Genicular Artery Embolization, Radiofrequency Ablation, and Corticosteroid Therapy for Knee Osteoarthritis: A...

BACKGROUND. Many patients with knee osteoarthritis (KOA) have symptoms that are refractory to traditional nonsurgical treatments, such as intraarticular corticosteroid (CS) injection, but are not yet eligible are not yet eligible for or decline surgery. Genicular artery embolization (GAE) and radiofrequency ablation (RFA) are emerging adjunctive or alternative minimally invasive treatments. OBJECTIVE. The purpose of this study was to perform a cost-effectiveness analysis (CEA) comparing CS therapy, GAE, and RFA for the treatment of symptomatic KOA using a Markov model based on a de novo network meta-analysis (NMA) of randomized control trials. METHODS. A CEA was conducted to compare GAE and RFA to CS using a Markov cohort state-transition model from a U.S. Medicare payer's perspective over a 4-year time horizon. The model incorporated each treatment's success and attrition rates, costs, and utility benefit. Utility benefit values were derived at short-term (0.5-3 months) and long-term (6-12 months) posttreatment follow-up from an NMA of published randomized controlled trials using an outcome of improved knee pain and/or function. Analyses were conducted at a willingness-to-pay threshold of US$100,000 per quality-adjusted life year (QALY) gained. Sensitivity analyses were performed, including when simulating various cost setting scenarios (i.e., office vs hospital outpatient treatment). RESULTS. RFA showed larger treatment effect than GAE, which was more pronounced at short-term follow-up (standardized mean difference [SMD] for RFA, -1.6688 [95% CI, -2.7806 to -0.5571], p = .003; SMD for GAE, -0.3822 [95% CI, -1.9743 to 1.2100], p = .64) than at long-term follow-up. Across cost setting scenarios, incremental cost-effectiveness ratios relative to CS therapy were US$561-1563 per QALY gained for GAE versus US$76-429 per QALY gained for RFA (not counting scenarios in which RFA was dominated by CS). GAE showed higher cost-effectiveness probability compared with RFA (41.6-54.8% vs 18.4-29.2%, respectively). GAE was more cost-effective than RFA when the GAE clinical success rate and post-GAE utility value exceeded 32.1-51.0% and 0.562-0.617, respectively, and when the GAE quarterly attrition rate was less than 8.8-17.4%. RFA was more cost-effective when baseline pretreatment utility values exceeded 0.695-0.713. Neither GAE costs nor RFA costs were sensitive parameters. CONCLUSION. Across scenarios, GAE was consistently the most likely cost-effective treatment option compared with RFA and CS, although clinical success rates, attrition rates, and utility values impact its cost-effectiveness. CLINICAL IMPACT. GAE is likely to be more cost-effective than RFA or CS for treatment of symptomatic KOA.