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Cost Drivers in Carpal Tunnel Release Surgery: An Analysis of 8,717 Patients in New York State

Published:December 27, 2021DOI:https://doi.org/10.1016/j.jhsa.2021.10.022

      Purpose

      The annual high volume of carpal tunnel releases (CTRs) has a large financial impact on the health care system. Validating the cost drivers related to CTR in a large, diverse patient population may aid in developing cost reduction strategies to benefit health care systems.

      Methods

      Adult patients with carpal tunnel syndrome who underwent CTR were identified in the New York Statewide Planning and Research Cooperative System database from 2016 to 2017. The Statewide Planning and Research Cooperative System is a comprehensive all-payer database that collects all inpatient and outpatient preadjudicated claims in New York. A multivariable mixed model regression with random effects was performed for the facility to assess the variables that contributed significantly to the total charge. The variables included were patient age, sex, anesthesia method, whether the surgery took place in an ambulatory surgery center or a hospital outpatient department, operation time in minutes, primary insurance type, race, ethnicity, Charlson Comorbidity Index, and categories for billed procedure codes.

      Results

      During the period of 2016 to 2017, 8,717 claims were included, with a mean charge per claim of $4,865. General anesthesia was associated with higher charges than local anesthesia. A procedure at a hospital outpatient department was associated with an approximately 48.2% increase in the total charge compared with that at an ambulatory surgery center. A 1-minute increase in the operation time was associated with a 0.3% increase in the total charge. Claims with antiemetics, antihistamines, benzodiazepines, intravenous fluids, narcotic agents, or preoperative antibiotics were associated with higher total charges than claims that did not bill for these. Compared with endoscopic procedures, open procedures had a 44.3% decrease in the total charges.

      Conclusions

      This comprehensive multivariable model has validated that general anesthesia, hospital-based surgery, the use of antibiotics and opioids, longer operative times, and endoscopic CTR significantly increased the cost of surgery.

      Type of study/level of evidence

      Economic and decision analyses II.

      Key words

      Carpal tunnel syndrome (CTS) is the most common upper extremity neuropathy that is present in nearly 4% of the population.
      • Aboonq M.S.
      Pathophysiology of carpal tunnel syndrome.
      Although CTS is initially treated nonsurgically, many patients ultimately undergo surgical management to relieve their symptoms. Over 600,000 carpal tunnel releases (CTRs) are performed annually in the United States, creating a large financial and economic impact.
      • Hubbard Z.S.
      • Law T.Y.
      • Rosas S.
      • Jernigan S.C.
      • Chim H.
      Economic benefit of carpal tunnel release in the medicare patient population.
      When considering the Medicare population alone, estimates of the economic impact in the United States are nearly $5 billion per year, with release providing close to $1.6 billion in economic benefit.
      • Hubbard Z.S.
      • Law T.Y.
      • Rosas S.
      • Jernigan S.C.
      • Chim H.
      Economic benefit of carpal tunnel release in the medicare patient population.
      There has been a recent emphasis by payers on minimizing costs in the setting of value-based health care models. Given the proportion of patients undergoing CTR, reducing the total costs can have substantial financial implications. Understanding the cost drivers associated with CTR is imperative in minimizing the cost of the procedure.
      Several recent studies have been published regarding the costs of CTR.
      • Kazmers N.H.
      • Presson A.P.
      • Xu Y.
      • Howenstein A.
      • Tyser A.R.
      Cost implications of varying the surgical technique, surgical setting, and anesthesia type for carpal tunnel release surgery.
      • Alter T.H.
      • Warrender W.J.
      • Liss F.E.
      • Ilyas A.M.
      A cost analysis of carpal tunnel release surgery performed wide awake versus under sedation.
      • Carr L.W.
      • Morrow B.
      • Michelotti B.
      • Hauck R.M.
      Direct cost comparison of open carpal tunnel release in different venues.
      • White M.
      • Parikh H.R.
      • Wise K.L.
      • Vang S.
      • Ward C.M.
      • Cunningham B.P.
      Cost savings of carpal tunnel release performed in-clinic compared to an ambulatory surgery center: time-driven activity-based-costing.
      • 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.
      • Koehler D.M.
      • Balakrishnan R.
      • Lawler E.A.
      • Shah A.S.
      Endoscopic versus open carpal tunnel release: a detailed analysis using time-driven activity-based costing at an academic medical center.
      Reduced costs were associated with open CTR, surgeries performed under local anesthesia, and surgeries performed in the ambulatory surgery centers (ASCs). However, most of these studies were conducted with smaller, single institution cohorts and may not be generalizable to the US population. 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.
      investigated CTR costs using the PearlDiver database, but they only considered the costs associated with the surgical technique, procedure setting, and anesthetic modality. They did not assess other potential cost drivers such as materials and medications used during surgery, and their database was limited to a single payer. Although several studies have characterized the cost drivers of CTR, none have evaluated them on a granular multivariable level.
      The purpose of the present study was to provide a contemporary update and validate the cost drivers of CTR set forth by previous studies using a comprehensive multivariable model in New York state that may be generalizable to the United States overall.
      United States Census Bureau
      ACS Demographic and Housing Estimates.
      Using the New York Statewide Planning and Research Cooperative System (SPARCS) database, we aimed to simultaneously analyze a variety of factors that could have an impact on costs, including surgical venue, the type of anesthesia, method of CTR, and antibiotic administration. By defining the cost associated with each factor, we aimed to propose strategies to reduce the total health care dollars spent on treating CTS.

