Letters
Intermittent Bolus or Continuous Infusion of Proton Pump Inhibitors for Ulcer Bleeding? To the Editor We read with great interest the article by Sachar et al.1 The authors are to be commended for their thorough literature review and careful analysis. However, several issues may need clarification before jumping to conclusions. First, how endoscopic therapy might interact with pharmacotherapy to determine outcomes was not addressed. Given that monotherapy with epinephrine injection is suboptimal to achieve hemostasis, it is intriguing to clarify whether the dosage of a proton pump inhibitor (PPI) should differ according to endoscopic treatment, especially when the meta-analysis included 6 studies that allowed injection therapy alone. Another important determinant for recurrent bleeding is the ulcer stigmata because an actively spurting ulcer is much more likely to rebleed. This kind of lesion may require more potent inhibition of gastric acid. In fact, an earlier randomized trial has demonstrated that in patients with active arterial bleeding ulcers, an intermittent PPI dose (intravenous, 40 mg every 8 hours) could not effectively decrease rebleeding compared with histamine receptor antagonist (ranitidine). 2 Conceivably, a higher dose of PPI may be indicated in patients at higher risk of rebleeding. A recent randomized trial has actually showed that double dose of oral PPI outperformed the standard dose among the high-risk patients (Rockall scores ⭌6) after 3-day PPI infusion.3 Moreover, with so many different dosing methods grouped together, it is difficult to conclude the treatment of choice. No single regimen can represent the intermittent bolus group, which is diverse in administration route, frequency, and dosage. Clearly, elevation of intragastric pH is mandatory to stabilize blood clot and prevent recurrent bleeding.4 What remains debatable is to what extent and for what duration of acid suppression is necessary to achieve clinical effectiveness. Unfortunately, most previous studies do not have intragastric pH data to correlate with clinical outcomes. For example, because the percentage of time with an intragastric pH higher than 6 is only 26.7% on the fifth day of intravenous esomeprazole, 40 mg once daily,5 it is questionable whether such degree of acid inhibition suffices to promote clot formation. In short, more research is warranted to clarify whether and how PPI therapy should be tailored according to risk stratification. Further mechanistic knowledge is needed to elucidate the correlation between acid inhibition and clinical benefits.
1. Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systemic review and meta-analysis. JAMA Intern Med. 2014;174(11):1755-1762. 2. Villanueva C, Balanzó J, Torras X, et al. Omeprazole versus ranitidine as adjunct therapy to endoscopic injection in actively bleeding ulcers: a prospective and randomized study. Endoscopy. 1995;27(4):308-312. 3. Cheng HC, Wu CT, Chang WL, Cheng WC, Chen WY, Sheu BS. Double oral esomeprazole after a 3-day intravenous esomeprazole infusion reduces recurrent peptic ulcer bleeding in high-risk patients: a randomised controlled study. Gut. 2014;63(12):1864-1872. 4. Green FW Jr, Kaplan MM, Curtis LE, Levine PH. Effect of acid and pepsin on blood coagulation and platelet aggregation. A possible contributor prolonged gastroduodenal mucosal hemorrhage. Gastroenterology. 1978;74(1):38-43. 5. Pisegna JR, Sostek MB, Monyak JT, Miner PB Jr. Intravenous esomeprazole 40 mg vs. intravenous lansoprazole 30 mg for controlling intragastric acidity in healthy adults. Aliment Pharmacol Ther. 2008;27(6):483-490.
