Intra-articular Hyaluronic Acid for Knee Osteoarthritis: Stabilizing Utilization Trends Amid Conflicting Clinical Practice Guidelines.

Abstract

Evidence has been mixed about the efficacy of intra-articular hyaluronic acid (HA) for knee osteoarthritis. This has led to conflicting clinical practice guidelines (CPGs) over the years. After the American Academy of Orthopaedic Surgeons (AAOS) issued a strong recommendation against HA in 2013, a claims-based study showed rapid decline in use. More recent endorsements from Osteoarthritis Research Society International (OARSI) in 2019 and the Veterans Affairs and Department of Defense (VA-DoD) in 2020 may have altered this trajectory. This study aimed to gauge contemporary utilization of HA knee injections. All patients aged 18 years and older diagnosed with knee osteoarthritis were identified from the 2010Q1-2023Q1 PearlDiver database. The percentage of patients receiving intra-articular HA relative to the number of patients diagnosed for knee osteoarthritis was calculated quarterly. Linear regression analyses were segmented by 2 key CPG inflection points: 2013Q3 AAOS' recommendation against HA injections and the 2019Q4 endorsements. Analyses were also stratified by provider specialty. Statistical significance was set at p < 0.05. A total of 16,581,526 knee OA patients were identified, among which HA knee injections were performed for 1,886,788 (11.4%). For the post-2013 AAOS CPG period (2013Q3-2019Q3), injection rates decreased (-0.10% per quarter; p < 0.001). However, following OARSI/VA-DoD endorsement (2019Q4-2023Q1), the slope leveled to -0.003% per quarter; p = 0.921. Through the study period, utilization declined for both women and men and both younger and older patients (<50 years old and ≥ 50 years old) (p < 0.001 for all). Utilization declined among orthopaedic surgeons, nonoperative musculoskeletal specialists, and primary care physicians, while utilization increased among pain medicine physicians (p < 0.001 for all). Intra-articular HA injection use decreased after the 2013 CPG from AAOS but has stabilized after more positive 2019 and 2020 CPGs from OARSI/VA-DoD. Notably, practice patterns are diverging patterns across specialties, suggesting variabilities in use. Level III. See Instructions for Authors for a complete description of levels of evidence.