Objectives: This study aims to describe how a negative reimbursement decision—based on the health technology assessment (HTA) report of a nondrug intervention—affects healthcare providers in Germany.

Methods: Knee arthroscopy was chosen as an example, because as of April 2016 this procedure is no longer reimbursed for osteoarthritis, but is still covered for other indications, including meniscal lesions. The exclusion followed an HTA report prepared by the Institute for Quality and Efficiency in Health Care (IQWiG). Here, we examine how the decision to revoke reimbursement for arthroscopy was perceived by the surgical community. Information was collected from official hospital statistics, the internet, and informal interviews with orthopedic surgeons.

Results: In 2015, a total of 37,920 arthroscopic procedures were performed for knee osteoarthritis in Germany. Several surgical societies were unhappy with the negative decision, which was issued as a directive in November 2015, and they challenged the decision-making process as well as the underlying scientific evidence. In March 2016, fifteen societies issued joint recommendations on how to differentiate osteoarthritis from other knee diseases and how to document other diseases in a way that inspections by representatives of health insurance funds would not detect any deficiencies. In informal interviews, orthopedic surgeons indicated that miscoding of the principal diagnosis (meniscal tear rather than knee osteoarthritis) is to be expected, especially in the hospital sector.

Conclusions: HTA can have a significant impact on the provision of health services, but various loopholes allow physicians to undermine policy decisions. Therefore, it is important to involve all stakeholders in HTA and to convince them of the benefits of evidence-based medicine.

Objectives: A randomized controlled trial (RCT) showed magnetic resonance imaging for patients waiting for knee arthroscopy did not reduce the number of arthroscopies. Our study aimed to identify decisions made by orthopedic surgeons about whether patients on a waiting list should proceed to arthroscopy, and to describe surgeons’ decisions.

Methods: Five surgeons were asked to Think Aloud (TA) as they made their decisions for twelve patients from the original RCT. Audiotapes of the decision making were transcribed for analysis.

Results: For five patients, surgeons agreed about proceeding with arthroscopy, although reasoning differed. In no cases did surgeons agree about not proceeding to arthroscopy. Agreement was more likely in patients with clinically diagnosed meniscal abnormality, and less likely in patients with osteoarthritis.

Conclusions: Surgeons’ decisions were influenced by patient wishes. For some patients, the decision to proceed with arthroscopy was based solely on clinical diagnosis; MRI may not be advantageous in these instances. Surgeons disagreed more often than they agreed about the decision to proceed with arthroscopy, particularly when OA was diagnosed. This has implications for decision making in the current NHS patient choice environment. Patients may choose a treatment provider from a list of available providers at time of original clinical assessment and diagnosis. The treating surgeon does not necessarily re-examine the patient until the day of surgery. Given the variation between surgeons about the merits of proceeding with arthroscopy, surgeons may end up in the invidious position of providing surgery to patients whom they do not believe will benefit from arthroscopy.

A randomized double-blinded study consisting of 107 patients was conducted to compare the effect on post-operative pain relief of intra-articular fentanyl and intra-articular bupivacaine after knee arthroscopy. The results showed that intra-articular bupivacaine produced superior analgesia in the immediate post-operative period. At 2 h post-operatively, the intra-articular bupivacaine group had a mean pain score of 2.0 (standard deviation 2.1, P <0.05) compared with the intra-articular fentanyl group which had a mean pain score of 3.2 (standard deviation 2.3, P <0.05) After 2 h post-operatively, intra-articular bupivacaine and intra-articular fentanyl had a similar effect on pain scores. The mean pain score 18 h post-operatively was 2.7 for the intra-articular bupivacaine group (standard deviation 2.2, P value 0.6) compared with the intra-articular fentanyl group which had a mean pain score of 2.8 (standard deviation 1.9, P value 0.6).

Magnetic resonance imaging (MRI) has excellent specificity and sensitivity for the diagnosis of internal derangement of the knee (IDK). The use of MRI to screen patients with suspected IDK could avoid unnecessary arthroscopies with a reduction in costs. The purpose of this study was to evaluate the use of arthroscopy among patients with IDK, and to estimate the potential cost-effectiveness of MRI in these patients to avoid unnecessary arthroscopies. The study was based on a retrospective cohort of all patients attending three orthopedic clinics between April and September 1993 with a new diagnosis of IDK. Charts were reviewed in 1994 to allow for a follow-up of more than 6 months. An economic evaluation was performed based on cost-effectiveness ratios (per averted arthroscopy), including direct and indirect costs. There were 241 patients with a new diagnosis of IDK (67% males, mean age 35 ± 12 years), and 110 (46%) underwent arthroscopy. The remaining patients received conservative therapy and were not scheduled for arthroscopy within the period of observation. Using a priori established criteria, 10% of the arthroscopies could be considered diagnostic only (e.g., normal knee) and 27% were of doubtful efficacy from a therapeutic perspective (e.g., debridement alone). Many of these arthroscopies could have been avoided by performing a prior MRI. Using these findings, we conducted decision tree analyses of the use of MRI among patients requiring arthroscopy of the knee. A sensitivity analysis was performed to evaluate the various model assumptions. In general, MRI appeared to be a cost-effective diagnostic procedure for patients with IDK requiring arthroscopy of the knee, and there were cost savings associated with it in some of the models tested.