Increased Left Ventricular Trabeculation Does Not Necessarily Equate to Left Ventricular Noncompaction in Athletes To the Editor We read with great interest the work published by Peritz et al1 highlighting the dilemmas associated with the identification of left ventricular (LV) hypertrabeculation in athletes. Improved echocardiographic resolution has enabled clearer images of the ventricular myocardium and frequently reveals trabeculations. Unsurprisingly, such advances in echocardiography have also coincided with increased reports of LV noncompaction (LVNC). The concerns regarding the current criteria for LVNC include their derivation from very small cohorts and lack of specificity, especially in low-risk populations such as athletes.2 A large study showed that 18% of athletes exhibited hypertrabeculation and 1 in 5 fulfilled criteria for LVNC.3 We believe that in most instances LV hypertrabeculation is an epiphenomenon to an increased preload. A recent longitudinal study based on a pregnancy model associated with a 50% increase in blood volume (preload) assessed the impact of loading conditions on LV trabeculations.4 The study demonstrated that of 102 women with a completely normal LV, 25% developed de novo trabeculations as pregnancy progressed, supporting that most athletes fulfilling criteria for LVNC do not have a cardiomyopathy and should not be unnecessarily disqualified from sport. A minority of athletes (0.9%) with LV hypertrabeculation demonstrate T-wave inversion and reduced systolic function that may be considered diagnostic of LVNC.3 Further studies are required in this small cohort to help facilitate the differentiation between physiological adaptation and LVNC. Sabiha Gati, MRCP Ahmed Merghani, MRCP Sanjay Sharma, BSc(Hons), MD, FRCP, FESC
Yao-Chun Hsu, MD Hwai-Jeng Lin, MD, FACG Author Affiliations: Center for Database Research, School of Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan (Hsu); Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Medical University Hospital, School of Medicine, Taipei Medical University, Taipei, Taiwan (Lin).
Author Affiliations: Department of Cardiovascular Sciences, St George’s, University of London, London, England.
Corresponding Author: Hwai-Jeng Lin, MD, FACG, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei Medical University, No. 252, Wuxing St, Taipei 11031, Taiwan.
Conflict of Interest Disclosures: None reported.
Conflict of Interest Disclosures: None reported. jamainternalmedicine.com
Corresponding Author: Sanjay Sharma, BSc(Hons), MD, FRCP, FESC, Clinical Cardiology, St George’s, University of London, Cranmer Terrace, London SW17 0RE, England ([email protected]). 1. Peritz DC, Vaughn A, Ciocca M, Chung EH. Hypertrabeculation vs left ventricular noncompaction on echocardiogram: a reason to restrict athletic participation? JAMA Intern Med. 2014;174(8):1379-1382. (Reprinted) JAMA Internal Medicine March 2015 Volume 175, Number 3
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Thomas Jefferson University User on 05/14/2015
461
Letters
2. Thavendiranathan P, Dahiya A, Phelan D, Desai MY, Tang WH. Isolated left ventricular non-compaction controversies in diagnostic criteria, adverse outcomes and management. Heart. 2013;99(10):681-689. 3. Gati S, Chandra N, Bennett RL, et al. Increased left ventricular trabeculation in highly trained athletes: do we need more stringent criteria for the diagnosis of left ventricular non-compaction in athletes? Heart. 2013;99(6):401-408. 4. Gati S, Papadakis M, Papamichael ND, et al. Reversible de novo left ventricular trabeculations in pregnant women: implications for the diagnosis of left ventricular noncompaction in low-risk populations. Circulation. 2014;130(6): 475-483.
LESS IS MORE
Philip A. Band, PhD
Using Medicare Data to Understand Health Care Value: Measures of Incremental Cost and Effectiveness are Both Needed to Estimate Value To the Editor The Research Letter by Schmajuk et al1 includes important conceptual errors, which result in an inappropriate conclusion about the value of intra-articular hyaluronic acid injections for treating knee osteoarthritis. Foremost, the authors incorrectly use the term value. Value is specifically defined in health economics as the incremental cost of a treatment divided by its incremental effectiveness.2 Though the authors’ analysis of Medicare costs for intra-articular hyaluronic acid injections is interesting, their analysis does not include a denominator (ie, incremental effectiveness) and therefore cannot allow any estimation of value. Second, as support for their contention that intraarticular hyaluronic acid injections are of low value, the authors cite a recommendation from the American Academy of Orthopaedic Surgeons (AAOS).3 The AAOS recommendation was based on a meta-analysis of efficacy studies. The analysis concluded that the difference between intraarticular hyaluronic acid and saline injections was statistically significant; the group-mean difference, however, was not deemed clinically important. This conclusion does not incorporate the distinction between clinical importance at the individual patient level and clinical importance at the group-mean level, a distinction clearly delineated in a consensus publication on the subject that included US Food and Drug Administration (FDA) coauthors.4 Small group-mean differences often include very meaningful improvements for individual patients. The cited meta-analysis should not supersede the FDA’s analysis of primary clinical trial data or the agency’s role in determining what constitutes valid scientific evidence of efficacy. When evaluating the value of a health care intervention, the difference between efficacy and effectiveness is particularly important to consider. Effectiveness refers to performance under real-world conditions, rather than the idealized conditions of a placebo-controlled trial. The AAOS metaanalysis excluded effectiveness studies by design. Because the article by Schmajuk et al1 questions the value of intraarticular hyaluronic acid injections, the authors should not neglect high-quality effectiveness trials. In particular, a randomized, pragmatic, health economic trial reported that intraarticular hyaluronic acid injections provided statistically significant and clinically important incremental improvement over appropriate care, with a cost-utility ratio of $10 000 per quality-adjusted life-year (QALY). 5 This cost-utility ratio 462
is well below the $50 000-per-QALY threshold widely considered a reference standard for the provision of reasonable medical value. In the United States, billions of dollars are spent each year to treat patients with osteoarthritis. Considering the reported costs of intra-articular hyaluronic acid injections to Medicare relative to the overall cost to society of caring for patients with osteoarthritis, this useful procedure should not be improperly described as one of low value.
