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Editor's choice| Volume 44, ISSUE 3, P192-200, March 2019

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Variations in Utilization of Carpal Tunnel Release Among Medicaid Beneficiaries

Published:December 20, 2018DOI:https://doi.org/10.1016/j.jhsa.2018.11.001

      Purpose

      To evaluate the null hypothesis that Medicaid patients receive carpal tunnel release (CTR) at the same time interval from diagnosis as do patients with Medicare Advantage or private insurance.

      Methods

      We conducted a retrospective review using a database containing claims records from 2007 to 2016. The cohort consisted of patient records with a diagnosis code of carpal tunnel syndrome (CTS) and a procedural code for CTR within 3 years of diagnosis. We stratified patients into 3 groups by insurance type (Medicaid managed care, Medicare Advantage, and private) for an analysis of the time from diagnosis until surgery and use of preoperative electrodiagnostic testing.

      Results

      Of all patients who received CTR within 3 years of diagnosis, Medicaid patients experienced longer intervals from CTS diagnosis to CTR compared with Medicare Advantage and privately insured patients (median, 99 days vs 65 and 62 days, respectively). The Medicaid cohort was significantly less likely to receive CTR within 1 year of diagnosis compared with the Medicare Advantage cohort (adjusted odds ratio [OR] = 0.54) or within 6 months of diagnosis compared with the privately insured cohort (adjusted OR = 0.61). Those in the Medicaid cohort were less likely to receive electromyography and nerve conduction studies within 9 months before surgery compared with their Medicare Advantage (adjusted OR = 0.43) and privately insured (adjusted OR = 0.41) counterparts. These effects were statistically significant after accounting for age, sex, region, and Charlson comorbidity index.

      Conclusions

      Medicaid managed care patients experience longer times from diagnosis to surgery compared with Medicare Advantage or privately insured patients in this large administrative claims database. Similar variation exists in the use of electrodiagnostic testing based on insurance type.

      Clinical relevance

      Medicaid patients may experience barriers to CTS care, such as delays from diagnosis to surgery and reduced use of electrodiagnostic testing.

      Key words

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      References

        • Dale A.M.
        • Harris-Adamson C.
        • Rempel D.
        • et al.
        Prevalence and incidence of carpal tunnel syndrome in US working populations: pooled analysis of six prospective studies.
        Scand J Work Environ Health. 2013; 39: 495-505
        • Gerritsen A.M.
        • de Vet H.W.
        • Scholten R.M.
        • Bertelsmann F.W.
        • de Krom M.M.
        • Bouter L.M.
        Splinting vs surgery in the treatment of carpal tunnel syndrome: a randomized controlled trial.
        JAMA. 2002; 288: 1245-1251
        • Huisstede B.M.
        • Randsdorp M.S.
        • Coert J.H.
        • Glerum S.
        • van Middelkoop M.
        • Koes B.W.
        Carpal tunnel syndrome. Part II: effectiveness of surgical treatments—a systematic review.
        Arch Phys Med Rehabil. 2010; 91: 1005-1024
        • MacDermid J.C.
        • Richards R.S.
        • Roth J.H.
        • Ross D.C.
        • King G.J.W.
        Endoscopic versus open carpal tunnel release: a randomized trial.
        J Hand Surg. 2003; 28: 475-480
        • Foley M.
        • Silverstein B.
        • Polissar N.
        The economic burden of carpal tunnel syndrome: long-term earnings of CTS claimants in Washington State.
        Am J Ind Med. 2007; 50: 155-172
      1. Milone MT, Karim A, Klifto CS, Capo JT. Analysis of expected costs of carpal tunnel syndrome treatment strategies [published online ahead of print November 1, 2017]. Hand (N Y). https://doi.org/10.1177/1558944717743597.