      Materials and Methods

      Adult patients (18 years and older) were identified in the New York SPARCS database from 2016 to 2017. SPARCS is a comprehensive all-payer database that collects all inpatient and outpatient preadjudicated claims in New York. This includes all International Classification of Diseases diagnosis codes and International Classification of Diseases/Current Procedural Terminology (CPT) procedure codes associated with all visits.
      Claims in the outpatient setting were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification and International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for CTS (G56.01, G56.02, G56.03). The patients included in the analysis had a primary diagnosis of CTS to avoid more complex cases that would have increased charges. Claims were then further filtered for carpal tunnel surgery (CPT codes 64721, 29848).

      Statistical analyses

      A multivariable mixed model regression with random effects was performed for the facility to assess the variables that contributed significantly to the total charge of the claim. The total charge was modeled as the natural logarithm of the total charge. The variables included in the regression were patient age, sex, anesthesia method, whether the surgery took place in an ASC or a hospital outpatient department, operation time in minutes, primary insurance type, race, ethnicity, Charlson Comorbidity Index (CCI), and categories for billed procedure codes. For example, the coding for penicillin use was categorized as “antibiotic” in the model. The CCI was calculated using the method described by Deyo et al
      • Deyo R.A.
      • Cherkin D.C.
      • Ciol M.A.
      Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.
      and extended to International Classification of Diseases, Tenth Revision, Clinical Modification. The CCI was dichotomized to a score of 0 versus ≥1.
      Outliers for operation time in minutes were removed. A lower limit was set at 5 minutes, and an upper limit was set at Q3 + 1.5 ∗ IQR, where the equation is the calculation for the upper limit of estimation; Q3 is the third quartile (75th percentile); and IQR is the interquartile range (75th–25th percentile). Once these outliers were removed, to avoid modeling outlier charges, we used 80% the average charge reported by Medicare for CPT 29848 and 64721 in each year in New York.

      Centers for Medicare & Medicaid Services. Search the Physician Fee Schedule | CMS. Accessed November 24, 2021. https://www.cms.gov/medicare/physician-fee-schedule/search

      These lower bounds were applied to the charges before they were adjusted for inflation. After charges were adjusted for inflation, an upper bound was set at Q3 + 1.5 ∗ IQR for the billed charges. All claims that had a procedure code category with less than 10 occurrences were excluded because of the lesser likelihood that those categories can be reliably modeled.
      P values were adjusted using the false discovery rate method. An adjusted P value of <.05 was considered significant for all statistical analyses.