Author Affiliations: Department of Orthopaedic Surgery, New York University School of Medicine, New York; Department of Biochemistry and Molecular Pharmacology, New York University School of Medicine, New York. Corresponding Author: Philip A. Band, PhD, NYU Hospital for Joint Diseases, 301 E 17th St, Ste 1402, New York, NY 10003 (philip.band@nyumc .org). Conflict of Interest Disclosures: Dr Band reports that as an employee of Biomatrix between 1983 and 2000, he was involved with the development of hyaluronic acid for ophthalmic surgery, soft-tissue augmentation, drug delivery, and intra-articular injection. Patents relevant to the intra-articular use of hyaluronic acid were issued in 1987 and 1992 to Dr Band and others; these patents have expired, and Dr Band did not receive royalties or compensation other than as a Biomatrix employee. Between 2001 and about 2009, Dr Band reports receiving consulting fees from Smith & Nephew, which markets intraarticular hyaluronic acid products. In 2011, Dr Band reports receiving a single consulting fee from Ferring Pharmaceuticals, which markets an intra-articular hyaluronic acid product. 1. Schmajuk G, Bozic KJ, Yazdany J. Using Medicare data to understand low-value health care: the case of intra-articular hyaluronic acid injections. JAMA Intern Med. 2014;174(10):1702-1704. 2. Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB. Recommendations of the Panel on Cost-effectiveness in Health and Medicine. JAMA. 1996;276 (15):1253-1258. 3. American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee: evidence-based guideline, 2nd edition. 2013. http://www.aaos.org /research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdf. Accessed October 22, 2014. 4. Dworkin RH, Turk DC, McDermott MP, et al. Interpreting the clinical importance of group differences in chronic pain clinical trials: IMMPACT recommendations. Pain. 2009;146(3):238-244. 5. Raynauld JP, Torrance GW, Band PA, et al; Canadian Knee OA Study Group. A prospective, randomized, pragmatic, health outcomes trial evaluating the incorporation of hylan G-F 20 into the treatment paradigm for patients with knee osteoarthritis (part 1 of 2): clinical results. Osteoarthritis Cartilage. 2002;10 (7):506-517.
