, age, income level, and Charlson comorbidity index (CCI).

The latter we have discussed on the blog before: Can acupuncture prevent neck surgery? I have just run my CCI again and I see that COVID has been included since I last looked. I am pleased to tell you that I scored 1 (based purely on my age), and a very friendly looking Professor Mary Charlson at the bottom of the web page tells me I have a 96% chance of lasting another 10 years.

After matching the AG was reduced to 8 605 and the CG to 25 815 – still nice big samples. Then the Gang et al looked for the incidence of knee surgery and found that acupuncture was associated with a considerably lower rate (HR 0.26). The lowest rates (more correctly HRs) were in women, the elderly and those with higher CCI (ie greater co-morbidity).

Could we save over 0.5 billion per year in surgical costs?

If we use these figures and apply them to the UK population,[15,16] this might suggest we could save over 0.5 billion per year in surgical costs by giving all patients with a new diagnosis of OA access to acupuncture.

Figures used:
95000 TKR per year in 2020 [16]
£7500 for the cost of TKR [15]
HR of 0.26 ie a reduction of 74% of the total [1]

But there is just a slight problem with that as only 0.76% of the population newly diagnosed with knee OA in the Korean retrospective cohort ended up having surgery,[1] which means 12.5 million would need treatment (if the same figures were applied to the UK), and that could cost nearly 2 billion in the first year (6 sessions at £25 per session).

I guess this cost could be reduced by only offering treatment to folks referred for consideration of TKR, and this was indeed done in one area some years ago, with large estimated savings.[17] Unfortunately, the service did not continue to receive funding.

Reference list

1         Gang B-G, Shin J-S, Lee J, et al. Association Between Acupuncture and Knee Surgery for Osteoarthritis: A Korean, Nationwide, Matched, Retrospective Cohort Study. Front Med 2020;7:524628. doi:10.3389/fmed.2020.524628

2         Wu M-Y, Huang M-C, Chiang J-H, et al. Acupuncture decreased the risk of coronary heart disease in patients with fibromyalgia in Taiwan: a nationwide matched cohort study. Arthritis Res Ther 2017;19:37. doi:10.1186/s13075-017-1239-7

3         Wu M-Y, Huang M-C, Liao H-H, et al. Acupuncture decreased the risk of coronary heart disease in patients with rheumatoid arthritis in Taiwan: a Nationwide propensity score-matched study. BMC Complement Altern Med 2018;18:341. doi:10.1186/s12906-018-2384-5

4         Shih C-C, Yeh C-C, Yang J-L, et al. Reduced use of emergency care and hospitalization in patients with post-stroke cognitive impairment treated with traditional Chinese medicine. QJM An Int J Med Published Online First: 18 February 2019. doi:10.1093/qjmed/hcz044

5         Lin S-K, Liu J, Hsu R, et al. Incidence of iatrogenic pneumothorax following acupuncture treatments in Taiwan. Acupunct Med Published Online First: 21 August 2019. doi:10.1136/acupmed-2018-011697

6         Chen L-Y, Yen H-R, Sun M-F, et al. Acupuncture treatment is associated with a decreased risk of developing stroke in patients with depression: A propensity-score matched cohort study. J Affect Disord 2019;250:298–306. doi:10.1016/j.jad.2019.03.020

7         Han D, Koh W, Shin J-S, et al. Cervical surgery rate in neck pain patients with and without acupuncture treatment: a retrospective cohort study. Acupunct Med Published Online First: 20 August 2019. doi:10.1136/acupmed-2018-011724

8         Moon H, Kim M, Hwang D, et al. Safety of acupuncture during pregnancy: a retrospective cohort study in Korea. BJOG An Int J Obstet Gynaecol Published Online First: 19 September 2019. doi:10.1111/1471-0528.15925

9         Kazis LE, Ameli O, Rothendler J, et al. Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use. BMJ Open 2019;9:e028633. doi:10.1136/bmjopen-2018-028633

10       Lin JC-F, Lin T-C, Cheng C-F, et al. Lower rates of mortality, readmission and reoperation in patients receiving acupuncture after hip fracture: a population-based analysis. Acupunct Med 2020;:096452842091166. doi:10.1177/0964528420911664

11       Ton G, Yang Y-C, Lee L-W, et al. Acupuncture Decreased the Risk of Coronary Heart Disease in Patients with Osteoarthritis in Taiwan: A Nationwide Matched Cohort Study. J Altern Complement Med 2020;18:acm.2020.0153. doi:10.1089/acm.2020.0153

12       Huang M, Yen H-R, Lin C, et al. Acupuncture decreased the risk of stroke among patients with fibromyalgia in Taiwan: A nationwide matched cohort study. PLoS One 2020;15:e0239703. doi:10.1371/journal.pone.0239703

13       Jung H, Yeo S, Lim S. Effects of acupuncture on cardiovascular risks in patients with hypertension: a Korean cohort study. Acupunct Med Published Online First: 20 June 2020. doi:10.1177/0964528420920290

14       Sangtin S, Supasiri T, Tangsathitporn R, et al. Application of survival analysis techniques to determine the optimal number of acupuncture therapy sessions for stroke patients. Acupunct Med 2020;38:194–200. doi:10.1177/0964528419883268

15       Dakin H, Gray A, Fitzpatrick R, et al. Rationing of total knee replacement: a cost-effectiveness analysis on a large trial data set. BMJ Open 2012;2:e000332. doi:10.1136/bmjopen-2011-000332

16       Culliford D, Maskell J, Judge A, et al. Future projections of total hip and knee arthroplasty in the UK: Results from the UK Clinical Practice Research Datalink. Osteoarthr Cartil 2015;23:594–600. doi:10.1016/j.joca.2014.12.022

17       White A, Richardson M, Richmond P, et al. Group Acupuncture for Knee Pain: Evaluation of a Cost-Saving Initiative in the Health Service. Acupunct Med 2012;30:170–5. doi:10.1136/acupmed-2012-010151

Declaration of interests MC