      Results

      After searching for a primary diagnosis of CTS, 8,717 CTR claims were included from 2016 to 2017. The median charge per claim was $4,162, with a mean of $4,865. The maximum total charge amount included in the analysis was $14,386. Women significantly outnumbered men (P < .0001). Most patients did not have a qualifying comorbidity at the time of surgery. The median time in the operating room was 28 minutes, with a mean of 30 minutes and a maximum of 72 minutes (Table 1).
      Table 1Patient Demographics and Characteristics
      DemographicsValue (N = 8,717)
      Total charge, median (mean, SD)$4,162.19 ($4,865.21, $3,179.58)
      Age (y), median (mean, SD)58 (58.67, 14.97)
      Operation time in min, median, (mean, SD)28 (30.07, 13.97)
      Sex, n (%)
       Female5,423 (62.2)
       Male3,294 (37.8)
      Race, n (%)
       White6,841 (78.5)
       Asian67 (0.8)
       African-American644 (7.4)
       Multiracial141 (1.6)
       Other1,024 (11.8)
      Primary insurance, n (%)
       Private4,021 (46.1)
       Federal3,665 (42)
       Worker’s compensation975 (11.2)
       Self-pay56 (0.6)
      Charlson score, n (%)
       07,305 (83.8)
       ≥11,412 (16.2)
      Primary procedure
       Endoscopic2,889 (33.1)
       Open5,828 (66.9)
      Figure 1 shows that the health service areas in southern New York have average charges that differ by upward of $6,000 compared with those in western New York. The most expensive region was the health service area 8 at $8,606 per average claim, whereas the least expensive was health service area 1 at $2,378 (Fig. 1).
      Figure thumbnail gr1
      Figure 1Average carpal tunnel surgery charge by health service area in New York state. Breakdown of the cities in each health service area is included in (available online on the Journal’s website at www.jhandsurg.org).
      The CPT code 64721 was the dominant procedure with approximately 66.9% cases (Table 1). Besides the primary CPT codes, the top 3 most common procedure code categories were the administration of benzodiazepines (36.2% of cases), antiemetic agents (24.1% of cases), and preoperative antibiotics (20.3% of cases). Most cases were performed at a hospital outpatient department (54.7%) as opposed to an ASC. Local anesthesia was the most common method of anesthesia accounting for 47.7% of cases (Table 2).
      Table 2Predictors for Total Billed Amount for Carpal Tunnel Surgery
      VariableTotal Number, N = 8,717 (%)Estimate (95% CI)Standard ErrorP Value
      Age-−0.1% (−0.1% to 0%)0.0002<.05
      Statistically significant.
      Female patients
      Compared with male patients.
      5,423 (62.2)−0.5% (−1.5% to −0.6%)0.0054.52
      Anesthesia method
      Compared with local anesthesia.
       General3,088 (35.4)3.6% (1.7% to −5.5%)0.0098<.05
      Statistically significant.
       Regional1,471 (16.9)−1.4% (−3.6% to −0.8%)0.0111.33
      Hospital outpatient department
      Compared with ASC.
      4,767 (54.7)48.2% (27.7% to −68.6%)0.1043<.05
      Statistically significant.
      Operation time (min)-0.3% (0.3% to −0.4%)0.0002<.05
      Statistically significant.
      Primary payer
      Compared with private primary insurance.
       Federal3,665 (42)1.3% (0.1% to −2.5%)0.0061.07
       Self-pay56 (0.6)−3.5% (−10.1% to −3.2)0.0338.47
       Worker’s compensation975 (11.2)−1.1% (−3.4% to −1.3%)0.012.52
      Comorbidities
       CCI ≥ 1