        • DeStefano F.
        • Nordstrom D.L.
        • Vierkant R.A.
        Long-term symptom outcomes of carpal tunnel syndrome and its treatment.
        J Hand Surg. 1997; 22: 200-210
        • Jung J.
        • Hahn P.
        • Choi B.
        • Mozaffar T.
        • Gupta R.
        Early surgical decompression restores neurovascular blood flow and ischemic parameters in an in vivo animal model of nerve compression injury.
        J Bone Joint Surg Am. 2014; 96: 897-906
        • Obama B.
        United States health care reform: Progress to date and next steps.
        JAMA. 2016; 316: 525-532
        • Centers for Medicare and Medicaid Services
        December 2017 Medicaid and CHIP Application, Eligibility Determinations, and Enrollment Report.
        (Available at:) (Accessed March 3, 2018)
        • Gates A.
        • Rudowitz R.
        • Artiga S.
        Two year trends in Medicaid and CHIP enrollment data: findings from the CMS Performance Indicator Project.
        (Available at:) (Accessed June 20, 2018)
        • Courtemanche C.
        • Marton J.
        • Ukert B.
        • Yelowitz A.
        • Zapata D.
        Early impacts of the Affordable Care Act on health insurance coverage in Medicaid expansion and non-expansion states.
        J Policy Anal Manage. 2016; 36: 178-210
        • Decker S.L.
        • Lipton B.J.
        • Sommers B.D.
        Medicaid expansion coverage effects grew in 2015 with continued improvements in coverage quality.
        Health Aff (Millwood). 2017; 36: 819-825
        • Medicaid Access Study Group
        Access of Medicaid recipients to outpatient care.
        N Engl J Med. 1994; 330: 1426-1430
        • Asplin B.R.
        • Rhodes K.V.
        • Levy H.
        • et al.
        Insurance status and access to urgent ambulatory care follow-up appointments.
        JAMA. 2005; 294: 1248-1254
        • Bisgaier J.
        • Rhodes K.V.
        Auditing access to specialty care for children with public insurance.
        N Engl J Med. 2011; 364: 2324-2333
        • Cykert S.
        • Kissling G.
        • Layson R.
        • Hansen C.
        Health insurance does not guarantee access to primary care.
        J Gen Intern Med. 1995; 10: 345-348
        • Oostrom T.
        • Einav L.
        • Finkelstein A.
        Outpatient office wait times and quality of care for Medicaid patients.
        Health Aff (Millwood). 2017; 36: 826-832
        • McMorrow S.
        • Long S.K.
        • Fogel A.
        Primary care providers ordered fewer preventive services for women with Medicaid than for women with private coverage.
        Health Aff (Millwood). 2015; 34: 1001-1009
        • Chaudhry S.B.
        • Armbrecht E.S.
        • Shin Y.
        • et al.
        Pediatric access to dermatologists: Medicaid versus private insurance.
        J Am Acad Dermatol. 2013; 68: 738-748
        • Hwang A.H.
        • Hwang M.M.
        • Xie H.-W.
        • Hardy B.E.
        • Skaggs D.L.
        Access to urologic care for children in California: Medicaid versus private insurance.
        Urology. 2005; 66: 170-173
        • Skaggs D.L.
        • Clemens S.M.
        • Vitale M.G.
        • Femino J.D.
        • Kay R.M.
        Access to orthopedic care for children with Medicaid versus private insurance in California.
        Pediatrics. 2001; 107: 1405-1408
        • Skaggs D.L.
        • Lehmann C.L.
        • Rice C.
        • et al.
        Access to orthopaedic care for children with Medicaid versus private insurance: results of a national survey.
        J Pediatr Orthop. 2006; 26: 400-404
        • Pierce T.R.
        • Mehlman C.T.
        • Tamai J.
        • Skaggs D.L.
        Access to care for the adolescent anterior cruciate ligament patient with Medicaid versus private insurance.
        J Pediatr Orthop. 2012; 32: 245-248
        • Patterson B.M.
        • Draeger R.W.
        • Olsson E.C.
        • Spang J.T.
        • Lin F.-C.
        • Kamath G.V.
        A regional assessment of Medicaid access to outpatient orthopaedic care: the influence of population density and proximity to academic medical centers on patient access.
        J Bone Joint Surg Am. 2014; 96e156
        • Labrum J.T.
        • Paziuk T.
        • Rihn T.C.
        • et al.
        Does Medicaid insurance confer adequate access to adult orthopaedic care in the era of the patient protection and Affordable Care Act?.
        Clin Orthop Relat Res. 2017; 475: 1527-1536
        • Draeger R.W.
        • Patterson B.M.
        • Olsson E.C.
        • Schaffer A.
        • Patterson J.M.M.
        The influence of patient insurance status on access to outpatient orthopedic care for flexor tendon lacerations.
        J Hand Surg Am. 2014; 39: 527-533
        • Patterson B.M.
        • Spang J.T.
        • Draeger R.W.
        • Olsson E.C.
        • Creighton R.A.
        • Kamath G.V.
        Access to outpatient care for adult rotator cuff patients with private insurance versus Medicaid in North Carolina.
        J Shoulder Elbow Surg. 2013; 22: 1623-1627
        • Kim C.-Y.
        • Wiznia D.H.
        • Hsiang W.R.
        • Pelker R.R.
        The effect of insurance type on patient access to knee arthroplasty and revision under the Affordable Care Act.
        J Arthroplasty. 2015; 30: 1498-1501
        • Kim C.-Y.
        • Wiznia D.H.
        • Wang Y.
        • et al.
        The effect of insurance type on patient access to carpal tunnel release under the Affordable Care Act.
        J Hand Surg. 2016; 41 (503.e1–509.e1)
        • Nau H.-E.
        • Lange B.
        • Lange S.
