The New Normal for OA Knee Treatment

Thanks everybody for joining us and spending a few, uh, couple of minutes with us to learn a little bit more about some of the impact COVID, uh, is having on the management of some of our NIOA patients.

So, from a surgical and Business perspective, there's a huge impact, uh, of COVID-19. We do a number of implant-based cases. 800,000 is one estimate. We have a lot of worries around virus transmission, about people and patients coming in and out of our hospitals and in our, in and out of our offices. We're looking at redefining who essential personnel are for the operating room. So, do we keep the same complement of people that we've come to expect in the OR?

Inpatient hospitals will still have COVID patients even as we see the flu fluctuations, uh, within the Pandemic, uh, which creates anxiety and fear amongst the community. A lot of folks feel that ASCs may be the potential relief valve. So, can we offload some of our Inpatient cases, uh, to the Surgery centers? This is still, uh, remains to be seen, but we see a shift happening there.

There's some questions around OR competency and knowledge transfer. So as our OR staff either become sick, get quarantined, leave, or furloughed, what have you, do we still have that level of experience and expertise in our operating rooms to facilitate?

surgeries. There's going to be competition for OR time, whether it's ENT, urology, or or Orthopedics. These are valuable assets now, OR time. And so will we all be vying for a limited amount of resources to get our cases back and generating revenue. Private offices have laid off or furloughed many staff, so will those people come back? Many were instrumental in the communication flow between the operating room, vendors, hospitals, so on and so forth.

Supply chain in a lot of health systems are under increasing pressure to control costs to offset the loss in revenue. So there's a lot of RFPs, a lot of work being done by Supply chain to figure out, do we have the greatest value that we potentially can generate, especially during this time period.

Device manufacturers are struggling. They've laid off and furloughed many of their staff. Will those people come back as they ramp back up as different regions shut down or come back online? Do they have the wherewithal to adjust and manage the ebbs and flows of COVID-19? And then from Medical Education or from

A communication perspective, I think we're going to struggle and we'll have a new normal in terms of engaging each Other either from an educational perspective or from a sales perspective as we move forward. So national meetings, regional meetings, local meetings, will that look like what we've been used to for the last however many decades?

And then there's worries about the biology around COVID-19 on a lot of the implants and instruments that we handle. Now, Orthopedics is somewhat unique because we're a heavily-based implant specialty. And so, one of the worries is, does COVID-19, uh, remain on the boxes and the totes and all the things that we've, uh, gotten used to in terms of our functioning of our offices and our operating rooms.

Now, aside from the Business and the logistics, uh, side of Medicine, we've also got to obviously think about the patient and how does this impact the patient from a clinical perspective. A number of us have had to cancel total Knee replacements. Again, as the rules and regulations around, uh, COVID-19 changed. How do we manage those patients who had their surgeries canceled? I've got a number of patients who are simply scared. They're older or they're sicker, and they.

don't want to have Surgery right now. They were booked or they were canceled, and so they want to delay until all the craziness is over. What about patients who test positive for COVID-19? They're kind of stuck, uh, in this, uh, somewhat, uh, imprisonment, if you will, where they're quarantined and they're not allowed to really engage with the health system or with the public for one week, two weeks, depending on where you are. So, what do we do with those patients?

We've got a number of patients that are high risk. Maybe they want Surgery, but we're reluctant to offer the Surgery because, number one, we're worried that they may stay, uh, many days or may, may need an ICU stay. So they may, uh, take, uh, significant, uh, hospital resources in a time where, uh, those are extremely valuable, or we're worried about those patients being in the hospital and contracting the virus, uh, by virtue of, uh, uh, transmission from Other patients or, uh, surfaces.

