Comparative Effectiveness of Hyaluronic Acid Injections for Management of Knee Osteoarthritis

August 4, 2021 updated by: University of Arkansas

Comparative Effectiveness of Hyaluronic Acid Injections to Prevent/Delay Knee Surgical Interventions Among Patients With Knee Osteoarthritis

Osteoarthritis (OA) is a degenerative joint disease in which there is an imbalance between the breakdown and repair of the joint tissue. Intraarticular hyaluronic acid (HA) injections are used for the management of knee OA. Currently, there is limited and inconclusive evidence supporting use of HA injections for management of knee OA. The primary objective of our study is to evaluate the effectiveness of HA injections in the management of knee OA. Investigators will evaluate if HA injections prevent or delay knee OA surgical interventions.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

Osteoarthritis (OA) is a degenerative joint disease in which there is an imbalance between the breakdown and repair of the joint tissue.Intraarticular hyaluronic acid (HA) injections are used for the management of knee OA. The pooled estimates of randomized clinical trials in various meta-analyses do not have consistent conclusions, some conclude no benefit while others conclude small benefit (reducing the pain or improving the daily functioning) to overall benefit (alleviating pain as well as improving daily functioning).The variation in conclusions is due to the heterogeneity in the methodology of the clinical trials included in these meta-analyses as well as a difference in the interpretation of clinical findings.Furthermore, most of the trials (63%) evaluating efficacy of HA are industry funded, raising the concern for publication bias. Furthermore Although the evidence favoring the use of HA injections is limited, these injections still have a significant market share with an annual sale of $725 million per year. Given the high dollar amount spent on the intervention, evaluation of its effectiveness in real world setting is important. Currently, there is limited and inconclusive evidence supporting use of HA injections for management of knee OA. The primary objective of the current study is to evaluate the effectiveness of HA injections in the management of knee OA. Specifically, the investigators will compare the risk of any surgical intervention of knee as a primary outcome among the knee OA patients who are exposed to HA injections with those who are not exposed to HA injections (HA non-users) and those who are exposed to intra-articular corticosteroid (CS) injections. Three separate outcome definitions, which includes: i) composite surgical outcome measure (includes total knee replacement, partial knee replacement, arthroscopic procedures, osteotomy and free-floating inter-positional devices), ii) total and partial knee replacements only and iii) total knee replacement (TKR) only will be used to compare the effectiveness of HA users with HA non-users and CS users.

This study will be conducted using knee OA patients aged 40 years and above from the Lifelink Plus claims data (2006-2015). Knee OA patients with a specialist visit and a recent history of medications used for pain management (proxy for moderate-severe pain) will be identified. Patients will be classified into 3 groups: 1) HA users, 2) CS users and 3) HA non-users based on exposure/non-exposure to these interventions within first 90 days after specialist visit. HA users will be matched separately with two comparison (CS users and HA non-users) groups using a propensity score matching approach to reduce the imbalance between the intervention and comparison group. HA users will be matched separately to each comparison group (1:1 ratio) using a greedy matching approach within a predefined caliper (0.2 of the pooled standard deviation of the logit of the PS). Cox models will be used to compare the risk of 1) any surgical interventions for knee, 2) TKR and partial knee replacements only and 3) TKR only, among HA users and the comparison groups. For both comparisons, investigators will use four approaches to compare the risk of each outcome measure: 1) Unadjusted bivariate analysis, 2) Adjusted multivariate analysis, 3) Propensity score-matched sample and 4) Inverse probability weighting (IPW) using propensity score.

Study Type

Observational

Enrollment (Actual)

13849

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

40 years to 100 years (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Sampling Method

Non-Probability Sample

Study Population

Patients with a moderate to severe knee OA identified by using a specialist visit along with recent history of pain medication use (proxy for moderate to severe pain)

Description

Inclusion Criteria:

  • Patients with a specialist visit (orthopedic surgeon, physical medicine and rehabilitation, orthopedic, physical therapy, and rheumatologist) will enter in cohort and the date of the first visit will be considered as index date.
  • Patients should have at least one claim with a primary diagnosis of knee osteoarthritis (ICD-9-Center for Medicare (CM) code 715.x6) on the index date
  • Patients with a specialist visit should have at least one claim for pain medications (NSAIDs or opioids) within 90 days prior to or on the day of visit.
  • The age of a patient should be at least 40 years on the date of their index date
  • Patients to have continuous eligibility for pharmacy and medical benefits for at least six months prior to their index diagnosis.
  • Patients to have at least three months of continuous eligibility for pharmacy and medical benefits after their index diagnosis.