In Reply We disagree with Band; our analysis of intra-articular hyaluronic acid injections for knee osteoarthritis in the Medicare program does not have conceptual errors.1 Our analysis accurately presented the utilization of this procedure, including clinician and regional variation. The American Academy of Orthopaedic Surgeons (AAOS) is among the many organizations that recommend against the use of this procedure, including the United Kingdom’s National Institute for Health and Care Excellence and a group of independent investigators who performed a systematic review and meta-analysis.2,3 The meta-analysis performed by the AAOS of hyaluronic acid studies showed that among highquality studies, there was no clinically significant difference between hyaluronic acid and sham injection groups. Although some individual studies reported differences that were
JAMA Internal Medicine March 2015 Volume 175, Number 3 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Thomas Jefferson University User on 05/14/2015
jamainternalmedicine.com
Intermittent Bolus or Continuous Infusion of Proton Pump Inhibitors for Ulcer Bleeding? To the Editor We read with great interest the article by Sachar et al.1 The authors are to be commended for their thorough literature review and careful analysis. However, several issues may need clarification before jumping to conclusions. First, how endoscopic therapy might interact with pharmacotherapy to determine outcomes was not addressed. Given that monotherapy with epinephrine injection is suboptimal to achieve hemostasis, it is intriguing to clarify whether the dosage of a proton pump inhibitor (PPI) should differ according to endoscopic treatment, especially when the meta-analysis included 6 studies that allowed injection therapy alone. Another important determinant for recurrent bleeding is the ulcer stigmata because an actively spurting ulcer is much more likely to rebleed. This kind of lesion may require more potent inhibition of gastric acid. In fact, an earlier randomized trial has demonstrated that in patients with active arterial bleeding ulcers, an intermittent PPI dose (intravenous, 40 mg every 8 hours) could not effectively decrease rebleeding compared with histamine receptor antagonist (ranitidine). 2 Conceivably, a higher dose of PPI may be indicated in patients at higher risk of rebleeding. A recent randomized trial has actually showed that double dose of oral PPI outperformed the standard dose among the high-risk patients (Rockall scores ⭌6) after 3-day PPI infusion.3 Moreover, with so many different dosing methods grouped together, it is difficult to conclude the treatment of choice. No single regimen can represent the intermittent bolus group, which is diverse in administration route, frequency, and dosage. Clearly, elevation of intragastric pH is mandatory to stabilize blood clot and prevent recurrent bleeding.4 What remains debatable is to what extent and for what duration of acid suppression is necessary to achieve clinical effectiveness. Unfortunately, most previous studies do not have intragastric pH data to correlate with clinical outcomes. For example, because the percentage of time with an intragastric pH higher than 6 is only 26.7% on the fifth day of intravenous esomeprazole, 40 mg once daily,5 it is questionable whether such degree of acid inhibition suffices to promote clot formation. In short, more research is warranted to clarify whether and how PPI therapy should be tailored according to risk stratification. Further mechanistic knowledge is needed to elucidate the correlation between acid inhibition and clinical benefits.
1. Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systemic review and meta-analysis. JAMA Intern Med. 2014;174(11):1755-1762. 2. Villanueva C, Balanzó J, Torras X, et al. Omeprazole versus ranitidine as adjunct therapy to endoscopic injection in actively bleeding ulcers: a prospective and randomized study. Endoscopy. 1995;27(4):308-312. 3. Cheng HC, Wu CT, Chang WL, Cheng WC, Chen WY, Sheu BS. Double oral esomeprazole after a 3-day intravenous esomeprazole infusion reduces recurrent peptic ulcer bleeding in high-risk patients: a randomised controlled study. Gut. 2014;63(12):1864-1872. 4. Green FW Jr, Kaplan MM, Curtis LE, Levine PH. Effect of acid and pepsin on blood coagulation and platelet aggregation. A possible contributor prolonged gastroduodenal mucosal hemorrhage. Gastroenterology. 1978;74(1):38-43. 5. Pisegna JR, Sostek MB, Monyak JT, Miner PB Jr. Intravenous esomeprazole 40 mg vs. intravenous lansoprazole 30 mg for controlling intragastric acidity in healthy adults. Aliment Pharmacol Ther. 2008;27(6):483-490.
