Advertisement

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

      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.

      Key words

      The value of health care delivered in the United States has received increased attention in the past decade, in part owing to policy changes that have included value-based payment models.
      • Lee V.S.
      • Kawamoto K.
      • Hess R.
      • et al.
      Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality.
      • Kawamoto K.
      • Martin C.J.
      • Williams K.
      • et al.
      Value driven outcomes (VDO): A pragmatic, modular, and extensible software framework for understanding and improving health care costs and outcomes.
      Carpal tunnel syndrome (CTS) is one of the most common clinical entities involving the hand and wrist, and treatment costs attributed to CTS represent a burden to the health care system.
      • Nguyen C.
      • Milstein A.
      • Hernandez-Boussard T.
      • Curtin C.M.
      The effect of moving carpal tunnel releases out of hospitals on reducing united states health care charges.
      Hand surgeons have several options to consider when performing carpal tunnel release (CTR) surgery for appropriately indicated patients, including use of open carpal tunnel release (OCTR) or endoscopic carpal tunnel release (ECTR) techniques, choice of surgical setting, and anesthetic type. Each of these decisions may have cost implications. The OCTR and ECTR techniques have been described as both safe and effective with equivalent results in the short term,
      • Sayegh E.T.
      • Strauch R.J.
      Open versus endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials.
      • Trumble T.E.
      • Diao E.
      • Abrams R.A.
      • Gilbert-Anderson M.M.
      Single-portal endoscopic carpal tunnel release compared with open release: a prospective, randomized trial.
      • Kang H.J.
      • Koh I.H.
      • Lee T.J.
      • Choi Y.R.
      Endoscopic carpal tunnel release is preferred over mini-open despite similar outcome: a randomized trial.
      • Thoma A.
      • Veltri K.
      • Haines T.
      • Duku E.
      A meta-analysis of randomized controlled trials comparing endoscopic and open carpal tunnel decompression.
      although ECTR may be costlier.
      • Zhang S.
      • Vora M.
      • Harris A.H.
      • Baker L.
      • Curtin C.
      • Kamal R.N.
      Cost-minimization analysis of open and endoscopic carpal tunnel release.
      • Foster B.D.
      • Sivasundaram L.
      • Heckmann N.
      • et al.
      Surgical approach and anesthetic modality for carpal tunnel release: a nationwide database study with health care cost implications.
      With regard to anesthetic type, performing CTR under local anesthetic without sedation has been shown to be effective,
      • Lichtman D.M.
      • Florio R.L.
      • Mack G.R.
      Carpal tunnel release under local anesthesia: evaluation of the outpatient procedure.
      • Rozanski M.
      • Neuhaus V.
      • Reddy R.
      • Jupiter J.B.
      • Rathmell J.P.
      • Ring D.C.
      An open-label comparison of local anesthesia with or without sedation for minor hand surgery.
      • Lalonde D.
      • Martin A.
      Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia.
      • Lalonde D.
      • Martin A.
      Tumescent local anesthesia for hand surgery: improved results, cost effectiveness, and wide-awake patient satisfaction.
      • Lalonde D.H.
      • Wong A.
      Dosage of local anesthesia in wide awake hand surgery.
      and other anesthetic methods including Bier block, monitored anesthesia care (MAC), or general anesthesia are also well-established options.
      Performing CTR under local anesthetic in a procedure room (PR) may provide an opportunity to reduce costs by eliminating the need for an anesthesia team, by reducing need for routine preoperative medical testing,
      • Davison P.G.
      • Cobb T.
      • Lalonde D.H.
      The patient's perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study.
      and allowing for wide-awake local anesthesia no tourniquet (WALANT) surgery in ambulatory- or clinic-based procedure rooms. WALANT has been utilized successfully for CTR,
      • Rhee P.C.
      • Fischer M.M.
      • Rhee L.S.
      • McMillan H.
      • Johnson A.E.
      Cost savings and patient experiences of a clinic-based, wide-awake hand surgery program at a military medical center: a critical analysis of the first 100 procedures.
      • Leblanc M.R.
      • Lalonde D.H.
      • Thoma A.
      • et al.
      Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery.
      • Leblanc M.R.