      Compared with CCI = 0, the recorded CCI does not include age as a risk factor.
      1,412 (16.2)1.6% (0% to −3.2%)0.008.09
      Race
      Compared with White race.
       Asian67 (0.8)−0.3% (−6.1% to −5.6%)0.0299.97
       African-American644 (7.4)0.6% (−1.5% to −2.6%)0.0105.72
       Multiracial141 (1.6)0% (−6.1% to −6%)0.031.99
       Other1,024 (11.8)−1.5% (−3.4% to −0.4%)0.0096.21
      Procedure code categories
       Adrenergic agonist57 (0.7)7.1% (0.8% to −13.4%)0.0321.06
       Anticoagulant agent14 (0.2)3.5% (−10.1% to −17%)0.0691.72
       Antiemetic agent2,098 (24.1)2.5% (0.7% to −4.4%)0.0093<.05
      Statistically significant.
       Antihistamine agent94 (1.1)8% (3% to −13.1%)0.0257<.05
      Statistically significant.
       Benzodiazepine3,156 (36.2)2.6% (0.7% to −4.5%)0.0097<.05
      Statistically significant.
       Blood collection159 (1.8)2% (−3% to −7%)0.0256.57
       Clotting factor79 (0.9)2.5% (−3.3% to −8.3%)0.0297.56
       Electrocardiogram70 (0.8)7.6% (1.7% to −13.5%)0.03.03
       Hormone13 (0.2)4.9% (−8.2% to −18%)0.0668.60
       Bronchodilator40 (0.5)−2.3% (−10.2% to −5.5%)0.0399.70
       Intravenous fluids1,260 (14.5)6.5% (3.6% to −9.4%)0.0146<.05
      Statistically significant.
       Laboratories1,094 (12.6)1.5% (−0.3% to −3.4%)0.0094.19
       Narcotic241 (2.8)6.7% (3.3% to −10%)0.0172<.05
      Statistically significant.
       Nonsteroid/narcotic pain agents1,165 (13.4)2.1% (0.1% to −4%)0.0098.08
       Preoperative antibiotics1,766 (20.3)4.4% (2.5% to −6.2%)0.0094<.05
      Statistically significant.
       Recovery supplies36 (0.4)−6.2% (−15% to −2.7%)0.0453.30
       Sedation services71 (0.8)25.7% (−16.7% to −68%)0.2161.38
       Steroid954 (10.9)3.8% (1.7% to −5.9%)0.0108<.05
      Statistically significant.
       Miscellaneous equipment118 (1.4)6.8% (1.5% to −12.1%)0.027<.05
      Statistically significant.
       Unclassified drugs689 (7.9)−0.3% (−3.8% to −3.1%)0.0176.96
      Primary procedure code
      Compared with endoscopic surgery.
       Open surgery5,828 (66.9)−44.3% (−45.8% to −42.9%)0.0073<.05
      Statistically significant.
      Compared with male patients.
      Compared with local anesthesia.
      Compared with ASC.
      § Compared with private primary insurance.
      Compared with CCI = 0, the recorded CCI does not include age as a risk factor.
      Compared with White race.
      # Compared with endoscopic surgery.
      ∗∗ Statistically significant.
      General anesthesia was associated with higher charges than local or regional anesthesia. A procedure performed at a hospital’s outpatient department was associated with an approximately 48.2% increase in the total charge amount compared with that performed at an ASC. A 1-minute increase in the operation time was associated with a 0.3% increase in the total charge. In terms of the drugs used, claims with antiemetics, antihistamines, benzodiazepines, intravenous fluids, narcotic agents, or preoperative antibiotics were associated with higher total charge amounts than the claims that did not account for them. Compared with endoscopic procedures, open procedures had significantly less charges at a 44.3% reduction. Figure 2 demonstrates that an open CTS has total charge amounts distributed toward lower charges than that of an endoscopic CTS (Fig. 2).
      Figure thumbnail gr2
      Figure 2Distribution of total claim charges and average charges in endoscopic (above) and open (below) carpal tunnel releases.

