Skip to main navigation menu Skip to main content Skip to site footer

Original article

Vol. 153 No. 4 (2023)

Optimising the current model of care for knee osteoarthritis with the implementation of guideline recommended non-surgical treatments: a model-based health economic evaluation

  • Thomas Vetsch
  • Jan Taeymans
  • Nathanael Lutz
Cite this as:
Swiss Med Wkly. 2023;153:40059


AIMS OF THE STUDY: Structured exercise, education, weight management and painkiller prescription are guideline recommended non-surgical treatments for patients suffering from knee osteoarthritis. Despite its endorsement, uptake of guideline recommended non-surgical treatments remains low. It is unknown whether the implementation of these treatments into the current model of care for knee osteoarthritis would be cost-effective from a Swiss statutory healthcare perspective. We therefore aimed to (1) assess the incremental cost-effectiveness ratio of an optimised model of care incorporating guideline recommended non-surgical treatments in adults with knee osteoarthritis and (2) the effect of total knee replacement (TKR) delay with guideline recommended non-surgical treatments on the cost-effectiveness of the overall model of care.

METHODS: A Markov model from the Swiss statutory healthcare perspective was used to compare an optimised model of care incorporating guideline recommended non-surgical treatments versus the current model of care without standardised guideline recommended non-surgical treatments. Costs were derived from two Swiss health insurers, a national database, and a reimbursement catalogue. Utility values and transition probabilities were extracted from clinical trials and national population data. The main outcome was the incremental cost-effectiveness ratio for three scenarios: “base case” (current model of care vs optimised model of care with no delay of total knee replacement), “two-year delay” (current model of care vs optimised model of care + two-year delay of total knee replacement) and “five-year delay” (current model of care vs optimised model of care + five-year delay of total knee replacement). Costs and utilities were discounted at 3% per year and a time horizon of 70 years was chosen. Probabilistic sensitivity analyses were conducted.

RESULTS: The “base case” scenario led to 0.155 additional quality-adjusted life years (QALYs) per person at an additional cost per person of CHF 341 (ICER = CHF 2,203 / QALY gained). The “two-year delay” scenario led to 0.134 additional QALYs and CHF –14 cost per person. The “five-year delay” scenario led to 0.118 additional QALYs and CHF –501 cost per person. Delay of total knee replacement by two and five years led to an 18% and 36% reduction of revision surgeries, respectively, and had a cost-saving effect.

CONCLUSION: According to this Markov model, the optimisation of the current model of care by implementing guideline recommended non-surgical treatments would likely be cost-effective from a statutory healthcare perspective. If implementing guideline recommended non-surgical treatments delays total knee replacement by two or five years, the amount of revision surgeries may be reduced.