      • Lalonde J.
      • Lalonde D.H.
      A detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in canada.
      yielding significant cost reductions in the context of the U. S. Military Health Care System
      • Rhee P.C.
      • Fischer M.M.
      • Rhee L.S.
      • McMillan H.
      • Johnson A.E.
      Cost savings and patient experiences of a clinic-based, wide-awake hand surgery program at a military medical center: a critical analysis of the first 100 procedures.
      and in Canada.
      • Leblanc M.R.
      • Lalonde J.
      • Lalonde D.H.
      A detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in canada.
      It remains unclear whether these results are generalizable to the majority of the U.S. population covered by commercial and nonmilitary government payers.
      A study utilizing 2007 cost and payment data demonstrated cost savings for CTR performed in a PR, compared with the hospital-based operating room, at a U.S. tertiary care center.
      • Chatterjee A.
      • McCarthy J.E.
      • Montagne S.A.
      • Leong K.
      • Kerrigan C.L.
      A cost, profit, and efficiency analysis of performing carpal tunnel surgery in the operating room versus the clinic setting in the united states.
      Although these data are promising, use of a hospital-based operating room as the comparison group rather than an ambulatory surgical center (ASC) is a limitation, because performing CTR in the ASC setting has been shown to be less costly than a hospital-based operating room for CTR.
      • Nguyen C.
      • Milstein A.
      • Hernandez-Boussard T.
      • Curtin C.M.
      The effect of moving carpal tunnel releases out of hospitals on reducing united states health care charges.
      Therefore, generalizing the observed PR cost savings to practices predominantly utilizing an ASC may overestimate potential savings. A recent study utilizing payment data from United Health Group insurance records concluded that OCTR performed under local anesthetic was less costly than other methods of CTR.
      • Foster B.D.
      • Sivasundaram L.
      • Heckmann N.
      • et al.
      Surgical approach and anesthetic modality for carpal tunnel release: a nationwide database study with health care cost implications.
      However, surgical setting (operating room vs PR) was not included as a study variable.
      • Foster B.D.
      • Sivasundaram L.
      • Heckmann N.
      • et al.
      Surgical approach and anesthetic modality for carpal tunnel release: a nationwide database study with health care cost implications.
      Although superior short-term outcomes and greater rates of nerve injury have been demonstrated with ECTR than with OCTR, mid- to long-term results are similar between these 2 surgical methods.
      • Sayegh E.T.
      • Strauch R.J.
      Open versus endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials.
      • Trumble T.E.
      • Diao E.
      • Abrams R.A.
      • Gilbert-Anderson M.M.
      Single-portal endoscopic carpal tunnel release compared with open release: a prospective, randomized trial.
      • Kang H.J.
      • Koh I.H.
      • Lee T.J.
      • Choi Y.R.
      Endoscopic carpal tunnel release is preferred over mini-open despite similar outcome: a randomized trial.
      • Thoma A.
      • Veltri K.
      • Haines T.
      • Duku E.
      A meta-analysis of randomized controlled trials comparing endoscopic and open carpal tunnel decompression.
      In addition, surgical setting and anesthetic type have cost implications without proven impact on overall patient outcomes in the current literature. Therefore, costs should be considered in the surgical treatment of CTS. Our institution has developed a Value-Driven Outcomes (VDO) database containing detailed patient- and item-level total direct cost (TDC) and payment data for a variety of health care services. This has successfully identified areas of high variability in cost, leading to improved value of care delivered.
      • Lee V.S.
      • Kawamoto K.
      • Hess R.
      • et al.
      Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality.
      In the current study, the VDO tool was utilized to test our null hypothesis that choice of CTR technique, surgical setting, and anesthetic type do not affect TDC or total combined payments (TCP).

      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 performed to confirm the surgery type, surgical setting, and anesthesia type. Patients undergoing additional simultaneous procedures including other surgeries, injections, or bilateral CTR, were excluded. Also excluded were patients undergoing revision CTR, ECTR converted to OCTR, or those undergoing surgery prior to July 2014 (corresponding with initiation of WALANT hand surgery at our institution).
