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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

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      References

        • Aboonq M.S.
        Pathophysiology of carpal tunnel syndrome.
        Neurosciences (Riyadh). 2015; 20: 4-9
        • Hubbard Z.S.
        • Law T.Y.
        • Rosas S.
        • Jernigan S.C.
        • Chim H.
        Economic benefit of carpal tunnel release in the medicare patient population.
        Neurosurg Focus. 2018; 44: E16
        • 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.
        J Hand Surg Am. 2018; 43: 971-977.e1
        • 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.
        Plast Reconstr Surg. 2018; 142: 1532-1538
        • Carr L.W.
        • Morrow B.
        • Michelotti B.
        • Hauck R.M.
        Direct cost comparison of open carpal tunnel release in different venues.
        Hand (N Y). 2019; 14: 462-465
        • 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.
        Hand (N Y). 2021; 16: 746-752
        • 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
        • 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.
        J Hand Surg Am. 2019; 44: 62.e1-62.e9
        • United States Census Bureau
        ACS Demographic and Housing Estimates.
        • Deyo R.A.
        • Cherkin D.C.
        • Ciol M.A.
        Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.
        J Clin Epidemiol. 1992; 45: 613-619
      1. Centers for Medicare & Medicaid Services. Search the Physician Fee Schedule | CMS. Accessed November 24, 2021. https://www.cms.gov/medicare/physician-fee-schedule/search

        • Nejim B.J.
        • Wang S.
        • Arhuidese I.
        • et al.
        Regional variation in the cost of infrainguinal lower extremity bypass surgery in the United States.
        J Vasc Surg. 2018; 67: 1170-1180.e4
        • Aultman H.
        • Roth C.A.
        • Curran J.
        • et al.
        Prospective evaluation of surgical and anesthetic technique of carpal tunnel release in an orthopedic practice.
        J Hand Surg Am. 2021; 46: 69.e1-69.e7
        • Gillis J.A.
        • Williams J.G.
        Cost analysis of percutaneous fixation of hand fractures in the main operating room versus the ambulatory setting.
        J Plast Reconstr Aesthet Surg. 2017; 70: 1044-1050
        • 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
        • 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.
        JAMA. 2015; 314: 1399-1401
        • 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: 1107-1115
        • 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.
        Ann Plast Surg. 2014; 73: S157-S160
        • 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.
        J Hand Surg Am. 2021; 46: 758-764
        • 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.
        J Hand Surg Am. 2012; 37: 1997-2003.e3
        • 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.
        J Bone Joint Surg Am. 2016; 98: 1970-1977
        • 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.
        J Hand Surg Am. 2021; 46: 868-876
        • Johnson S.P.
        • Zhong L.
        • Chung K.C.
        • Waljee J.F.
        Perioperative antibiotics for clean hand surgery: a national study.
        J Hand Surg Am. 2018; 43: 407-416.e1
        • 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.
        J Hand Surg Am. 2010; 35: 189-196
        • 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.
        Clin Orthop Relat Res. 2018; 476: 664-673
        • 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.
        J Bone Joint Surg Am. 2019; 101: e43
        • 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.
        J Orthop Trauma. 2020; 34: e114-e120
        • 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.
        Spine J. 2020; 20: 69-77
        • Shah K.N.
        • Ruddell J.H.
        • Reid D.B.C.
        • et al.
        Opioid-limiting regulation: effect on patients undergoing knee and shoulder arthroscopy.
        Arthroscopy. 2020; 36: 824-831
        • 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.
        J Hand Surg Am. 2018; 43: 913-919
        • Miller A.
        • Kim N.
        • Ilyas A.M.
        Prospective evaluation of opioid consumption following hand surgery performed wide awake versus with sedation.
        Hand (N Y). 2017; 12: 606-609