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The article introduces the updated Osteoarthritis of the Knee Clinical Care Standard, reflecting new evidence and contemporary guidelines aimed at improving care and reducing low-value treatments such as unnecessary imaging and surgeries. Topics discussed include the revised approach to imaging and opioid use, the emphasis on self-management through physical activity and weight management, and the incorporation of cultural safety and equity in care delivery.

The updated Osteoarthritis of the Knee Clinical Care Standard aims to provide evidence-based care for individuals with knee osteoarthritis. The standard emphasizes non-surgical management and recommends against unnecessary procedures such as knee arthroscopy. It also focuses on comprehensive assessment and diagnosis, appropriate use of imaging, education and self-management, physical activity and exercise, weight management and nutrition, and the use of medicines to manage pain and mobility. The standard includes cultural safety and equity considerations and provides recommendations for effective communication between clinicians and patients. Resources are available to support consumers, clinicians, and health services in implementing the standard. [Extracted from the article]

Objective: This study aimed to estimate the temporal trend of osteoarthritis (OA) burden in China by age, sex, and joint sites from 1990 to 2019 and predict the long‐term trend over the next 25 years. Methods: Using data from the Global Burden of Disease Study 2019, we estimated incident cases, prevalent cases, disability‐adjusted life years (DALYs) of OA, and DALYs of OA attributed to high body mass index (BMI), as well as corresponding age‐standardized rates (ASRs) for aforementioned indicies. Estimated annual percentage change (EAPC) and Nordpred age‐period‐cohort model were used to describe temporal trend changes and predict future disease burden. Results: From 1990 to 2019, the ASR of OA incidence increased from 472.53 per 100,000 to 509.84 per 100,000 people (EAPC: 0.36, 95% confidence interval [CI] 0.29–0.44); the ASR of OA prevalence increased from 5,880.58 per 100,000 to 6,330.06 per 100,000 people (EAPC 0.35, 95% CI 0.28–0.42); the ASR of OA DALYs increased from 206.38 per 100,000 to 224.78 per 100,000 people (EAPC 0.40, 95% CI 0.32–0.48). The ASR of OA DALYs attributed to high BMI increased rapidly, especially in men and patients with hip OA. Projections suggest an increasing trend in the incidence, prevalence, and DALYs of OA from 2019 to 2044, with the prevalent cases and DALYs of OA in China expected to increase by approximately 1.5 times over the next 25 years. Conclusion: The disease burden of OA has increased in China over the past 30 years and is expected to continue rising over the next 25 years. [ABSTRACT FROM AUTHOR]

Importance: Approximately 5% of all primary care visits in adults are related to knee pain. Osteoarthritis (OA), patellofemoral pain, and meniscal tears are among the most common causes of knee pain. Observations: Knee OA, affecting an estimated 654 million people worldwide, is the most likely diagnosis of knee pain in patients aged 45 years or older who present with activity-related knee joint pain with no or less than 30 minutes of morning stiffness (95% sensitivity; 69% specificity). Patellofemoral pain typically affects people younger than 40 years who are physically active and has a lifetime prevalence of approximately 25%. The presence of anterior knee pain during a squat is approximately 91% sensitive and 50% specific for patellofemoral pain. Meniscal tears affect an estimated 12% of the adult population and can occur following acute trauma (eg, twisting injury) in people younger than 40 years. Alternatively, a meniscal tear may be a degenerative condition present in patients with knee OA who are aged 40 years or older. The McMurray test, consisting of concurrent knee rotation (internal or external to test lateral or medial meniscus, respectively) and extension (61% sensitivity; 84% specificity), and joint line tenderness (83% sensitivity; 83% specificity) assist diagnosis of meniscal tears. Radiographic imaging of all patients with possible knee OA is not recommended. First-line management of OA comprises exercise therapy, weight loss (if overweight), education, and self-management programs to empower patients to better manage their condition. Surgical referral for knee joint replacement can be considered for patients with end-stage OA (ie, no or minimal joint space with inability to cope with pain) after using all appropriate conservative options. For patellofemoral pain, hip and knee strengthening exercises in combination with foot orthoses or patellar taping are recommended, with no indication for surgery. Conservative management (exercise therapy for 4-6 weeks) is also appropriate for most meniscal tears. For severe traumatic (eg, bucket-handle) tears, consisting of displaced meniscal tissue, surgery is likely required. For degenerative meniscal tears, exercise therapy is first-line treatment; surgery is not indicated even in the presence of mechanical symptoms (eg, locking, catching). Conclusions and Relevance: Knee OA, patellofemoral pain, and meniscal tears are common causes of knee pain, can be diagnosed clinically, and can be associated with significant disability. First-line treatment for each condition consists of conservative management, with a focus on exercise, education, and self-management. This review summarizes current evidence regarding the diagnosis and treatment of knee osteoarthritis, patellofemoral pain, and meniscal tears. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether baseline joint space narrowing (JSN) predicted disease remission, knee pain, and physical function changes in persons with knee osteoarthritis (OA). Methods: This study is a secondary analysis of a two‐armed randomized controlled trial. Participants were aged ≥50 years (n = 171) with a body mass index ≥28 kg/m2 and radiographic medial tibiofemoral OA. Participants in the intervention group received diet and exercise programs and special treatment (cognitive behavioral therapy, knee brace, and muscle strengthening exercises) according to the disease remission. Remission of pain and remission of patient global assessment of disease activity and/or functional impairment were used to define the disease remission. The control group were provided with an education pamphlet. The primary outcome was disease remission at 32 weeks, and the secondary outcomes were the changes in knee pain and physical function at 20 and 32 weeks. Baseline JSN was scored from 0 to 3, and the association between baseline JSN and outcomes was assessed using multiple regression. Results: There was no association of baseline JSN with disease remission at 32 weeks when the disease remission has been achieved. The baseline JSN grade 3 was associated with changes in knee pain at 20 weeks (p <.05). There was no association between baseline JSN and physical function. Conclusion: Baseline JSN severity predicted changes in knee pain but not the disease remission or changes in physical functions. Identification of baseline radiographic severity may be helpful in identifying differences in response to diet and exercise programs in knee OA. [ABSTRACT FROM AUTHOR]