  1. Cross M , Smith E , Hoy D , Nolte S , Ackerman I , Fransen M , et al. The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014 Jul;73(7):1323–30.
  2. GHDx. Global Burden of Disease Study 2019 (GBD 2019) results. Published 2020. Accessed March 15, 2021.
  3. Schneider H , Venetz W. Cost of Obesity in Switzerland in 2012. Rep Prep Behalf Bundesamt Gesundh. Published online 2012:82.
  4. Wang H , Bai J , He B , Hu X , Liu D . Osteoarthritis and the risk of cardiovascular disease: a meta-analysis of observational studies. Sci Rep. 2016 Dec;6(1):39672.
  5. Arden NK , Perry TA , Bannuru RR , Bruyère O , Cooper C , Haugen IK , et al. Non-surgical management of knee osteoarthritis: comparison of ESCEO and OARSI 2019 guidelines. Nat Rev Rheumatol. 2021 Jan;17(1):59–66.
  6. McGrory BJ , Weber KL , Jevsevar DS , Sevarino K . Surgical Management of Osteoarthritis of the Knee: evidence-based Guideline. J Am Acad Orthop Surg. 2016 Aug;24(8):e87–93.
  7. Carr AJ , Robertsson O , Graves S , Price AJ , Arden NK , Judge A , et al. Knee replacement. Lancet. 2012 Apr;379(9823):1331–40.
  8. Skou ST , Roos EM , Laursen MB , Rathleff MS , Arendt-Nielsen L , Simonsen O , et al. A Randomized, Controlled Trial of Total Knee Replacement. N Engl J Med. 2015 Oct;373(17):1597–606.
  9. Beswick AD , Wylde V , Gooberman-Hill R , Blom A , Dieppe P . What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open. 2012 Feb;2(1):e000435.
  10. Healy WL , Della Valle CJ , Iorio R , Berend KR , Cushner FD , Dalury DF , et al. Complications of total knee arthroplasty: standardized list and definitions of the Knee Society. Clin Orthop Relat Res. 2013 Jan;471(1):215–20.
  11. Bayliss LE , Culliford D , Monk AP , Glyn-Jones S , Prieto-Alhambra D , Judge A , et al. The effect of patient age at intervention on risk of implant revision after total replacement of the hip or knee: a population-based cohort study. Lancet. 2017 Apr;389(10077):1424–30.
  12. Hagen KB , Smedslund G , Østerås N , Jamtvedt G . Quality of Community-Based Osteoarthritis Care: A Systematic Review and Meta-Analysis. Arthritis Care Res (Hoboken). 2016 Oct;68(10):1443–52.
  13. GLA . D® Schweiz: Arthrose nachhaltig mit Übungen behandeln. GLAD Schweiz. Accessed December 10, 2022.
  14. physioswiss - Schweizer Physiotherapie Verband. Statistiken Mitgliederservices. Accessed December 10, 2022.
  15. Mazzei DR , Ademola A , Abbott JH , Sajobi T , Hildebrand K , Marshall DA . Are education, exercise and diet interventions a cost-effective treatment to manage hip and knee osteoarthritis? A systematic review. Osteoarthritis Cartilage. Published online November 2020:S1063458420311651. doi:
  16. Skou ST , Roos E , Laursen M , Arendt-Nielsen L , Rasmussen S , Simonsen O , et al. Cost-effectiveness of total knee replacement in addition to non-surgical treatment: a 2-year outcome from a randomised trial in secondary care in Denmark. BMJ Open. 2020 Jan;10(1):e033495.
  17. Teoh LS , Eyles JP , Makovey J , Williams M , Kwoh CK , Hunter DJ . Observational study of the impact of an individualized multidisciplinary chronic care program for hip and knee osteoarthritis treatment on willingness for surgery. Int J Rheum Dis. 2017 Oct;20(10):1383–92.
  18. Husereau D , Drummond M , Petrou S , Carswell C , Moher D , Greenberg D , et al.; ISPOR Health Economic Evaluation Publication Guidelines-CHEERS Good Reporting Practices Task Force . Consolidated Health Economic Evaluation Reporting Standards (CHEERS)—explanation and elaboration: a report of the ISPOR Health Economic Evaluation Publication Guidelines Good Reporting Practices Task Force. Value Health. 2013;16(2):231–50.
  19. Roberts M , Russell LB , Paltiel AD , Chambers M , McEwan P , Krahn M ; ISPOR-SMDM Modeling Good Research Practices Task Force . Conceptualizing a model: a report of the ISPOR-SMDM Modeling Good Research Practices Task Force-2. Med Decis Making. 2012;32(5):678–89.
  20. RStudio Team . RStudio: Integrated Development Environment for R. Published online 2020.
  21. Wickham H , Averick M , Bryan J , Chang W , McGowan L , François R , et al. Welcome to the tidyverse. J Open Source Softw. 2019;4(43):1686.
  22. Carta A , Conversano C . On the Use of Markov Models in Pharmacoeconomics: Pros and Cons and Implications for Policy Makers. Front Public Health. 2020 Oct;8:569500. [cited 2022 Mar 23] Available from:
  23. Losina E , Usiskin IM , Smith SR , Sullivan JK , Smith KC , Hunter DJ , et al. Cost-effectiveness of generic celecoxib in knee osteoarthritis for average-risk patients: a model-based evaluation. Osteoarthritis Cartilage. 2018 May;26(5):641–50.