      The TDC and payment data were collected from the VDO database for each individual surgical encounter. The VDO information technology tool draws prospectively collected payment data and patient- and item-level TDC data from our institution’s data warehouse for specific patient encounters. The VDO costing methods have been previously described, yielding TDC for materials used for patient care, facility utilization direct costs (including sterile processing costs), and time-based cost allocations including procedure/operative time and cost of staff involved in care (nursing, surgical technicians, medical assistants).
      • Lee V.S.
      • Kawamoto K.
      • Hess R.
      • et al.
      Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality.
      The TDC categories, as tabulated by the VDO tool, are further described in Appendix A (available on the Journal’s Web site at www.jhandsurg.org).
      Using the VDO tool, TCPs were calculated as the sum of hospital payment, surgeon payment, and anesthesia payment. All reported cost or payment data were normalized using each individual’s cost divided by the average cost in the data set to comply with institutional guidelines prohibiting the public reporting of any financial data related to the details of nonpublicly disclosed contractual agreements. At our institution, both the operating room and the PR are located within an orthopedic ASC, and the PR is considered a “site of service 22” (a procedure room within a hospital). Both the PR and the operating room incur a facility cost (operating room costs are 8.4-fold greater than the PR per minute of use for CTR surgeries).
      Each unique combination of surgery technique (OCTR, ECTR), operation location (operating room, PR), and anesthesia type (local, MAC, Bier block, general) was defined as a distinct group. Continuous variables were summarized as mean ± SD, and categorical variables were summarized as count and percentage (%). Relative costs (or payments) were calculated relative to the lowest group by dividing each distinct group average by the lowest group mean. The TDCs and TCPs were compared between groups using Kruskal-Wallis tests, followed by Nemenyi post hoc tests to adjust for multiple comparisons.
      • Pohlert T.
      The pairwise multiple comparison of mean ranks package (PMCMR).
      Statistical significance was assessed at the .05 level and all tests were 2-tailed.
      We based our sample size calculations on a medium effect size of 0.35 in SD units. We expect a 1:1.5 ratio of PR versus operating room cases for OCTR surgeries based on prior experience. With a 2-sided, 2-sample t test, we required a total sample size of 270 (108 PR and 162 operating room) to detect a medium effect size of 0.35 for cost between groups with 80% power at a .05 alpha level.

      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 or ASC. The 3 patients treated at a main hospital operating room setting declined treatment in the PR and had medical comorbidities that precluded treatment in the ASC setting: 2 had cardiac comorbidities, and 1 had diabetes, morbid obesity and obstructive sleep apnea. Owing to insufficient sample size representation of the main hospital operating room, these 3 patients were excluded. The breakdown of CTR surgeries performed by surgical method, surgical setting, and anesthesia type is illustrated in Table 2 with associated sample sizes—a total of 8 unique groups were identified.
      Table 1Summary of Payer Mix
      Insurance TypePercentage (%)
      Commercial45.1
      Medicare37.0
      Medicaid12.7
      Other2.9
      Workers’ compensation2.1
      Self-pay0.6
      Table 2Summary of Unique Study Groups Based Upon Surgical Method, Surgical Setting, and Anesthesia Type
      Sample Size (n)Surgical MethodSurgical SettingAnesthesia Type
      135OCTRPR (WALANT)Local only
      122OCTROperating roomMAC
      100ECTROperating roomMAC
      57ECTROperating roomBier block and MAC
      42OCTROperating roomBier block and MAC
      14OCTROperating roomGeneral
      5OCTROperating roomLocal only
      4ECTROperating roomGeneral
      The TDCs differed significantly between each CTR release group (P < .05; Fig. 1). CTR performed under WALANT (OCTR in the PR under local anesthesia) was associated with the lowest TDCs (relative cost of 1.0). Performing OCTR in the operating room under local anesthesia was associated with 6.3-fold higher TDCs than an OCTR using WALANT in a PR setting, and using MAC anesthesia for OCTR in the operating room was 11.0-fold higher. Depending on the chosen anesthesia type, performing ECTR in the operating room was associated with 12.4- to 16.6-fold greater TDCs than WALANT.