Aim: To explore inflammatory ultrasound predictors of improvements in pain and function over 2, 6, and 12 months following administration of intra‐articular platelet‐rich plasma (PRP) in knee osteoarthritis (OA). Method: Patients with painful mild–moderate radiographic knee OA from a subset of the RESTORE RCT underwent ultrasound assessment according to the standardized OMERACT scanning protocol to detect inflammatory features such as synovitis, synovial hypertrophy, and effusion with power Doppler. The study knee was treated with 3 once‐weekly PRP injections obtained after centrifugation at 1500 g for 5 min. Numerical Rating Score (NRS), Intermittent and Constant Osteoarthritis Pain (ICOAP) questionnaire, and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) function sub‐score were used to measure pain and functional severity. Separate linear regression models were performed to determine whether baseline ultrasound‐detected features of inflammation predicted the improvement in pain and function following PRP injection in both unadjusted and adjusted models for confounders. Results: Forty‐four participants were included, with 25 (56.8%) being female. In an unadjusted model, higher OMERACT scores for inflammatory features such as global synovitis and/or effusion were significantly associated with greater improvement in all outcomes measured at 2 months but not at 6 and 12 months for pain measures. Only global synovitis showed significant association with functional improvement at 2 and 12 months. Similar findings were observed in the adjusted model. Conclusion: Ultrasound indices of knee inflammation predicted short‐term improvements in pain severity and both short‐ and longer‐term improvements in function following intra‐articular PRP injection. [ABSTRACT FROM AUTHOR]