Exclusion Criteria:

  • Patients with a procedure claim for HA or CS in the pre-index period
  • Patients with a procedure claim for knee OA surgical procedures (arthroscopic procedures, osteotomy, free-floating interpositional devices, partial and total knee replacement) in the pre-index period.
  • In order to focus on knee OA pain, patients with a claim for joint fusion, rheumatoid arthritis, knee fracture, post-traumatic arthritis, avascular necrosis, benign/malignant bone tumors and Paget's disease in the pre-index period will be excluded

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

Cohorts and Interventions

Group / Cohort
Intervention / Treatment
Hyaluronic acid (HA) injection users
Patients with at least one procedure claim for intra-articular administration of hyaluronic acid (procedure codes: J7320, J7322, J7325, Q4084, J7317, Q4083, J7321, Q4085, J7323, Q4086, J7324, J7327, J7326) within 90 days after their first specialist (physical medicine, physical therapy, orthopedic surgeon, rheumatologist or orthopedic) visit will be considered as HA users.
Drug: Hyaluronic Acid injections
Other Names:
  • Synvisc, Orthovisc, Euflexxa, Monovisc, Hyglan or Supartz
Corticosteroids (CS) injections users
Patients with at least one procedure claim for intra-articular administration of corticosteroids (procedure codes: J1020, J1030, J1040, J1094, J1100, J2920, J2930, J0702, J0704, J3300, J3301, J3302, J3303, J1700, J1710, J1720, J2650, J2920, J2930) within 90 days after their first specialist (physical medicine, physical therapy, orthopedic surgeon, rheumatologist or orthopedic) visit will be considered as CS users.
HA non-users
Patients who do not have any claims for procedural or surgical intervention including HA and CS injections in first 90 days after their first specialist visit will be considered as HA non-users

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Number of patients with any knee surgical intervention assessed using the inpatient and outpatient claims in the follow up time
Time Frame: Person follow up time between 2006-2015
Each patient will be followed after index date + 90days until the date of his/her first arthroscopic procedure, osteotomy, placement of a free-floating interpositional device, partial or total knee replacement, the study end date, or until the subject is no longer enrolled. The number of events and follow up time will be used to calculate hazard ratios in order to assess the risk of surgical intervention for each comparison
Person follow up time between 2006-2015

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Number of patients with total or partial knee replacement assessed using the inpatient and outpatient claims in the follow up time
Time Frame: Person follow up time between 2006-2015
Each patient will be followed after index date + 90days until the date of his/her first total or partial knee replacement, the study end date, or until the subject is no longer enrolled. The number of events and follow up time will be used to calculate hazard ratios in order to assess the risk of total or partial knee replacement for each comparison
Person follow up time between 2006-2015
Number of patients with total knee replacement assessed using the inpatient and outpatient claims in the follow up time
Time Frame: Person follow up time between 2006-2015
Each patient will be followed after index date + 90days until the date of his/her first TKR, the study end date, or until the subject is no longer enrolled. The number of events and follow up time will be used to calculate hazard ratios in order to assess the risk of total knee replacement for each comparison
Person follow up time between 2006-2015

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

University of Arkansas

Investigators

  • Study Chair: Bradley Martin, PharmD, PhD, University of Arkansas

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

February 1, 2016

Primary Completion (Actual)

July 1, 2016

Study Completion (Actual)

July 1, 2016

Study Registration Dates

First Submitted

January 20, 2016

First Submitted That Met QC Criteria

January 28, 2016

First Posted (Estimate)

February 2, 2016

Study Record Updates

Last Update Posted (Actual)

August 5, 2021

Last Update Submitted That Met QC Criteria

August 4, 2021

Last Verified

August 1, 2016

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 204982

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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