      Figure thumbnail gr1
      Figure 1Data represent mean ± standard error of the mean. #Reference group, normalized to 1.0. *P < .05 compared with left-sided neighboring value per Kruskal-Wallis tests and Nemenyi post hoc multiple comparison tests. Values over the graph bars represent fold-change differences relative to the reference group (WALANT).
      The TCPs differed significantly between each CTR group (P < .05; Fig. 2). The WALANT was associated with the lowest TCP (relative payment of 1.0). Performing OCTR in the operating room was associated with a 1.1- to 2.4-fold greater TCPs, depending on anesthesia type, than WALANT. The ECTR was associated with a 1.4- to 1.7-fold greater TCPs, depending on anesthesia type, than WALANT.
      Figure thumbnail gr2
      Figure 2Data represent mean ± standard error of the mean. #Reference group, normalized to 1.0. *P < .05 compared with left-sided neighboring value per Kruskal-Wallis tests and Nemenyi post hoc multiple comparison tests. Values over the graph bars represent fold-change differences relative to the reference group (WALANT).

      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 independent of anesthesia type or surgical method because performing OCTR under local in the PR versus the operating room significantly affected both TDCs and TCPs (6.3- and 1.1-fold greater in the operating room, respectively). Similarly, we conclude that anesthesia type independently influences CTR surgery costs. The TDCs differed significantly based upon anesthesia type for OCTR performed in the operating room (MAC, Bier block, and local were 62.6%, 66.4%, and 78.5% lower than general) and for ECTR performed in the operating room (MAC and Bier block were 8.8% and 25.3% lower than general). The TCPs also differed significantly based upon anesthesia type when controlling for surgical method.
      Our findings regarding the cost-saving potential of WALANT and the impact of surgical setting on cost are congruent with previous literature. Chatterjee et al
      • Chatterjee A.
      • McCarthy J.E.
      • Montagne S.A.
      • Leong K.
      • Kerrigan C.L.
      A cost, profit, and efficiency analysis of performing carpal tunnel surgery in the operating room versus the clinic setting in the united states.
      demonstrated cost savings for CTR performed in a PR, compared to the hospital-based operating room. Limitations of that study include possible overestimation of savings through use of a hospital-based operating room as the comparison group rather than an ASC, the latter of which incur lower costs for CTR surgery. Rhee et al
      • Rhee P.C.
      • Fischer M.M.
      • Rhee L.S.
      • McMillan H.
      • Johnson A.E.
      Cost savings and patient experiences of a clinic-based, wide-awake hand surgery program at a military medical center: a critical analysis of the first 100 procedures.
      observed significant cost savings related to performing small hand surgery procedures under WALANT, 34% of which were CTR. The authors projected nearly $400,000 in savings to the Military Health Care System by performing 100 surgeries in a clinic-based PR rather than the operating room. A study by Leblanc et al
      • Leblanc M.R.
      • Lalonde J.
      • Lalonde D.H.
      A detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in canada.
      considered differences in material and personnel costs between operating room and clinic-based CTR surgery and arrived at a similar conclusion in Canada. Limitations include questionable generalizability to the nonmilitary population in the United States.
      Although PR surgery was not studied specifically, Foster et al
      • Foster B.D.
      • Sivasundaram L.
      • Heckmann N.
      • et al.
      Surgical approach and anesthetic modality for carpal tunnel release: a nationwide database study with health care cost implications.
      concluded that OCTR performed under local was the least costly method of those studied. The ECTR cost $794 more than OCTR, and general/regional anesthesia was $654 more expensive than local—subjectively, these results parallel our findings. Limitations include use of United Health Group insurance records, which do not quantify direct costs, do not allow differentiation between general and regional anesthesia, and do not identify revision surgeries or bilateral simultaneous CTR patients for exclusion. Failure to exclude revision OCTR may bias the results by underestimating actual cost discrepancies between OCTR and ECTR. An additional critical limitation was the inability to differentiate costs based on operative setting (PR vs operating room). Generalizability of the results may be affected by the homogeneous payer mix because no Medicare or Medicaid patients were included in that database.
      In addition, we conclude that ECTR led to significantly greater TDCs and TCPs than OCTR when performed in the operating room under Bier block (20.5% and 23.8% greater, respectively) or in the operating room under MAC (33.5% and 23.1%, respectively). These results are also consistent with previous literature. Zhang et al
      • Zhang S.