Knee osteoarthritis (KOA) pain is a subjective and personal experience, making it challenging to characterise patients' experiences and assess their pain. In addition, there is no global standard for the assessment of pain in KOA. Therefore, this article examines the possible methods of assessing and characterising pain in patients with KOA using clinical symptoms, pain assessment tools, and imaging. We examine the current methods of assessment of pain in KOA and their application in clinical practice and clinical trials. Furthermore, we explore the possibility of creating individualised pain management plans to focus on different pain characteristics. With better evaluation and standardisation of pain assessment in these patients, it is hoped that patients would benefit from improved quality of life. At the same time, improvement in pain assessment would enable better data collection regarding symptom response in clinical trials for the treatment of osteoarthritis. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effectiveness and health costs of a new primary care service delivery model (the Optimising Primary Care Management of Knee Osteoarthritis [PARTNER] model) to improve health outcomes for patients with knee osteoarthritis (OA) compared to usual care. Methods: This study was a 2‐arm, cluster, superiority, randomized controlled trial with randomization at the general practice level, undertaken in Victoria and New South Wales, Australia. We aimed to recruit 44 practices and 572 patients age ≥45 years with knee pain for >3 months. Professional development opportunities on best practice OA care were provided to intervention group general practitioners (GPs). All recruited patients had an initial GP visit to confirm knee OA diagnosis. Control patients continued usual GP care, and intervention patients were referred to a centralized care support team (CST) for 12‐months. Via telehealth, the CST provided OA education and an agreed OA action plan focused on muscle strengthening, physical activity, and weight management. Primary outcomes were patient self‐reported change in knee pain (Numerical Rating Scale [range 0–10; higher score = worse]) and physical function (Knee Injury and Osteoarthritis Outcome Score activities of daily living subscale [range 0–100; higher score = better] at 12 months. Health care cost outcomes included costs of medical visits and prescription medications over the 12‐month period. Results: Recruitment targets were not reached. A total of 38 practices and 217 patients were recruited. The intervention improved pain by 0.8 of 10 points (95% confidence interval [95% CI] 0.2, 1.4) and function by 6.5 of 100 points (95% CI 2.3, 10.7), more than usual care at 12 months. Total costs of medical visits and prescriptions were $3,940 (Australian) for the intervention group versus $4,161 for usual care. This difference was not statistically significant. Conclusion: The PARTNER model improved knee pain and function more than usual GP care. The magnitude of improvement is unlikely to be clinically meaningful for pain but is uncertain for function. [ABSTRACT FROM AUTHOR]

Objective: Management guidelines encourage self‐care in patients with symptomatic osteoarthritis (OA). We undertook this study to investigate the relationship between health literacy (HL) and appropriateness of selection of self‐care strategies in people with self‐reported symptoms of OA. Methods: We conducted an online national observational, demographically representative, cross‐sectional survey of adults (ages 45–74 years). The eligibility criterion of "self‐reported OA symptoms" was screened for using guideline‐endorsed clinical criteria. Participants completed a custom‐built questionnaire that included validated scales for HL, pain intensity, sleep quality, and OA function/disability. Management strategies were grouped into self‐care activities, analgesics, and complementary medicines, and analyses of appropriateness were based on predefined, evidence‐based quality indicators. Results: Of 6,800 participants, 628 met the inclusion criteria and completed the survey. HL was categorized as follows: low (100 of 628, 15.9%), moderate (317 of 628, 50.5%), and excellent (211 of 628, 33.6%). In the past 7 days, mean pain intensity (0–10 scale) was 3.11 (95% confidence interval [95% CI] 3.06–3.16), and 71.7% of participants (450 of 628) had not achieved adequate pain relief. In the past month, 54.1% (340 of 628) reported disrupted sleep. Participants managed their pain with multiple self‐care activities (mean 1.44; 95% CI 1.32–1.57), analgesics (mean 1.74; 95% CI 1.60–1.88), and complementary medicines (mean 1.01; 95% CI 0.90–1.12). There was a statistically significant (P < 0.001) interaction between HL and appropriateness of current management strategies (HL low, guideline‐recommended management strategies less likely). Higher HL did not always translate into making appropriate pain management choices. Conclusion: Appropriate selection and use of evidence‐based management options is critical for patients with OA to obtain the full benefits from their treatment. Knowledge about suitable choices for OA self‐care is suboptimal, and future education should be tailored to different levels of HL. [ABSTRACT FROM AUTHOR]

Objective: Class III obesity (body mass index [BMI] ≥40 kg/m2) is associated with worse knee pain and total knee replacement (TKR) outcomes. Because bariatric surgery yields sustainable weight loss for individuals with BMI ≥40 kg/m2, our objective was to establish the value of Roux‐en‐Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) in conjunction with usual care for knee osteoarthritis (OA) patients with BMI ≥40 kg/m2. Methods: We used the Osteoarthritis Policy model to assess long‐term clinical benefits, costs, and cost‐effectiveness of RYGB and LSG. We derived model inputs for efficacy, costs, and complications associated with these treatments from published data. Primary outcomes included quality‐adjusted life‐years (QALYs), lifetime costs, and incremental cost‐effectiveness ratios (ICERs), all discounted at 3%/year. This analysis was conducted from a health care sector perspective. We performed sensitivity analyses to evaluate uncertainty in input parameters. Results: The usual care + RYGB strategy increased the quality‐adjusted life expectancy by 1.35 years and lifetime costs by $7,209, compared to usual care alone (ICER = $5,300/QALY). The usual care + LSG strategy yielded less benefit than usual care + RYGB and was dominated. Relative to usual care alone, both usual care + RYGB and usual care + LSG reduced opioid use from 13% to 4%, and increased TKR usage from 30% to 50% and 41%, respectively. For cohorts with BMI between 38 and 41 kg/m2, usual care + LSG dominated usual care + RYGB. In the probabilistic sensitivity analysis, at a willingness‐to‐pay threshold of $50,000/QALY, usual care + RYGB and usual care + LSG were cost‐effective in 70% and 30% of iterations, respectively. Conclusion: RYGB offers good value among knee OA patients with BMI ≥40 kg/m2, while LSG may provide good value among those with BMI between 35 and 41 kg/m2. [ABSTRACT FROM AUTHOR]

