Are Knee Injections by Rural Providers Cost-Effective?

SALT LAKE CITY – If enough patients are treated, training rural providers to perform knee injections for patients with osteoarthritis can be cost-effective, according to a new study funded by the VHA.

Using the common threshold of $50,000 per quality-adjusted life year (QALY), the training was deemed to be cost-effective when more than 20 patients are seen at rural primary care clinics for the procedure. The study, led by researchers from the Salt Lake City VAMC, was published in the journal Arthritis Care & Research.1

Background in the article noted that community-based outpatient clinics (CBOCs) were established by the VA to provide primary care services to veterans living in remote and rural regions. The study was designed to evaluate the cost effectiveness of training rural primary care providers to perform knee injections in CBOCs. That way, patients would not have to be referred to an urban medical center where rheumatology or orthopedic specialists would handle the injections.

For the study, researchers designed a decision analytic model to compare costs and outcomes between rural providers who are trained to perform knee injections vs. those who are not trained, resulting in a referral to a specialist. Results indicated that the incremental cost-effectiveness ratio (ICER) for trained rural providers was $21,190/QALY using costs from the VA’s perspective and $205/QALY using costs from the patient’s perspective. Training rural providers was cost effective in 74.4% and 93.6% of 10,000 Monte Carlo simulations at a willingness to pay threshold of $50,000/QALY from the VA’s and patient’s perspectives, respectively.

“Training rural providers to perform knee injections for patients with knee pain secondary to osteoarthritis appears cost-effective using the commonly used threshold of $50,000/QALY if more than 20 such patients per year are seen at rural primary care clinics,” the authors concluded. “These results provide support for our ongoing efforts to implement such a training program.”

1 Nelson RE, Battistone MJ, Ashworth WD, Barker AM, Grotzke M, Huhtala TA, Lafleur J, Tashjian RZ, Cannon GW. COST-effectiveness of training rural providers to perform joint injections. Arthritis Care Res (Hoboken). 2013 Sep 19. doi: 10.1002/acr.22179. [Epub ahead of print] PubMed PMID: 24106223.

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