In a double-blind, randomized, controlled study, 61 patients who received a standardized anaesthetic for day case arthroscopic knee surgery were studied. Group T (n=31) received tramadol 1.5 mg kg−1, and group F (n=30) received fentanyl 1.5 μg kg−1 at the induction of anaesthesia. All patients also received 20 mL of intra-articular bupivacaine 0.5% at the end of surgery. Assessments were made of pain at rest and on movement, analgesic requirements and side-effects at hourly intervals up to 6 h and by means of a postal questionnaire at 24 h and 48 h post-operatively. Group F had higher pain scores than group T at 4 h only [VAS 3.3 (1.6–5.5) vs. 2.4 (1–4), P=0.039, respectively; median (interquartile range)]. There were no other significant differences between the groups in terms of pain scores, supplemental analgesic requirements or incidence of side-effects. We conclude that tramadol offers little benefit clinically compared with fentanyl when used at induction of anaesthesia for day case arthroscopic knee surgery. Further studies are indicated in patients with more severe pain to determine the role of tramadol in post-operative analgesia.

The increasing use of ambulatory surgery requires methods of anaesthesia that allow patients to be discharged soon after the operation is completed. Spinal anaesthesia is usually simple and quick, and the incidence of post-spinal headache has been reduced by using non-cutting small-gauge needles. Limiting the spread of spinal anaesthesia, as long as it still provides analgesia for surgery, should reduce the haemodynamic effects and speed recovery. Restricted spinal anaesthesia, intended to be unilateral using 0.18% hypobaric bupivacaine via a 25G or 27G Whitacre unidirectional needle, was compared with epidural anaesthesia (using a mixture of lignocaine and prilocaine) in 64 matched-pair patients undergoing ambulatory arthroscopy. Motor blockade, assessed for the specific myotomes L2 to S1, was significantly more unilateral in the spinal group. Two patients in the spinal group and nine patients in the epidural group were treated for hypotension (P < 0.05). One patient in the spinal group developed a post-spinal headache. One patient in the epidural group rated the anaesthesia poor.

One hundred and three patients ASA grades I–II, 16–80 years of age scheduled for arthroscopic meniscectomy were prospectively studied, and randomly allocated to one of four groups: group 1 (n=25): 0.25% bupivacaine (50 mg) intra-articular (IA), group 2 (n=27): 1 mg of 0.1% preservative free morphine chloride in saline, group 3 (n=26): 1 mg of 0.1% preservative free morphine chloride in 0.25% bupivacaine and group 4 (n=25): normal saline (0.9%). The volume given was always 20 mL. Ketorolac [Toradol®, 30 mg intramuscularly (i.m.)] was used as rescue medication; analgesia was assessed using a visual analogue scale (VAS), a verbal rating scale (VRS), supplemental analgesic consumption post-operatively (SAC) and the presence of side effects. Verbal rating scale and visual analogue scale scores showed better pain control in group 1, 20 min after surgery, and in groups 1 and 2 at 4 h and 10 h as well as in the global VAS. In multi-factorial analysis no significant differences among groups or side effects was found. pH analysis of the substances used showed no alterations in the basal pH range. The analgesic efficacy of 20 mL of bupivacaine 0.25% is similar to that of 1 mg of morphine in 20 mL of saline 0.9%. The morphine–bupivacaine mixture was no more efficacious than bupivacaine or morphine alone.

This present study investigated the effects of intraarticular morphine administration in 1mg and 5mg doses on post-operative pain relief and analgesic requirements for patients undergoing arthroscopic procedures. At the end of the operation patients were randomly allocated in a double-blinded fashion into three groups. The control group (Group 1) received normal saline 20 mL intraarticularly. The patients in the second and third groups received intraarticular morphine sulphate 1 and 5mg in saline 20 mL, respectively. Post-operative pain was assessed on the 1st, 6th and 24th hour by visual analogue scale (VSA). Supplementary analgesic requirement and possible complications were also followed. The intensity of pain and analgesic requirement were reduced more in the morphine 5mg group than in the control group. It is concluded, that the administration of intraarticular morphine 5mg provides long-lasting and effective analgesia after knee arthroscopy.