Background: Knee osteoarthritis (OA) is a leading cause of global disability. The understanding of the role of psychosocial factors in knee OA outcomes is still evolving particularly in an Asian context. The primary aim of this study is to explore psychosocial factors that prognosticate short and long-term clinical outcomes, productivity, and healthcare utilization in patients with knee OA. Secondary aims are to explore the mediation and directional relationships and the role it plays in predicting the discordance between self-reported measures (SRM), physical-performance measures (PPMs) and objective clinical parameters. Methods: A multi-centre prospective cohort study of community ambulant knee OA patients seeking treatment in the tertiary healthcare institutions in Singapore will be conducted. Patients with secondary arthritis, significant cognitive impairment, severe medical comorbidities or previous knee arthroplasty will be excluded. Primary clinical outcome measure is the Knee injury and OA Outcome Score-12 (KOOS-12). Baseline characteristics include sociodemographic status, arthritis status including symptom duration and radiographic severity, comorbidities and functional status through Charlson Comorbidities Index (CCI), Barthel Index (BI) and Parker Mobility Score (PMS). Psychosocial variables include social support, kinesiophobia, negative affect, self-efficacy, injustice, chronic illness shame and the built environment. Clinical outcomes include quality of life, physical performance, global assessment, satisfaction and physical activity levels. Productivity and healthcare utilization will be assessed by a modified OA Cost and Consequences Questionnaire (OCC-Q) and the Work Productivity and Activity Impairment Questionnaire (WPAI). Variables will be collected at baseline, 4, 12 months and yearly thereafter. Regression, mediation and structural equation modelling will be used for analysis. Discussion: Results will allow contextualization, identification, and phenotyping of the critical (and potentially modifiable) psychosocial parameters that predict positive clinical outcomes in the OA population to guide optimization and refinement of healthcare and community. This will facilitate: 1. identification of high-risk knee OA subpopulations that will likely experience poor outcomes and 2. formulation of targeted multidisciplinary comprehensive approaches to address these psychosocial factors to optimize non-surgical treatment care, maximize functional outcomes and create more value-based care model for knee OA. Ethics and dissemination: The study has been registered under clinicaltrials.gov registry (Identifier: NCT04942236). [ABSTRACT FROM AUTHOR]

Background Health coaching aims to empower people to reach their goals and is increasingly used in health care settings. Whether health coaching improves pain and disability for people with hip or knee osteoarthritis (OA) or low back pain (LBP) is unknown. Methods Six databases were searched for randomized controlled trials assessing health coaching or motivational programs in adults with hip or knee OA or LBP, with each condition investigated independently. Meta-analyses were performed with random-effects models in the Cochrane Collaboration Review Manager 5.3 program. Results Seventeen eligible studies were found. No studies analyzing hip OA alone were found. Pooled analyses found statistically significant decreases in mid-term pain (mean difference [MD]: –7.57; 95% confidence interval [CI]: –10.08 to –5.07; P  < 0.001, I 2 = 0%), short-term disability (standard mean difference [SMD]: –0.22; 95% CI: –0.41 to –0.03; P  = 0.02, z  = 2.32, I 2 = 0%), and mid-term disability (SMD: –0.42; 95% CI: –0.75 to –0.09; P  = 0.01, z  = 2.49, I 2 = 60%), favoring the intervention for chronic LBP. There were significant improvements in knee OA long-term functional disability (MD: –3.04; 95% CI: –5.70 to –0.38; P  = 0.03; z  = 2.24; I 2 = 0%). Conclusion Meta-analyses provide evidence that health coaching reduces both disability and pain in people with chronic LBP and reduces disability in people with knee OA, though the clinical significance is unknown. There is currently no evidence supporting or refuting the use of health coaching for hip OA. [ABSTRACT FROM AUTHOR]