      • Vora M.
      • Harris A.H.
      • Baker L.
      • Curtin C.
      • Kamal R.N.
      Cost-minimization analysis of open and endoscopic carpal tunnel release.
      used payer fees to define cost and concluded that ECTR was associated with greater fees than OCTR when considering facility fees, surgeon fees, and occupational therapy fees ($2,602 versus $1,751, respectively). However, specific anesthesia fees and TDC data were not evaluated, and the authors were limited in precisely identifying the sources of cost differences.
      • Zhang S.
      • Vora M.
      • Harris A.H.
      • Baker L.
      • Curtin C.
      • Kamal R.N.
      Cost-minimization analysis of open and endoscopic carpal tunnel release.
      Thoma et al
      • Thoma A.
      • Wong V.H.
      • Sprague S.
      • Duku E.
      A cost-utility analysis of open and endoscopic carpal tunnel release.
      performed a cost-effectiveness analysis to compare OCTR with ECTR using direct cost data at a Canadian academic institution and concluded that ECTR was not cost effective based upon their calculated incremental cost-utility ratio of $124,311 per quality-adjusted life years.
      Limitations of the current study deserve mention. Initial identification of patients by procedure code and the retrospective study design introduce potential for selection bias. Generalizability of our results may be limited by our observed payer mix or unique pricing agreements between our institution and suppliers, which may affect payments and TDCs, respectively. Given that we identified only 3 patients undergoing CTR in a main hospital operating room setting, we could not analyze cost or payment differences based upon this variable. Nonetheless, it has been previously established that CTR surgery is more expensive when performed in the hospital-based setting than in an ASC setting.
      • Nguyen C.
      • Milstein A.
      • Hernandez-Boussard T.
      • Curtin C.M.
      The effect of moving carpal tunnel releases out of hospitals on reducing united states health care charges.
      We believe that excluding this costlier surgical setting does not curtail the goal of the current investigation, which is to highlight opportunities for cost savings for CTR surgery. We are unable to comment on costs associated with CTR treatment strategies beyond those performed at our institution, including endoscopic release under WALANT. Prior studies have described cost savings of bilateral simultaneous CTR compared with staged unilateral releases for those with bilateral disease.
      • Thoma A.
      • Wong V.H.
      • Sprague S.
      • Duku E.
      A cost-utility analysis of open and endoscopic carpal tunnel release.
      American Medical Association
      However, our study did not evaluate the potential additional cost savings of performing bilateral simultaneous releases in the PR setting. Because we did not evaluate costs or payments related to preoperative or postoperative care following CTR, our results are not intended to reflect cost savings beyond the surgical encounter itself. We speculate that it is possible that evaluating costs for the treatment process in its entirety may uncover even greater cost savings afforded by WALANT, through minimization of the need for preoperative medical evaluation.
      • Davison P.G.
      • Cobb T.
      • Lalonde D.H.
      The patient's perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study.
      We did not evaluate the opportunity cost associated with procedure room utilization, which may afford the ability to perform more CTR surgeries per unit time through increased efficiency.
      • Chatterjee A.
      • McCarthy J.E.
      • Montagne S.A.
      • Leong K.
      • Kerrigan C.L.
      A cost, profit, and efficiency analysis of performing carpal tunnel surgery in the operating room versus the clinic setting in the united states.
      The VDO database does not include indirect cost data such as housekeeping, electricity, or property rent/depreciation. Although the relative dollar amounts reported in this manuscript allow for comparison of costs and payments between groups, an additional limitation is that our institution does not allow raw cost or payment data to be presented. Despite literature supporting similar clinical outcomes regardless of how the transverse carpal ligament is cut and paucity of literature supporting differences in outcomes based upon anesthesia type or operative setting, it deserves emphasis that we did not perform a true cost-effectiveness analysis. Therefore, our results describe only cost differences rather than differences in value.