        Prediction of outcome of decompression for carpal tunnel syndrome.
        J Hand Surg Br. 1988; 13: 391-394
        • Mühlau G.
        • Both R.
        • Kunath H.
        Carpal tunnel syndrome—course and prognosis.
        J Neurol. 1984; 231: 83-86
        • Bland J.D.P.
        Do nerve conduction studies predict the outcome of carpal tunnel decompression?.
        Muscle Nerve. 2001; 24: 935-940
        • Charlson M.
        • Szatrowski T.P.
        • Peterson J.
        • Gold J.
        Validation of a combined comorbidity index.
        J Clin Epidemiol. 1994; 47: 1245-1251
        • Adamson A.S.
        • Zhou L.
        • Baggett C.D.
        • Thomas N.E.
        • Meyer A.
        Association of delays in surgery for melanoma with insurance type.
        JAMA Dermatol. 2017; 153: 1106-1113
        • Kaplan S.J.
        • Glickel S.Z.
        • Eaton R.G.
        Predictive factors in the non-surgical treatment of carpal tunnel syndrome.
        J Hand Surg Br. 1990; 15: 106-108
        • Choi S.
        • Ahn D.
        Correlation of clinical history and electrodiagnostic abnormalities with outcome after surgery for carpal tunnel syndrome.
        Plast Reconstr Surg. 1998; 102: 2374-2380
        • Chandra P.S.
        • Singh P.K.
        • Goyal V.
        • Chauhan A.K.
        • Thakkur N.
        • Tripathi M.
        Early versus delayed endoscopic surgery for carpal tunnel syndrome: prospective randomized study.
        World Neurosurg. 2013; 79: 767-772
        • Graham B.
        The value added by electrodiagnostic testing in the diagnosis of carpal tunnel syndrome.
        J Bone Joint Surg Am. 2008; 90: 2587-2593
        • Finsen V.
        • Russwurm H.
        Neurophysiology not required before surgery for typical carpal tunnel syndrome.
        J Hand Surg Br. 2001; 26: 61-64
        • Smith N.
        Nerve conduction studies for carpal tunnel syndrome: essential prelude to surgery or unnecessary luxury?.
        J Hand Surg Br. 2002; 27: 83-85
        • Weissman J.S.
        • Stern R.
        • Fielding S.L.
        • Epstein A.M.
        Delayed access to health care: risk factors, reasons, and consequences.
        Ann Intern Med. 1991; 114: 325-331
        • Calfee R.P.
        • Shah C.M.
        • Canham C.D.
        • Wong A.H.
        • Gelberman R.H.
        • Goldfarb C.A.
        The influence of insurance status on access to and utilization of a tertiary hand surgery referral center.
        J Bone Joint Surg Am. 2012; 94: 2177-2184
        • Pugely A.J.
        • Martin C.T.
        • Harwood J.
        • Ong K.L.
        • Bozic K.J.
        • Callaghan J.J.
        Database and registry research in orthopaedic surgery: Part I: claims-based data.
        J Bone Joint Surg Am. 2015; 97: 1278-1287
        • Kandil A.
        • Werner B.C.
        • Gwathmey W.F.
        • Browne J.A.
        Obesity, morbid obesity and their related medical comorbidities are associated with increased complications and revision rates after unicompartmental knee arthroplasty.
        J Arthroplasty. 2015; 30: 456-460
        • Centers for Medicare and Medicaid Services
        Medicaid managed care enrollment and program characteristics.
        (Available at:) (Accessed February 18, 2018)
        • Sisk J.E.
        • Gorman S.A.
        • Reisinger A.
        • Glied S.A.
        • DuMouchel W.H.
        • Hynes M.M.
        Evaluation of medicaid managed care: satisfaction, access, and use.
        JAMA. 1996; 276: 50-55
        • Ayanian J.Z.
        • Kohler B.A.
        • Abe T.
        • Epstein A.M.
        The relation between health insurance coverage and clinical outcomes among women with breast cancer.
        N Engl J Med. 1993; 329: 326-331
        • Ward E.
        • Halpern M.
        • Schrag N.
        • et al.
        Association of insurance with cancer care utilization and outcomes.
        CA Cancer J Clin. 2008; 58: 9-31
        • Canto J.G.
        • Rogers W.J.
        • French W.J.
        • et al.
        Payer status and the utilization of hospital resources in acute myocardial infarction: a report from the National Registry of Myocardial Infarction 2.
        Arch Intern Med. 2000; 160: 817-823
        • Sada M.J.
        • French W.J.
        • Carlisle D.M.
        • Chandra N.C.
        • Gore J.M.
        • Rogers W.J.
        Influence of payor on use of invasive cardiac procedures and patient outcome after myocardial infarction in the United States.
        J Am Coll Cardiol. 1998; 31: 1474-1480
        • Hinman A.
        • Bozic K.J.
        Impact of payer type on resource utilization, outcomes and access to care in total hip arthroplasty.
        J Arthroplasty. 2008; 23: 9-14
        • Browne J.A.
        • Novicoff W.M.
        • D’Apuzzo M.R.
        Medicaid payer status is associated with in-hospital morbidity and resource utilization following primary total joint arthroplasty.
        J Bone Joint Surg Am. 2014; 96e180
        • Sabesan V.J.
        • Petersen-Fitts G.
        • Lombardo D.
        • Briggs D.
        • Whaley J.
        Medicaid payer status is linked to increased rates of complications after treatment of proximal humerus fractures.
        J Shoulder Elbow Surg. 2016; 26: 948-953
        • Xu H.F.
        • White R.S.
        • Sastow D.L.
        • Andreae M.H.
        • Gaber-Baylis L.K.
        • Turnbull Z.A.
        Medicaid insurance as primary payer predicts increased mortality after total hip replacement in the state inpatient databases of California, Florida and New York.
        J Clin Anesth. 2017; 43: 24-32