  24. Ponnusamy KE , Vasarhelyi EM , Somerville L , McCalden RW , Marsh JD . Cost-Effectiveness of Total Knee Arthroplasty vs Nonoperative Management in Normal, Overweight, Obese, Severely Obese, Morbidly Obese, and Super-Obese Patients: A Markov Model. J Arthroplasty. 2018 Jul;33(7 7S):S32–8.
  25. Rajan PV , Ng MK , Klika A , Kamath AF , Muschler GF , Higuera CA , et al. The Cost-Effectiveness of Platelet-Rich Plasma Injections for Knee Osteoarthritis: A Markov Decision Analysis. J Bone Joint Surg Am. 2020 Sep;102(18):e104.
  26. Ademi Z , Gloy V , Glinz D , Raatz H , Van S , Bucher HC , et al. Cost-effectiveness of primarily surgical versus primarily conservative treatment of acute and subacute radiculopathies due to intervertebral disc herniation from the Swiss perspective. Swiss Med Wkly. 2016;146:w14382.
  27. Cui A , Li H , Wang D , Zhong J , Chen Y , Lu H . Global, regional prevalence, incidence and risk factors of knee osteoarthritis in population-based studies. EClinicalMedicine. 2020 Nov;29-30:100587.
  28. BFS . Struktur der ständigen Wohnbevölkerung nach Kanton, 1999-2019 - 1999-2019 | Tabelle. Bundesamt für Statistik. Published August 27, 2020. Accessed March 15, 2021. /content/bfs/de/home/statistiken/bevoelkerung/stand-entwicklung.assetdetail.13707204.html
  29. TARMED . TARMED Online Browser. TARMED Leistungen und Tarife nach Dignität, Leistungsblöcken oder Leistungsgruppen online abfragen. Published March 15, 2021. Accessed March 15, 2021.
  30. Swiss DR . SwissDRG. Published March 15, 2021. Accessed March 15, 2021.
  31. BAG . Statistik der obligatorischen Krankenversicherung. Published online June 1, 2021. Accessed August 27, 2021.
  32. Skou ST , Roos EM , Laursen M , Arendt-Nielsen L , Rasmussen S , Simonsen O , et al. Cost-effectiveness of 12 weeks of supervised treatment compared to written advice in patients with knee osteoarthritis: a secondary analysis of the 2-year outcome from a randomized trial. Osteoarthritis Cartilage. 2020 Jul;28(7):907–16.
  33. Konopka JF , Lee Y , Su EP , McLawhorn AS . Lee Y yu, Su EP, McLawhorn AS. Quality-Adjusted Life Years After Hip and Knee Arthroplasty. JBJS Open Access. 2018;3(3):e0007.
  34. SIRIS . Swiss National Hip & Knee Joint Registry.; 2020. Accessed December 11, 2020.
  35. Bager CL , Karsdal M , Bihlet A , Thudium C , Byrjalsen I , Bay-Jensen AC . Incidence of total hip and total knee replacements from the prospective epidemiologic risk factor study: considerations for event driven clinical trial design. BMC Musculoskelet Disord. 2019 Jun;20(1):303.
  36. Briggs AH , Claxton K , Sculpher MJ . Decision Modelling for Health Economic Evaluation. Oxford University Press; 2006.
  37. Murphy L , Schwartz TA , Helmick CG , Renner JB , Tudor G , Koch G , et al. Lifetime risk of symptomatic knee osteoarthritis. Arthritis Rheum. 2008 Sep;59(9):1207–13.
  38. Weinstein AM , Rome BN , Reichmann WM , Collins JE , Burbine SA , Thornhill TS , et al. Estimating the burden of total knee replacement in the United States. J Bone Joint Surg Am. 2013 Mar;95(5):385–92.
  39. Gademan MG , Van Steenbergen LN , Cannegieter SC , Nelissen RG , Marang-Van De Mheen PJ . Population-based 10-year cumulative revision risks after hip and knee arthroplasty for osteoarthritis to inform patients in clinical practice: a competing risk analysis from the Dutch Arthroplasty Register. Acta Orthop. 2021 Jun;92(3):280–4.
  40. OECD . Health at a Glance 2017: OECD Indicators. Published 2017. Accessed December 8, 2020.
  41. Ong KL , Lau E , Suggs J , Kurtz SM , Manley MT . Risk of subsequent revision after primary and revision total joint arthroplasty. Clin Orthop Relat Res. 2010 Nov;468(11):3070–6.
  42. Bae DK , Song SJ , Heo DB , Lee SH , Song WJ . Long-term survival rate of implants and modes of failure after revision total knee arthroplasty by a single surgeon. J Arthroplasty. 2013 Aug;28(7):1130–4.
  43. Mandl LA . Determining who should be referred for total hip and knee replacements. Nat Rev Rheumatol. 2013 Jun;9(6):351–7.
  44. Wright JG , Hawker GA , Hudak PL , Croxford R , Glazier RH , Mahomed NN , et al.; Toronto Arthroplasty Research Group Writing Committee . Variability in physician opinions about the indications for knee arthroplasty. J Arthroplasty. 2011 Jun;26(4):569–575.e1.
  45. Ong KL , Lotke PA , Lau E , Manley MT , Kurtz SM . Prevalence and Costs of Rehabilitation and Physical Therapy After Primary TJA. J Arthroplasty. 2015 Jul;30(7):1121–6.
  46. McLawhorn AS , Southren D , Wang YC , Marx RG , Dodwell ER . Cost-Effectiveness of Bariatric Surgery Prior to Total Knee Arthroplasty in the Morbidly Obese: A Computer Model-Based Evaluation. J Bone Joint Surg Am. 2016 Jan;98(2):e6.