Key Points: Question: Does a weight loss and exercise program in community settings lead to improvement in knee pain in patients with osteoarthritis and overweight or obesity? Findings: This randomized clinical trial included 823 patients with knee osteoarthritis and overweight or obesity treated with diet and exercise vs an attention control. After 18 months, the adjusted mean difference in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score (range, 0-20) was −0.6, a difference that met statistical significance. Meaning: In patients with knee osteoarthritis and overweight or obesity, an 18-month program of weight loss and exercise based in community settings, compared with an attention control group, led to a small difference in knee pain of uncertain clinical importance. Importance: Some weight loss and exercise programs that have been successful in academic center–based trials have not been evaluated in community settings. Objective: To determine whether adaptation of a diet and exercise intervention to community settings resulted in a statistically significant reduction in pain, compared with an attention control group, at 18-month follow-up. Design, Setting, and Participants: Assessor-blinded randomized clinical trial conducted in community settings in urban and rural counties in North Carolina. Patients were men and women aged 50 years or older with knee osteoarthritis and overweight or obesity (body mass index ≥27). Enrollment (N = 823) occurred between May 2016 and August 2019, with follow-up ending in April 2021. Interventions: Patients were randomly assigned to either a diet and exercise intervention (n = 414) or an attention control (n = 409) group for 18 months. Main Outcomes and Measures: The primary outcome was the between-group difference in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) knee pain score (range, 0 [none] to 20 [severe]; minimum clinically important difference, 1.6) over 18 months, tested using a repeated-measures mixed linear model with adjustments for covariates. There were 7 secondary outcomes including body weight. Results: Among the 823 randomized patients (mean age, 64.6 years; 637 [77%] women), 658 (80%) completed the trial. At 18-month follow-up, the adjusted mean WOMAC pain score was 5.0 in the diet and exercise group (n = 329) compared with 5.5 in the attention control group (n = 316) (adjusted difference, −0.6; 95% CI, −1.0 to −0.1; P =.02). Of 7 secondary outcomes, 5 were significantly better in the intervention group compared with control. The mean change in unadjusted 18-month body weight for patients with available data was −7.7 kg (8%) in the diet and exercise group (n = 289) and −1.7 kg (2%) in the attention control group (n = 273) (mean difference, −6.0 kg; 95% CI, −7.3 kg to −4.7 kg). There were 169 serious adverse events; none were definitely related to the study. There were 729 adverse events; 32 (4%) were definitely related to the study, including 10 body injuries (9 in diet and exercise; 1 in attention control), 7 muscle strains (6 in diet and exercise; 1 in attention control), and 6 trip/fall events (all 6 in diet and exercise). Conclusions and Relevance: Among patients with knee osteoarthritis and overweight or obesity, diet and exercise compared with an attention control led to a statistically significant but small difference in knee pain over 18 months. The magnitude of the difference in pain between groups is of uncertain clinical importance. Trial Registration: ClinicalTrials.gov Identifier: NCT02577549 This randomized clinical trial assesses the effect of a diet and exercise intervention vs an attention control condition on knee pain at 18-month follow-up among individuals aged 50 years or older with knee osteoarthritis and overweight or obesity. [ABSTRACT FROM AUTHOR]

Objective: To determine the optimal combination of imaging and biochemical biomarkers for use in the prediction of knee osteoarthritis (OA) progression. Methods: The present study was a nested case–control trial from the Foundation of the National Institutes of Health OA Biomarkers Consortium that assessed study participants with a Kellgren/Lawrence grade of 1–3 who had complete biomarker data available (n = 539 to 550). Cases were participants' knees that had radiographic and pain progression between 24 and 48 months compared to baseline. Radiographic progression only was assessed in secondary analyses. Biomarkers (baseline and 24‐month changes) that had a P value of <0.10 in univariate analysis were selected, including quantitative cartilage thickness and volume on magnetic resonance imaging (MRI), semiquantitative MRI markers, bone shape and area, quantitative meniscal volume, radiographic progression (trabecular bone texture [TBT]), and serum and/or urine biochemical markers. Multivariable logistic regression models were built using 3 different stepwise selection methods (complex models versus parsimonious models). Results: Among baseline biomarkers, the number of locations affected by osteophytes (semiquantitative), quantitative central medial femoral and central lateral femoral cartilage thickness, patellar bone shape, and semiquantitative Hoffa‐synovitis predicted OA progression in most models (C statistic 0.641–0.671). In most models, 24‐month changes in semiquantitative MRI markers (effusion‐synovitis, meniscal morphologic changes, and cartilage damage), quantitative central medial femoral cartilage thickness, quantitative medial tibial cartilage volume, quantitative lateral patellofemoral bone area, horizontal TBT (intercept term), and urine N‐telopeptide of type I collagen predicted OA progression (C statistic 0.680–0.724). A different combination of imaging and biochemical biomarkers (baseline and 24‐month change) predicted radiographic progression only, which had a higher C statistic of 0.716–0.832. Conclusion: The present study highlights the combination of biomarkers with potential prognostic utility in OA disease‐modifying trials. Properly qualified, these biomarkers could be used to enrich future trials with participants likely to experience progression of knee OA. [ABSTRACT FROM AUTHOR]

