Cost Implications of Varying the Surgical Technique, Surgical Setting, and Anesthesia Type for Carpal Tunnel Release Surgery

doi:10.1016/j.jhsa.2018.03.051

The Journal of Hand Surgery

Volume 43, Issue 11, November 2018, Pages 971-977.e1

https://doi.org/10.1016/j.jhsa.2018.03.051 Get rights and content

Purpose

Carpal tunnel release (CTR) is a common surgical procedure, representing a financial burden to the health care system. The purpose of this study was to test whether the choice of CTR technique (open carpal tunnel release [OCTR] vs endoscopic carpal tunnel release [ECTR]), surgical setting (operating room vs procedure room [PR]), and anesthetic type (local, monitored anesthesia care [MAC], Bier block, general) affected costs or payments.

Methods

Consecutive adult patients undergoing isolated unilateral CTR between July 2014, and October 2017, at a single academic medical center were identified. Patients undergoing ECTR converted to OCTR, revision surgery, or additional procedures were excluded. Using our institution’s information technology value tools, we calculated total direct costs (TDCs), total combined payment (TCP), hospital payment, surgeon payment, and anesthesia payment for each surgical encounter. Cost data were normalized using each participant’s surgical encounter cost divided by the average cost in the data set and compared across 8 groups (defined by surgery type, operation location, and anesthesia type).

Results

Of 479 included patients, the mean age was 55.3 ± 16.1 years, and 68% were female. Payer mix included commercial (45%), Medicare (37%), Medicaid (13%), workers’ compensation (2%), self-pay (1%), and other (3%) insurance types. The TDC and TCP both differed significantly between each CTR group, and OCTR in the PR under local anesthesia was the lowest. The OCTR/local/operating room, OCTR/MAC/operating room, and ECTR/operating room, were associated with 6.3-fold, 11.0-fold, and 12.4-16.6-fold greater TDC than OCTR/local/PR, respectively.

Conclusions

Performing OCTR under local anesthetic in the PR setting significantly minimizes direct surgical encounter costs relative to other surgical methods (ECTR), anesthetic methods (Bier block, MAC, general), and surgical settings (operating room).

Clinical relevance

This study identifies modifiable factors that may lead to cost reductions for CTR surgery.

Section snippets

Methods

This institutional review board–approved retrospective cost analysis study included all adult (≥18 years of age) patients undergoing isolated unilateral CTR between July 2014 and October 2016 by fellowship-trained hand surgeons at a single tertiary academic institution. Patients were identified by Current Procedural Terminology code (64721 and 29848), and corresponding basic demographic and surgical data were tabulated. Manual chart review of all operative, anesthesia, and clinic notes was

Results

After excluding 168 patients undergoing other simultaneous procedures (122 bilateral simultaneous CTR, and 46 patients with other additional procedures) and 34 patients treated by nonfellowship-trained surgeons, 479 patients remained for analysis. Mean age was 55.2 years ± 16.2 years, and 68% were female. Payer mix is summarized in Table 1. Nearly half of patients were covered by commercial insurance and half covered by nonmilitary government insurance. All but 3 patients were treated in the PR

Discussion

The main finding of this study is that performing OCTR using local anesthetic only in a PR setting was the least costly CTR method at our institution. We observed differing TDCs and TCPs between each of 8 CTR groups and, therefore, reject our null hypothesis that choice of CTR technique (OCTR vs ECTR), surgical setting (operating room vs PR), and anesthetic type (local, MAC, Bier block, general) does not affect costs or payments.

Surgical setting contributed significantly to surgical costs

Acknowledgments

This investigation was supported by the University of Utah Population Health Research (PHR) Foundation, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant 5UL1TR001067-05 (formerly 8UL1TR000105 and UL1RR025764).