What about the patients with limited access? So, as regions shut down, and let's say we have patients that live in rural areas, there may not be healthcare for them to go get if, uh, they have issues or they have problems because we have limited access. And then, as we transition from the hospital to the ASC setting, a lot of logistics and clinical issues, uh, come into play. Are you prepared or is the facility

prepared to handle patients. Let's say if they have to stay overnight, you anticipate them being in ambulatory or Outpatient Surgery, but lo and behold, maybe they need to stay overnight. What about Pain control? Are you doing the appropriate blocks, the Multimodal analgesia, uh, the perioperative Pain control that you need, uh, to keep these patients moving and create an efficient process? We certainly don't want patients coming back to the emergency room, especially if the Surgery.

done in a Surgery center, let alone a hospital, uh, because there's significant reporting and, and, uh, issues associated in terms of quality. And then, of course, if there are complications or things during Surgery, are you equipped or, or is the facility able to handle all these issues? So, COVID is bringing up a lot of issues, a lot of things that we need to think about as we look at healthcare and kind of decide what the new normal looks like.

So in terms of managing these patients who may have had delayed Surgery or canceled Surgery or are simply just scared.

What do we do? And so, at the bottom here of this pyramid, this is kind of the treatment paradigm for managing NOA. When you talk about an orthopedic practice, most of our patients have already failed a lot of these kind of early, uh, initial treatments. And we typically see this with patients with mild uh OA exercise, Physical therapy, nutraceuticals, so on and so forth. As the OA progresses, we start getting a little more interventional and a little more aggressive. Uh, we may start using simple analgesics,

And, uh, we want to be careful, uh, as we start moving into the opiates, uh, as, uh, the disease progresses. We may start prescribing low-dose anti-inflammatories. And then what's really, uh, come into, uh, uh, uh, kind of the forefront here are some of the new nerve ablation, uh, treatments that are out there, whether it's superficial or deep geniculate nerves. You can burn or freeze the nerves around the Knee. And a lot of interest in the biologics, whether it's PRP, stem cells, some.

Sentinel tissues, a lot of Research going on there, uh, about some of the, uh, new innovations and technologies that we can deploy to manage this. Because if you think about it, it's, it's really been a barren space. We haven't had many tools, uh, in our toolbox. As OA progresses, we get a little more aggressive. Uh, we start using intraarticular steroids. Again, a lot of, uh, issues around steroids and the potential chondrotoxicity. And we'll talk about kind of from a, from a macro, uh, perspective, health economics perspective.

the impact of steroids may be. And then we get a little more aggressive with prescription-strength anti-inflammatories, or even narcotics or opiates and maybe some discrete situations where you need short-term Pain control. But we really need to resist the urge to use narcotics and opiates for long-term chronic Pain management. Then ultimately, as Surgery progresses and it gets to bone on bone or, uh, or to a stage where, uh, the patient simply can't take it anymore and we're running out of tools, ultimately.

rely on Surgery. If we look at Hyaluronic acid injections, really, the bulk of the work is really in the mild to moderate NOA area. There's a lot of literature now supporting the use of Hyaluronic acid injections for mild to moderate NOA. And if you look at a lot of the new literature coming out, they really focus on KL-2 and 3 as a target patient where we're seeing the responders, we're seeing the clinical benefit in those patients with mild to moderate, NOA.

Now, if we look at the impact of HA not from a clinical perspective, but really from a health economic and more macro perspective, we recently published a study comparing the impact of Hyaluronic acid injections with steroid injections. And we use a large administrative claims database, Blue Cross Blue Shield, about 260,000 patients in this database. And we looked at the impact of HA and steroids on overall healthcare costs, complications such as adverse events, such as, uh.

Uh, renal failure, uh, blood clots, VTEs, uh, so on and so forth. And then we also looked at the costs associated with that. And what we found was a significant reduction in overall healthcare utilization, healthcare costs using HA injections compared to steroid injections in this, uh, Blue Cross Blue Shield database. And then more compelling, at least for me, is we saw a significant reduction in opioid use in the HA group compared to the steroid group.

And so, not only from a cost perspective, from a complication or adverse event perspective, but opioid use and narcotic use, we found a statistically and clinically significant impact in those patients that, uh, received HA injections in this administrative claims database study, uh, compared to patients who received, uh, typical steroid injections.

So as we try to figure out what the new normal is and how we address how COVID-19 impacts our clinical practice and then specifically in patients with NOA, I hope this lecture helps give you some insight about the various treatment options that you have available to you.

Thank you.