      Discussion

      Carpal tunnel release surgery is one of the most common hand procedures performed in the United States; therefore, it is associated with a substantial financial impact on the health care system, given the sheer volume of surgeries.
      • Hubbard Z.S.
      • Law T.Y.
      • Rosas S.
      • Jernigan S.C.
      • Chim H.
      Economic benefit of carpal tunnel release in the medicare patient population.
      We determined a mean $4,865 per procedure in a large, diverse population in the New York SPARCS database. The mean cost varied tremendously based on the region of New York, from $2,378 in western New York to $8,606 in the area surrounding Manhattan. This is likely because of the higher cost of living in New York City than in the rest of the state and the country overall. Services and goods are typically more expensive in the northeastern region, and medical costs are not exempt from this trend.
      • Nejim B.J.
      • Wang S.
      • Arhuidese I.
      • et al.
      Regional variation in the cost of infrainguinal lower extremity bypass surgery in the United States.
      Using a comprehensive multivariable approach, we found several statistically significant cost drivers in our database evaluation that serve as validation of previous studies regarding CTS cost, including the use of general anesthesia, hospital-based surgery, operative time, endoscopic release, antibiotic use, narcotic use and the additional use of adrenergic agonists, antiemetics, antihistamines, benzodiazepines, and intravenous fluids (Table 2). We believe that by using a comprehensive multivariable approach simultaneously accounting for all materials, the operation room time, and procedures used in the operating room, we have been able to validate, update, and more accurately describe the marginal effects of these cost drivers of CTR as the accuracy of the magnitude of cost savings is likely to play an integral role in economic decision-making. Furthermore, this provides the opportunity to ordinally rank cost drivers by their magnitude of effect with respect to one another. This study validates the choice of anesthesia to be a significant cost driver for CTR as the use of general anesthesia has previously been shown to cost more than local or regional anesthesia due to the additional costs of medications and the time and expertise of the anesthesiologist.
      • Kazmers N.H.
      • Presson A.P.
      • Xu Y.
      • Howenstein A.
      • Tyser A.R.
      Cost implications of varying the surgical technique, surgical setting, and anesthesia type for carpal tunnel release surgery.
      ,
      • 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.
      In addition to the lower cost, there is evidence that the use of wide-awake local anesthesia no tourniquet technique has similar postoperative pain control and patient satisfaction compared with general or monitored anesthesia care anesthesia.
      • Aultman H.
      • Roth C.A.
      • Curran J.
      • et al.
      Prospective evaluation of surgical and anesthetic technique of carpal tunnel release in an orthopedic practice.
      The use of antiemetics, antihistamines, benzodiazepines, and intravenous fluids are also associated with the use of general anesthesia; thus, these costs could be eliminated with the decreased use of general anesthetic. With the lower cost and equivalent outcomes, an increase in local-only anesthesia use beyond the 47.7% rate we found could help decrease costs.
      • Aultman H.
      • Roth C.A.
      • Curran J.
      • et al.
      Prospective evaluation of surgical and anesthetic technique of carpal tunnel release in an orthopedic practice.
      Nevertheless, we understand that there are barriers to achieving this, such as patient expectations and tolerance of wide-awake local anesthesia no tourniquet, so this decision will likely still need to be made on a patient-to-patient basis.
      Hospital-based surgery was found to cost 48.2% more on average than ASC-based surgery and had the largest marginal effect on cost of all the variables modeled, thus providing the greatest opportunity to reduce costs in CTR. This also serves as validation of prior studies on CTR and other small hand surgeries.
      • Kazmers N.H.
      • Presson A.P.
      • Xu Y.
      • Howenstein A.
      • Tyser A.R.
      Cost implications of varying the surgical technique, surgical setting, and anesthesia type for carpal tunnel release surgery.
      ,
      • White M.
      • Parikh H.R.
      • Wise K.L.
      • Vang S.
      • Ward C.M.
      • Cunningham B.P.
      Cost savings of carpal tunnel release performed in-clinic compared to an ambulatory surgery center: time-driven activity-based-costing.
      ,
      • Gillis J.A.