Increased Left Ventricular Trabeculation Does Not Necessarily Equate to Left Ventricular Noncompaction in Athletes To the Editor We read with great interest the work published by Peritz et al1 highlighting the dilemmas associated with the identification of left ventricular (LV) hypertrabeculation in athletes. Improved echocardiographic resolution has enabled clearer images of the ventricular myocardium and frequently reveals trabeculations. Unsurprisingly, such advances in echocardiography have also coincided with increased reports of LV noncompaction (LVNC). The concerns regarding the current criteria for LVNC include their derivation from very small cohorts and lack of specificity, especially in low-risk populations such as athletes.2 A large study showed that 18% of athletes exhibited hypertrabeculation and 1 in 5 fulfilled criteria for LVNC.3 We believe that in most instances LV hypertrabeculation is an epiphenomenon to an increased preload. A recent longitudinal study based on a pregnancy model associated with a 50% increase in blood volume (preload) assessed the impact of loading conditions on LV trabeculations.4 The study demonstrated that of 102 women with a completely normal LV, 25% developed de novo trabeculations as pregnancy progressed, supporting that most athletes fulfilling criteria for LVNC do not have a cardiomyopathy and should not be unnecessarily disqualified from sport. A minority of athletes (0.9%) with LV hypertrabeculation demonstrate T-wave inversion and reduced systolic function that may be considered diagnostic of LVNC.3 Further studies are required in this small cohort to help facilitate the differentiation between physiological adaptation and LVNC. Sabiha Gati, MRCP Ahmed Merghani, MRCP Sanjay Sharma, BSc(Hons), MD, FRCP, FESC
Yao-Chun Hsu, MD Hwai-Jeng Lin, MD, FACG Author Affiliations: Center for Database Research, School of Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan (Hsu); Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Medical University Hospital, School of Medicine, Taipei Medical University, Taipei, Taiwan (Lin).
Author Affiliations: Department of Cardiovascular Sciences, St George’s, University of London, London, England.
Corresponding Author: Hwai-Jeng Lin, MD, FACG, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei Medical University, No. 252, Wuxing St, Taipei 11031, Taiwan.
Conflict of Interest Disclosures: None reported.
Conflict of Interest Disclosures: None reported. jamainternalmedicine.com
Corresponding Author: Sanjay Sharma, BSc(Hons), MD, FRCP, FESC, Clinical Cardiology, St George’s, University of London, Cranmer Terrace, London SW17 0RE, England ([email protected]). 1. Peritz DC, Vaughn A, Ciocca M, Chung EH. Hypertrabeculation vs left ventricular noncompaction on echocardiogram: a reason to restrict athletic participation? JAMA Intern Med. 2014;174(8):1379-1382. (Reprinted) JAMA Internal Medicine March 2015 Volume 175, Number 3
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Thomas Jefferson University User on 05/14/2015
461
Letters
2. Thavendiranathan P, Dahiya A, Phelan D, Desai MY, Tang WH. Isolated left ventricular non-compaction controversies in diagnostic criteria, adverse outcomes and management. Heart. 2013;99(10):681-689. 3. Gati S, Chandra N, Bennett RL, et al. Increased left ventricular trabeculation in highly trained athletes: do we need more stringent criteria for the diagnosis of left ventricular non-compaction in athletes? Heart. 2013;99(6):401-408. 4. Gati S, Papadakis M, Papamichael ND, et al. Reversible de novo left ventricular trabeculations in pregnant women: implications for the diagnosis of left ventricular noncompaction in low-risk populations. Circulation. 2014;130(6): 475-483.
LESS IS MORE
Philip A. Band, PhD
Using Medicare Data to Understand Health Care Value: Measures of Incremental Cost and Effectiveness are Both Needed to Estimate Value To the Editor The Research Letter by Schmajuk et al1 includes important conceptual errors, which result in an inappropriate conclusion about the value of intra-articular hyaluronic acid injections for treating knee osteoarthritis. Foremost, the authors incorrectly use the term value. Value is specifically defined in health economics as the incremental cost of a treatment divided by its incremental effectiveness.2 Though the authors’ analysis of Medicare costs for intra-articular hyaluronic acid injections is interesting, their analysis does not include a denominator (ie, incremental effectiveness) and therefore cannot allow any estimation of value. Second, as support for their contention that intraarticular hyaluronic acid injections are of low value, the authors cite a recommendation from the American Academy of Orthopaedic Surgeons (AAOS).3 The AAOS recommendation was based on a meta-analysis of efficacy studies. The analysis concluded that the difference between intraarticular hyaluronic acid and saline injections was statistically significant; the group-mean difference, however, was not deemed clinically important. This conclusion does not incorporate the distinction between clinical importance at the individual patient level and clinical importance at the group-mean level, a distinction clearly delineated in a consensus publication on the subject that included US Food and Drug Administration (FDA) coauthors.4 Small group-mean differences often include very meaningful improvements for individual patients. The cited meta-analysis should not supersede the FDA’s analysis of primary clinical trial data or the agency’s role in determining what constitutes valid scientific evidence of efficacy. When evaluating the value of a health care intervention, the difference between efficacy and effectiveness is particularly important to consider. Effectiveness refers to performance under real-world conditions, rather than the idealized conditions of a placebo-controlled trial. The AAOS metaanalysis excluded effectiveness studies by design. Because the article by Schmajuk et al1 questions the value of intraarticular hyaluronic acid injections, the authors should not neglect high-quality effectiveness trials. In particular, a randomized, pragmatic, health economic trial reported that intraarticular hyaluronic acid injections provided statistically significant and clinically important incremental improvement over appropriate care, with a cost-utility ratio of $10 000 per quality-adjusted life-year (QALY). 5 This cost-utility ratio 462
is well below the $50 000-per-QALY threshold widely considered a reference standard for the provision of reasonable medical value. In the United States, billions of dollars are spent each year to treat patients with osteoarthritis. Considering the reported costs of intra-articular hyaluronic acid injections to Medicare relative to the overall cost to society of caring for patients with osteoarthritis, this useful procedure should not be improperly described as one of low value.