Objective: To study the longitudinal performance of fully automated cartilage segmentation in knees with radiographic osteoarthritis (OA), we evaluated the sensitivity to change in progressor knees from the Foundation for the National Institutes of Health OA Biomarkers Consortium between the automated and previously reported manual expert segmentation, and we determined whether differences in progression rates between predefined cohorts can be detected by the fully automated approach. Methods: The OA Initiative Biomarker Consortium was a nested case–control study. Progressor knees had both medial tibiofemoral radiographic joint space width loss (≥0.7 mm) and a persistent increase in Western Ontario and McMaster Universities Osteoarthritis Index pain scores (≥9 on a 0–100 scale) after 2 years from baseline (n = 194), whereas non‐progressor knees did not have either of both (n = 200). Deep‐learning automated algorithms trained on radiographic OA knees or knees of a healthy reference cohort (HRC) were used to automatically segment medial femorotibial compartment (MFTC) and lateral femorotibial cartilage on baseline and 2‐year follow‐up magnetic resonance imaging. Findings were compared with previously published manual expert segmentation. Results: The mean ± SD MFTC cartilage loss in the progressor cohort was –181 ± 245 μm by manual segmentation (standardized response mean [SRM] –0.74), –144 ± 200 μm by the radiographic OA–based model (SRM –0.72), and –69 ± 231 μm by HRC‐based model segmentation (SRM –0.30). Cohen's d for rates of progression between progressor versus the non‐progressor cohort was –0.84 (P < 0.001) for manual, –0.68 (P < 0.001) for the automated radiographic OA model, and –0.14 (P = 0.18) for automated HRC model segmentation. Conclusion: A fully automated deep‐learning segmentation approach not only displays similar sensitivity to change of longitudinal cartilage thickness loss in knee OA as did manual expert segmentation but also effectively differentiates longitudinal rates of loss of cartilage thickness between cohorts with different progression profiles. [ABSTRACT FROM AUTHOR]

Objective: Duloxetine is a treatment approved by the US Food and Drug Administration for both osteoarthritis (OA) pain and depression, though uptake of duloxetine in knee OA management varies. We examined the cost‐effectiveness of adding duloxetine to knee OA care in the absence or presence of depression screening. Methods: We used the Osteoarthritis Policy Model, a validated computer microsimulation of knee OA, to examine the value of duloxetine for patients with knee OA who have moderate pain by comparing 3 strategies: 1) usual care, 2) usual care plus duloxetine for patients who screen positive for depression on the Patient Health Questionnaire 9 (PHQ‐9), and 3) usual care plus universal duloxetine. Outcome measures included quality‐adjusted life years (QALYs), lifetime direct medical costs, and incremental cost‐effectiveness ratios (ICERs), discounted at 3% annually. Model inputs, drawn from the published literature and national databases, included annual cost of duloxetine ($721–937); average pain reduction for duloxetine (17.5 points on the Western Ontario and McMaster Universities Osteoarthritis Index pain scale [0–100]), and likelihood of depression remission with duloxetine (27.4%). We considered 2 willingness‐to‐pay (WTP) thresholds of $50,000/QALY and $100,000/QALY. We varied parameters related to the PHQ‐9 and the cost of duloxetine, efficacy, and toxicities to address uncertainty in model inputs. Results: The screening strategy led to an additional 17 QALYs per 1,000 subjects and increased costs by $289/subject (ICER = $17,000/QALY). Universal duloxetine led to an additional 31 QALYs per 1,000 subjects and $1,205 per subject (ICER = $39,300/QALY). Under the majority of sensitivity analyses, universal duloxetine was cost‐effective at the $100,000/QALY threshold. Conclusion: The addition of duloxetine to usual care for knee OA patients with moderate pain, regardless of depressive symptoms, is cost‐effective at frequently used WTP thresholds. [ABSTRACT FROM AUTHOR]