      We think it is critical to recognize that, although we did not observe any nerve or vascular transections in our series, this study was not designed nor adequately powered to make any conclusions or comments on the relative safety of CTR performed in various settings or with differing anesthetic choices, including WALANT in a procedure room. We did not observe any catastrophic complications such as nerve transections in our series, which precludes a number-needed-to-treat analysis to determine whether CTR method, surgical setting, or anesthetic type contribute to such complications. Although not demonstrated in the current literature, we recognize the possibility that use of sedation or general anesthesia may reduce the risk of nerve transections by keeping the patients relaxed and reducing the chance that they unexpectedly withdraw the operative limb. The increased direct and indirect costs to both patient and society resulting from iatrogenic neurovascular injury during CTR surgery are likely extraordinary. A single median nerve transection may lead to costly additional operations to address the injury (nerve repair or grafting) or its sequelae (opponensplasty tendon transfer, sensory nerve transfer), additional costs attributable to provider visits and nerve conduction studies, loss of productivity from time off of work or decreased efficiency from the resulting functional disability, and intangible costs of patient morbidity. Potential risks of nerve transection must be considered when choosing a surgical method, anesthesia method, and procedure setting for CTR.
      Despite the cost-reducing potential of a PR for CTR surgery, barriers to implementation do exist. Regulatory and compliance issues may make it difficult to establish a PR in a surgery center or office setting. The need for sterile processing and limited space in the office may pose logistical barriers. For surgeons who currently derive compensation through facility fees of a surgical center or other operational setting, changing the paradigm for CTR by transitioning into the PR setting may have implications for surgeon reimbursement because profit-sharing groups may be incentivized to perform CTR in the operating room, which is associated with greater facility fees than the PR. Surgeon concern regarding costs of supplies and personnel for office-based PR cases may also pose as a barrier, although the Place of Service Code 11 for Professional Claims modifier may offset some of these expenses.
      American Medical Association
      Additional potential barriers include concerns that cost savings may not be realized at the patient level, patient refusal of treatment in a PR, or surgeon concerns for safety in the PR setting. We also acknowledge that surgeon preference and training background influence choices in how to perform CTR, and we are not advocating that the least costly way is the best or only way to perform CTR. Lastly, we acknowledge potential safety concerns arising from lack of anesthesia monitoring or preoperative medical work-up for these surgical patients, and further investigation is warranted to determine the safety effects of this practice, particularly for high-risk patients with extensive comorbidities such as newly placed coronary stents or other major active medical problems.
      In conclusion, this study demonstrates substantial cost savings for CTR surgery performed under WALANT (OCTR under local anesthesia, in the PR setting) for a U.S. nonmilitary population. Compared with WALANT, other variations of CTR are associated with 6.3- to 29.3-fold and 1.1- to 2.4-fold greater TDCs and TCPs, respectively, depending on the chosen surgical technique, surgical setting, and anesthesia type.

      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 ).

      Appendix A. Breakdown of VDO Database Categories for TDCs

      • Imaging cost: All imaging, scans, and radiology services used.
      • Supply cost: All supplies and devices used, excluding implants.
      • Implant cost: All supply costs that are grouped as an Other implant supply.
      • Pharmacy cost: Total cost of all medication used during the patient’s stay.
      • Laboratory cost: All laboratory work associated with visit, including blood work, urinalysis, hematology, and all other laboratory- or chemistry-related costs.
      • Other services cost: Services that do not fall into one of the other categories. Services include physical therapy, occupational therapy, speech pathology, respiratory service, electrocardiography, recovery room nursing/staff, and other therapeutic services.
      • Facility utilization cost: Time and labor costs for patient’s stay in each unit (excluding professional costing). Cost is mapped to the individual patient level based on time spent on specific unit (surgery minutes, patient hours) or by completed visit.

      References

        • Lee V.S.
        • Kawamoto K.
        • Hess R.
        • et al.
        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. 2016; 316: 1061-1072
        • Kawamoto K.
        • Martin C.J.
        • Williams K.
        • et al.
        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. 2015; 22: 223-235
        • Nguyen C.
        • Milstein A.
        • Hernandez-Boussard T.
        • Curtin C.M.
        The effect of moving carpal tunnel releases out of hospitals on reducing united states health care charges.
        J Hand Surg Am. 2015; 40: 1657-1662
        • Sayegh E.T.