Author Affiliations: Department of Orthopaedic Surgery, New York University School of Medicine, New York; Department of Biochemistry and Molecular Pharmacology, New York University School of Medicine, New York. Corresponding Author: Philip A. Band, PhD, NYU Hospital for Joint Diseases, 301 E 17th St, Ste 1402, New York, NY 10003 (philip.band@nyumc .org). Conflict of Interest Disclosures: Dr Band reports that as an employee of Biomatrix between 1983 and 2000, he was involved with the development of hyaluronic acid for ophthalmic surgery, soft-tissue augmentation, drug delivery, and intra-articular injection. Patents relevant to the intra-articular use of hyaluronic acid were issued in 1987 and 1992 to Dr Band and others; these patents have expired, and Dr Band did not receive royalties or compensation other than as a Biomatrix employee. Between 2001 and about 2009, Dr Band reports receiving consulting fees from Smith & Nephew, which markets intraarticular hyaluronic acid products. In 2011, Dr Band reports receiving a single consulting fee from Ferring Pharmaceuticals, which markets an intra-articular hyaluronic acid product. 1. Schmajuk G, Bozic KJ, Yazdany J. Using Medicare data to understand low-value health care: the case of intra-articular hyaluronic acid injections. JAMA Intern Med. 2014;174(10):1702-1704. 2. Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB. Recommendations of the Panel on Cost-effectiveness in Health and Medicine. JAMA. 1996;276 (15):1253-1258. 3. American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee: evidence-based guideline, 2nd edition. 2013. http://www.aaos.org /research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdf. Accessed October 22, 2014. 4. Dworkin RH, Turk DC, McDermott MP, et al. Interpreting the clinical importance of group differences in chronic pain clinical trials: IMMPACT recommendations. Pain. 2009;146(3):238-244. 5. Raynauld JP, Torrance GW, Band PA, et al; Canadian Knee OA Study Group. A prospective, randomized, pragmatic, health outcomes trial evaluating the incorporation of hylan G-F 20 into the treatment paradigm for patients with knee osteoarthritis (part 1 of 2): clinical results. Osteoarthritis Cartilage. 2002;10 (7):506-517.
In Reply We disagree with Band; our analysis of intra-articular hyaluronic acid injections for knee osteoarthritis in the Medicare program does not have conceptual errors.1 Our analysis accurately presented the utilization of this procedure, including clinician and regional variation. The American Academy of Orthopaedic Surgeons (AAOS) is among the many organizations that recommend against the use of this procedure, including the United Kingdom’s National Institute for Health and Care Excellence and a group of independent investigators who performed a systematic review and meta-analysis.2,3 The meta-analysis performed by the AAOS of hyaluronic acid studies showed that among highquality studies, there was no clinically significant difference between hyaluronic acid and sham injection groups. Although some individual studies reported differences that were
JAMA Internal Medicine March 2015 Volume 175, Number 3 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Thomas Jefferson University User on 05/14/2015
jamainternalmedicine.com