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There were 61 patients identified as having a preexisting psychiatric diagnosis compared to 70 patients without who underwent WALANT surgery. Comparing psychiatric diagnosis and nonpsychiatric diagnosis cohorts, there was no significant difference in preoperative anxiety (3.75 vs 3.30), pain during procedure (0.67 vs 0.56), or pain after surgery (4.89 vs 4.26). There was a significantly higher pain score with preoperative injection in the psychiatric diagnosis cohort (4.07 vs 2.93). When asked if they would have a WALANT procedure again, 95.1% of patients in the psychiatric diagnosis cohort and 98.6% of patients in the nonpsychiatric diagnosis group said they would. There was no significant difference in average preoperative SANE scores (59.67 [no psych diagnosis] vs 61.70 [psych diagnosis]) or postoperative SANE scores (82.82 [no psych diagnosis] vs 81.06 [psych diagnosis]) between the two cohorts.
WALANT surgery was nearly as well tolerated in patients with a preexisting mental health diagnosis when compared to those without a preexisting diagnosis.
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Preemptive analgesia has been used to reduce postsurgery pain and improve patient satisfaction. The effectiveness of multimodal preemptive analgesia in open carpal tunnel release under local anesthetic with a tourniquet is still debated. This study aimed to determine the effectiveness of preemptive analgesia on the postoperative tourniquet site and the surgical site.
A total of 44 patients were randomly assigned to one of 2 groups. An experimental group was given 300 mg of gabapentin, 200 mg of celecoxib, and 500 mg of acetaminophen 2 hours before surgery. Placebos were given to the control group. All surgeries were done under local anesthetic by a specialist hand surgeon. A tourniquet was inflated to the recommended pressure. The outcomes included the immediate postoperative tourniquet site pain scores, surgical site pain scores (at 1, 6, 12, 18, and 24 hours after surgery), and acetaminophen consumption in the first 48 hours.
The immediate postoperative tourniquet site pain score in the experimental group was significantly lower than in the placebo group. Although the surgical site pain score in the experimental group was significantly lower than the placebo group at 1, 6, 12, and 18 hours after surgery, these differences were not clinically significant. In addition, there was no statistically significant difference in surgical site pain score at 24 hours after surgery. The amount of acetaminophen consumed during the first 48 hours after surgery was significantly lower in the experimental group than in the placebo group.
Multimodal preemptive analgesia effectively reduced immediate postoperative pain at the tourniquet site in open carpal tunnel release. It also reduced postoperative acetaminophen consumption.
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Procedure rooms (PRs) are increasingly used for hand surgeries, but few studies have directly compared surgical site infection (SSI) rates between the PR and operating room. We tested the hypothesis that procedure setting is not associated with an increased SSI incidence in the VA population.
We identified carpal tunnel, trigger finger, and first dorsal compartment releases performed at our VA institution from 1999 to 2021 of which 717 were performed in the main operating room and 2,000 were performed in the PR. The incidence of SSI, defined as signs of wound infection within 60 days of the index procedure, which was treated with oral antibiotics, intravenous antibiotics, and/or operating room irrigation and debridement, was compared. We constructed a multivariable logistic regression analysis to assess the association between procedure setting and SSI incidence, adjusting for age, sex, procedure type, and comorbidities.
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Minor hand surgeries can be performed safely in the PR without an increased rate of SSI.
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Identifying High Direct Variable Costs of Open Carpal Tunnel Release Patients Using Time-Driven Activity-Based Costing
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To improve value in health care delivery, a deeper understanding of the cost drivers in hand surgery is necessary. Time-driven activity-based costing (TDABC) more accurately reflects true resource use compared with traditional accounting methods. This study used TDABC to explore the facility cost of carpal tunnel release and identify preoperative characteristics of high-cost patients.
Using TDABC, we calculated the facility costs of 516 consecutive patients undergoing open carpal tunnel release at an orthopedic specialty hospital between 2015 and 2021. Patients in the top decile cost were defined as high-cost patients. Multivariable logistic regression was used to determine preoperative characteristics (age, sex, body mass index, race, ethnicity, Elixhauser comorbidity index, American Society of Anesthesiology score, preoperative Disabilities of the Arm, Shoulder and Hand score, Short-Form 12, and anesthesia type) independently associated with high-cost patients.
Surgery-related personnel costs were the main driver (38.0%) of total facility costs, followed by preoperative personnel costs (21.3%). There was a 1.8-fold variation in facility cost between patients in the 90th and 10th percentiles ($774.69 vs $431.35), with the widest cost variations belonging to medication costs ($17.67 vs $1.85; variation, 9.6-fold) and other supply costs ($213.56 vs $65.56; variation, 3.3-fold). Using multivariable regression, predictors of high cost were patient age and use of general anesthesia. Total facility costs correlated strongly with the total operating room time and incision to closure time.
Efforts to decrease operating room time may translate into reduced personnel costs and greater cost savings. Multidisciplinary initiatives to control medication expenses for patients at risk of high costs may narrow the existing variation in costs.