        • Strauch R.J.
        Open versus endoscopic carpal tunnel release: a meta-analysis of randomized controlled trials.
        Clin Orthop Relat Res. 2015; 473: 1120-1132
        • Trumble T.E.
        • Diao E.
        • Abrams R.A.
        • Gilbert-Anderson M.M.
        Single-portal endoscopic carpal tunnel release compared with open release: a prospective, randomized trial.
        J Bone Joint Surg Am. 2002; 84-A: 1107-1115
        • Kang H.J.
        • Koh I.H.
        • Lee T.J.
        • Choi Y.R.
        Endoscopic carpal tunnel release is preferred over mini-open despite similar outcome: a randomized trial.
        Clin Orthop Relat Res. 2013; 471: 1548-1554
        • Thoma A.
        • Veltri K.
        • Haines T.
        • Duku E.
        A meta-analysis of randomized controlled trials comparing endoscopic and open carpal tunnel decompression.
        Plast Reconstr Surg. 2004; 114: 1137-1146
        • Zhang S.
        • Vora M.
        • Harris A.H.
        • Baker L.
        • Curtin C.
        • Kamal R.N.
        Cost-minimization analysis of open and endoscopic carpal tunnel release.
        J Bone Joint Surg Am. 2016; 98: 1970-1977
        • Foster B.D.
        • Sivasundaram L.
        • Heckmann N.
        • et al.
        Surgical approach and anesthetic modality for carpal tunnel release: a nationwide database study with health care cost implications.
        Hand (N Y). 2017; 12: 162-167
        • Lichtman D.M.
        • Florio R.L.
        • Mack G.R.
        Carpal tunnel release under local anesthesia: evaluation of the outpatient procedure.
        J Hand Surg Am. 1979; 4: 544-546
        • Rozanski M.
        • Neuhaus V.
        • Reddy R.
        • Jupiter J.B.
        • Rathmell J.P.
        • Ring D.C.
        An open-label comparison of local anesthesia with or without sedation for minor hand surgery.
        Hand (N Y). 2014; 9: 399-405
        • Lalonde D.
        • Martin A.
        Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia.
        J Am Acad Orthop Surg. 2013; 21: 443-447
        • Lalonde D.
        • Martin A.
        Tumescent local anesthesia for hand surgery: improved results, cost effectiveness, and wide-awake patient satisfaction.
        Arch Plast Surg. 2014; 41: 312-316
        • Lalonde D.H.
        • Wong A.
        Dosage of local anesthesia in wide awake hand surgery.
        J Hand Surg Am. 2013; 38: 2025-2028
        • Davison P.G.
        • Cobb T.
        • Lalonde D.H.
        The patient's perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study.
        Hand (N Y). 2013; 8: 47-53
        • Rhee P.C.
        • Fischer M.M.
        • Rhee L.S.
        • McMillan H.
        • Johnson A.E.
        Cost savings and patient experiences of a clinic-based, wide-awake hand surgery program at a military medical center: a critical analysis of the first 100 procedures.
        J Hand Surg Am. 2017; 42: e139-e147
        • Leblanc M.R.
        • Lalonde D.H.
        • Thoma A.
        • et al.
        Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery.
        Hand (N Y). 2011; 6: 60-63
        • Leblanc M.R.
        • Lalonde J.
        • Lalonde D.H.
        A detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in canada.
        Hand (N Y). 2007; 2: 173-178
        • Chatterjee A.
        • McCarthy J.E.
        • Montagne S.A.
        • Leong K.
        • Kerrigan C.L.
        A cost, profit, and efficiency analysis of performing carpal tunnel surgery in the operating room versus the clinic setting in the united states.
        Ann Plast Surg. 2011; 66: 245-248
        • Pohlert T.
        The pairwise multiple comparison of mean ranks package (PMCMR).
        (Available at:) (Cited July 1, 2017)
        • Thoma A.
        • Wong V.H.
        • Sprague S.
        • Duku E.
        A cost-utility analysis of open and endoscopic carpal tunnel release.
        Can J Plast Surg. 2006; 14: 15-20
        • American Medical Association
        CPT 2017 Professional Edition. American Medical Association, Chicago2016