      • Williams J.G.
      Cost analysis of percutaneous fixation of hand fractures in the main operating room versus the ambulatory setting.
      Along that trend, office-based procedures have shown an even greater reduction in cost than those in ASCs. Using time-driven activity-based costing, White et al
      • White M.
      • Parikh H.R.
      • Wise K.L.
      • Vang S.
      • Ward C.M.
      • Cunningham B.P.
      Cost savings of carpal tunnel release performed in-clinic compared to an ambulatory surgery center: time-driven activity-based-costing.
      demonstrated that ASC procedures using monitored anesthesia care + local anesthesia cost approximately 3.5 times more and took approximately 3 times longer than office-based procedures with wide-awake local anesthesia no tourniquet technique, with equivalent postoperative pain scores. Hospital-based surgery is associated with higher costs for several reasons, including slower turnover time, more operating room and perioperative staff, and more equipment used. Our study explicitly characterizes cost as a function of operating room time and found that increased time in the operating room increased the overall costs, which corresponds to the higher costs of hospital-based surgery.
      Additionally, we found open CTR was associated with 44.3% lower charges than endoscopic procedures on average, which is consistent with most of the literature.
      • Kazmers N.H.
      • Presson A.P.
      • Xu Y.
      • Howenstein A.
      • Tyser A.R.
      Cost implications of varying the surgical technique, surgical setting, and anesthesia type for carpal tunnel release surgery.
      ,
      • 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.
      ,
      • Koehler D.M.
      • Balakrishnan R.
      • Lawler E.A.
      • Shah A.S.
      Endoscopic versus open carpal tunnel release: a detailed analysis using time-driven activity-based costing at an academic medical center.
      Both open and endoscopic CTRs are viable options for CTR, with long-term outcomes showing equivalent symptomatic relief, pinch and grip strength, complications, and outcomes scores for both open and endoscopic releases in several studies.
      • Koehler D.M.
      • Balakrishnan R.
      • Lawler E.A.
      • Shah A.S.
      Endoscopic versus open carpal tunnel release: a detailed analysis using time-driven activity-based costing at an academic medical center.
      ,
      • Thoma A.
      • Veltri K.
      • Haines T.
      • Duku E.
      A meta-analysis of randomized controlled trials comparing endoscopic and open carpal tunnel decompression.
      • Atroshi I.
      • Hofer M.
      • Larsson G.U.
      • Ranstam J.
      Extended follow-up of a randomized clinical trial of open vs endoscopic release surgery for carpal tunnel syndrome.
      • 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.
      • Michelotti B.
      • Romanowsky D.
      • Hauck R.M.
      Prospective, randomized evaluation of endoscopic versus open carpal tunnel release in bilateral carpal tunnel syndrome: an interim analysis.
      However, more recent evidence from a large database study showed an increased rate of revision surgery within 1 year after endoscopic CTR.
      • Wessel L.E.
      • Gu A.
      • Asadourian P.A.
      • Stepan J.G.
      • Fufa D.T.
      • Osei D.A.
      The epidemiology of carpal tunnel revision over a 1-year follow-up period.
      Overall, most hand surgeons favor an open CTR, whereas only 36% of surgeons primarily use endoscopic release.
      • Leinberry C.F.
      • Rivlin M.
      • Maltenfort M.
      • et al.
      Treatment of carpal tunnel syndrome by members of the American Society for Surgery of the Hand: a 25-year perspective.
      Nevertheless, each approach has significantly different costs. Recent estimates of average annual reimbursement are over $1,700 in open CTR and over $2,500 in endoscopic CTR, which is consistent with our findings.
      • Zhang S.
      • Vora M.
      • Harris A.H.S.
      • Baker L.
      • Curtin C.
      • Kamal R.N.
      Cost-minimization analysis of open and endoscopic carpal tunnel release.
      Endoscopic releases require more equipment which must be set up and cleaned, increasing time and costs. The disposable endoscopic blade assembly alone costs $217 on average.
      • Koehler D.M.
      • Balakrishnan R.
      • Lawler E.A.
      • Shah A.S.
      Endoscopic versus open carpal tunnel release: a detailed analysis using time-driven activity-based costing at an academic medical center.
      Despite these increased costs and similar long-term outcomes, there are prospective, randomized trials showing an earlier return to work and better early (<3 months) improvement in scar tenderness, pinch strength, and subjective satisfaction in those undergoing endoscopic release.