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Citation Excerpt :
Evaluation was during the surgical intervention and only 3 of these studies were comparative [14,17,20]. Cost, as a primary outcome, was chosen only in those cost-minimisation study designs [45–49]. Satisfaction measure of the surgery or the level of comfort experienced by the patient during the surgery was evaluated in 4 studies [15,16,37,38].
The anaesthetic modality “wide-awake” or “WALANT” (wide awake local anaesthesia not tourniquet) is based on the combination of a local anaesthetic with a vasoconstrictor to reduce bleeding during surgery and to avoid the use of a pneumatic tourniquet. The combination of 1% lidocaine together with 1:100,000 epinephrine is the most commonly used formula. The objective of this work is to carry out a review of the literature about this anaesthetic modality in the field of orthopaedic surgery and traumatology.
PubMed and Embase databases were consulted with clearly defined operators. Two independent searches were conducted by two investigators, which were combined. Experimental, observational comparative studies, descriptive studies with n> 5 cases and cost studies were included. The individual results of the included studies are described.
A total of 8794 entries were collected of which a total of 36 studies were included in the review. A large number of these studies have been published since 2010 and refer almost entirely to hand surgery, with multiple indications applied. There is heterogeneity regarding the type of study design and variables studied, among others. In addition, there is a disparity when defining the methodology of the WALANT technique between the different studies.
This is the first comprehensive and reproducible review of the current state of the WALANT modality. There is great heterogeneity in terms of the study populations, the different comparators, variables studied between the different studies and a lack of precise details regarding the WALANT technique.
III, Therapeutic study.
The impact of WALANT anesthesia and office-based settings on patient satisfaction after carpal tunnel release: a patient reported outcome study
2023, Revue de Chirurgie Orthopedique et Traumatologique
La WALANT (Wide awake local anesthesia with no tourniquet) ainsi que les procédures de type « office surgery » deviennent de plus en plus populaires en chirurgie de la main. Il n’y a que peu de données dans la littérature concernant la satisfaction des patients comparant les méthodes d’anesthésie et la localisation de réalisation du geste chirurgical.
Nous avons réalisé une étude rétrospective, monocentrique, rapportant la satisfaction des patients répartis en trois groupes, en comparant le ressenti des patients vis-à-vis de l’anesthésie type WALANT et l’anesthésie loco-régionnale. Nous avons également comparé trois types de prise en charge : office surgery vs. bloc opératoire ambulatoire vs. bloc opératoire principal. Le Groupe 1 comporte des patients pris en charge sous WALANT en « office surgery » avec une procédure écho-guidée. Le Groupe 2 concerne des patients pris en charge sous WALANT en salle opératoire sans personnel d’anesthésie avec une procédure écho-guidée. Le Groupe 3 concerne la prise en charge au bloc principal, sous ALR avec utilisation d’un garrot et sous endoscopie. Chaque groupe comprend 30 patients avec un recul minimum de 2 mois postopératoire. Les critères d’évaluations regroupent : la satisfaction globale, la satisfaction concernant l’organisation du parcours de soin, l’administration et la qualité de l’anesthésie. Nous avons également recueilli les données concernant la résolution du syndrome acroparesthésique, la survenue de complications neurologiques, vasculaires ou infectieuses.
Les procédures réalisées en « office surgery » montrent un taux de satisfaction plus élevé comparé à la prise en charge au bloc, de même que l’anesthésie type WALANT comparé à l’ALR quel que soit le lieu de prise en charge. Nous n’avons pas mis en évidence de majoration des complications. Une résolution des symptômes neuropathiques a été constatée chez tous les patients.
Les résultats de cette étude montrent une augmentation de la satisfaction des patients pour les procédures réalisées en « office surgery ». Les résultats montrent également une augmentation de la satisfaction des patients sous WALANT comparé à l’ALR quel que soit le lieu de prise en charge. En conclusion il semblerait que la libération du canal carpien sous WALANT en « office surgery » apporte une amélioration significative du confort et de la satisfaction des patients, sans différence significative concernant les résultats cliniques.
III.

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Editor's choiceCost Implications of Varying the Surgical Technique, Surgical Setting, and Anesthesia Type for Carpal Tunnel Release Surgery

Purpose

Methods

Results

Conclusions

Clinical relevance

Section snippets

Methods

Results

Discussion

Acknowledgments

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

J Hand Surg Am

Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality

JAMA

Value driven outcomes (VDO): A pragmatic, modular, and extensible software framework for understanding and improving health care costs and outcomes

J Am Med Inform Assoc

Open versus endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials

Clin Orthop Relat Res

Single-portal endoscopic carpal tunnel release compared with open release: a prospective, randomized trial

J Bone Joint Surg Am

Endoscopic carpal tunnel release is preferred over mini-open despite similar outcome: a randomized trial

Clin Orthop Relat Res

A meta-analysis of randomized controlled trials comparing endoscopic and open carpal tunnel decompression

Plast Reconstr Surg

Cost-minimization analysis of open and endoscopic carpal tunnel release

J Bone Joint Surg Am

Editor's choice
Cost Implications of Varying the Surgical Technique, Surgical Setting, and Anesthesia Type for Carpal Tunnel Release Surgery