      • Koehler D.M.
      • Balakrishnan R.
      • Lawler E.A.
      • Shah A.S.
      Endoscopic versus open carpal tunnel release: a detailed analysis using time-driven activity-based costing at an academic medical center.
      ,
      • 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.
      ,
      • Michelotti B.
      • Romanowsky D.
      • Hauck R.M.
      Prospective, randomized evaluation of endoscopic versus open carpal tunnel release in bilateral carpal tunnel syndrome: an interim analysis.
      ,
      • Miles M.R.
      • Shetty P.N.
      • Bhayana K.
      • Yousaf I.S.
      • Sanghavi K.K.
      • Giladi A.M.
      Early outcomes of endoscopic versus open carpal tunnel release.
      These results evened out after 3 months, and both approaches maintained their clinical improvements at a mean of 12.8 years after surgery in the study by Atroshi et al.
      • Atroshi I.
      • Hofer M.
      • Larsson G.U.
      • Ranstam J.
      Extended follow-up of a randomized clinical trial of open vs endoscopic release surgery for carpal tunnel syndrome.
      These early benefits may be important for particular subsets of patients, and the increased costs associated with endoscopic release need to be weighed against these benefits.
      By controlling for all materials used, our study characterized increased costs of perioperative antibiotics in CTR. There is abundant evidence that perioperative antibiotics do not affect surgical site infection rates in clean hand surgery, even in patients with diabetes.
      • Johnson S.P.
      • Zhong L.
      • Chung K.C.
      • Waljee J.F.
      Perioperative antibiotics for clean hand surgery: a national study.
      • Harness N.G.
      • Inacio M.C.
      • Pfeil F.F.
      • Paxton L.W.
      Rate of infection after carpal tunnel release surgery and effect of antibiotic prophylaxis.
      • Li K.
      • Sambare T.D.
      • Jiang S.Y.
      • Shearer E.J.
      • Douglass N.P.
      • Kamal R.N.
      Effectiveness of preoperative antibiotics in preventing surgical site infection after common soft tissue procedures of the hand.
      Despite this, 20.3% of the patients in this study received perioperative antibiotics, which is higher than those in other studies of clean hand surgery (11% and 13.6%).
      • Johnson S.P.
      • Zhong L.
      • Chung K.C.
      • Waljee J.F.
      Perioperative antibiotics for clean hand surgery: a national study.
      ,
      • Li K.
      • Sambare T.D.
      • Jiang S.Y.
      • Shearer E.J.
      • Douglass N.P.
      • Kamal R.N.
      Effectiveness of preoperative antibiotics in preventing surgical site infection after common soft tissue procedures of the hand.
      Given the nature of our study, we were unable to evaluate the presence of immunocompromised status or other circumstances surrounding each decision to give antibiotics; however, the routine use of perioperative antibiotics in clean hand surgery does not improve outcomes and increases costs and potential complications related to medication side effects (eg, Clostridium difficile or selection of drug-resistant bacteria). The decision to administer preoperative antibiotics should weigh the risks and benefits for each patient.
      The use of opioid medications was also associated with increased costs, likely due to the physical cost of the medication in the operating room and perioperative period. Although the direct costs of opioid administration during CTR could be estimated in the current study, the emergence of public health and more widespread societal costs of chronic opioid dependence in the United States are important to consider. The routine use of opioid medications for postoperative pain is losing favor because of the risks of dependence and emerging state regulations.
      • Reid D.B.C.
      • Shah K.N.
      • Shapiro B.H.
      • Ruddell J.H.
      • Akelman E.
      • Daniels A.H.
      Mandatory prescription limits and opioid utilization following orthopaedic surgery.
      • Reid D.B.C.
      • Shah K.N.
      • Shapiro B.H.
      • et al.
      Opioid-limiting legislation associated with reduced postoperative prescribing after surgery for traumatic orthopaedic injuries.
      • Reid D.B.C.
      • Patel S.A.
      • Shah K.N.
      • et al.
      Opioid-limiting legislation associated with decreased 30-day opioid utilization following anterior cervical decompression and fusion.
      • Shah K.N.
      • Ruddell J.H.
      • Reid D.B.C.
      • et al.
      Opioid-limiting regulation: effect on patients undergoing knee and shoulder arthroscopy.
      There is clear evidence that opioids do not improve postoperative pain control compared with acetaminophen and ibuprofen. In a prospective randomized double-blinded trial, Ilyas et al
      • Ilyas A.M.
      • Miller A.J.
      • Graham J.G.
      • Matzon J.L.
      Pain management after carpal tunnel release surgery: a prospective randomized double-blinded trial comparing acetaminophen, ibuprofen, and oxycodone.
      demonstrated postoperative pain control was not significantly different between patients receiving an opioid, acetaminophen, or ibuprofen following both open and endoscopic CTR, with patients receiving opioids actually trending toward higher pain scores. Four of the 5 complications also occurred in the opioid group with minor side effects. Even if opioids are prescribed, other studies show that the number of pills actually taken by patients is less than that prescribed and for a shorter number of days.
      • Miller A.
      • Kim N.
      • Ilyas A.M.
      Prospective evaluation of opioid consumption following hand surgery performed wide awake versus with sedation.
      Overall, this is an area of potential cost reduction and public health improvement by decreasing the amount of prescribed opioids.
      The strengths of our study are that this is a large, economically diverse patient population that allowed for the evaluation of numerous cost variables in open and endoscopic CTRs. The limitations are that it is a retrospective study, and the nature of the database prevents the evaluation of the details and circumstances surrounding each case and decision. There is also the possibility that the data documented in the database are incomplete. For example, the recorded percentage of patients with a CCI of >1, excluding age, was only 16.2% in a population, with a median age of 58 years, which is low, given that the age of more than 50 years itself is worth at least 1 point. It is possible that noncontributory comorbidities were not completely documented for all CTRs. Also, given the nature of the data used in this investigation, we could not evaluate the effect of surgery costs on patient-centered outcomes. Additionally, this study evaluated only patients in New York state, which could limit its generalizability to other states with different payor mixes or different billing and payment structures. The data used in this study showed variability by region (Fig. 1). Nevertheless, our random effects modeling approach for facility not only helps control for the variances in cost by health service area but also provides greater control of these cost variances than controlling for health service areas would. Finally, this patient population was also predominantly White, and although we did not anticipate that the costs of the operating room and anesthesia would vary based on ethnicity, the costs associated with other patient ethnicities cannot be evaluated fairly. Future studies could investigate the effect of ethnicity on carpal tunnel surgery costs, utilization, and outcomes.
      Overall, the New York SPARCS database provided a large, economically diverse patient population to evaluate and validate the costs of CTS. Open surgeries, with local or regional anesthesia, in an ambulatory setting were found to be significant cost savers in this patient population. The additional use of medications, many associated with general anesthesia, was also a separate significant cost driver. Most of these factors are modifiable, and with evidence-based practices, the costs of carpal tunnel surgery can be reduced in the US population as a whole.

      Appendix

      Table E1Definitions of Health Service Areas in New York State
      Health Service AreaCounties Included
      Western New YorkAllegany

      Cattaraugus

      Chautauqua

      Erie

      Genesee

      Niagara

      Orleans

      Wyoming
      Finger LakesChemung

      Livingston

      Monroe

      Ontario

      Schuyler

      Seneca

      Steuben

      Wayne

      Yates
      Central New YorkCayuga

      Cortland

      Herkimer

      Jefferson

      Lewis

      Madison

      Oneida

      Onondaga

      Oswego

      St. Lawrence

      Tompkins
      New York, PennBroome

      Chenango

      Tioga
      Northeastern New YorkAlbany

      Clinton

      Columbia

      Delaware

      Essex

      Franklin

      Fulton

      Greene

      Hamilton

      Montgomery

      Otsego

      Rensselaer

      Saratoga

      Schenectady

      Schoharie

      Warren

      Washington
      Mid-HudsonDutchess

      Orange

      Putnam

      Rockland

      Sullivan

      Ulster

      Westchester
      New York CityBronx

      Kings

      New York

      Queens

      Richmond
      Nassau-SuffolkNassau

      Suffolk

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