Cost Implications of Varying the Surgical Setting and Anesthesia Type for De Quervain Release Surgery

Quantitative Analysis of Anesthesia Utilization in Ambulatory Hand Surgery

Background

Though evidence demonstrating benefits of local anesthetic continues to compound, a consensus among surgeons regarding optimal anesthetic modality has not been reached. General and regional anesthetic may still be preferred for patient anxiety, concomitant procedures, increased complexity, or poor patient pain tolerance. Therefore, the primary purpose of this study was to analyze trends in anesthetic utilization using a large-scale state healthcare database for common outpatient hand procedures. We hypothesize that over the 10 years between 2010-2019, local anesthetic [including Wide-Awake Local Anesthesia with no Tourniquet (WALANT)] utilization use for common hand procedures has increased, while the use of general and regional anesthesia has decreased.

Methods

A cross-sectional analysis was performed using the Texas Healthcare Information Collection Outpatient Database between 2010-2019. The de-identified data was queried for reported Current Procedure Terminology (CPT) anesthetic and associated procedure codes for the following ambulatory techniques: open carpal tunnel release, endoscopic carpal tunnel release, trigger finger release, De Quervain's release, partial palmar fasciectomy, and hand mass excision. Anesthetic options included: regional anesthesia (RA), local or WALANT anesthesia (LA), and general anesthesia (GA).

Results

There were 340,117 procedures performed during the study period. 98.14% of patient records reported LA application, while GA and RA only accounted for 0.41% and 1.45%, respectively. No significant growth was found for each form of anesthetic individually [LA: -0.12%, RA: 0.09%, and GA: 0.03%]. However, a significant difference in proportional growth is present when comparing all anesthetics (Figure 1, p<0.001). Commercial/ private insurance was the most common payer regardless of anesthesia type, though Medicaid payment source covered a larger proportion of procedures performed under GA [Medicaid: 2.48%, Medicare: 0.37%, worker's compensation: 0.12%, commercial/private insurance: 0.20%].

Conclusion

LA was the most utilized modality over the study period, though a significant proportion of usage has shifted back towards RA and GA over time. Commercial/private insurance was the most frequent reimbursement source for all procedures, though Medicaid covered disproportionately more procedures utilizing GA. RA use was noted to be disproportionately higher in mid-sized population centers (2-4 million in population). Level of Evidence: IV.

Cost Assessment of Plating Versus Tension Band Wiring Constructs for Treating Mayo Type 2A Olecranon Fractures

PURPOSE

Tension band wiring (TBW) or plating may be used for fixation with similar clinical outcomes for adults with displaced Mayo 2A olecranon fractures. The primary hypothesis is that total direct costs (TDCs) for surgery are lower for TBW than plating. Our secondary hypothesis is that combined surgical TDCs are lower for TBW even with a 100% rate of subsequent tension band hardware removal and a 0% rate of plate removal.

METHODS

Patients who underwent TBW or plating of an isolated unilateral Mayo 2A olecranon fracture between July 2011 and January 2020 at a single academic medical center were identified. Then, TDC for each surgery on plate fixation, TBW, and hardware removal was obtained and converted to 2020 US dollars using information technology cost tools provided by our institution. Finally, relative TDCs were compared between plate fixation and TBW groups using univariate and multivariable generalized estimating equations with log-link.

RESULTS

Of the 97 included patients, the mean age was 50 ± 21 years, and 48% were female. Tension band wiring and plate fixation were performed on 18% (17/97) and 82% (80/97) of male and female patients, respectively. Demographics were similar between groups, although the finding that plate fixation cost 2.6 times that of TBW within the index surgery was significant in the multivariable model, independent of potential confounders (coefficient 2.55, 95% confidence interval: 2.09-3.10). Additionally, mean TDC remained significantly greater for plate fixation even under the hypothetical situation where 100% TBW were removed, and the plate removal rate was 0% (cost difference 181%).

CONCLUSIONS

Using TBW relative to plate fixation may improve the cost of care for operative Mayo 2A olecranon fractures. Furthermore, this finding was robust to the rate of hardware removal.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and Decision Analyses III.

Comparison of Complication Risk for Open Carpal Tunnel Release: In-office versus Operating Room Settings

Background:

Performing open carpal tunnel release (oCTR) in an office-based procedure room setting (PR) decreases surgical costs when compared with the operating room (OR). However, it is unclear if the risk of major medical, wound, and iatrogenic complications differ between settings. Our purpose was to compare the risk of major medical complications associated with oCTR between PR and OR settings.

Methods:

Utilizing the MarketScan Database, we identified adults undergoing isolated oCTR between 2006 and 2015 performed in PR and OR settings. ICD-9-CM and/or CPT codes were used to identify major medical complications, surgical site complications, and iatrogenic complications within 90 days of oCTR. Multivariable logistic regression was used to compare complication risk between groups.

Results:

Of the 2134 PR and 76,216 OR cases, the risk of major medical complications was 0.89% (19/2134) and 1.20% (914/76,216), respectively, with no difference observed in the multivariable analysis (adjusted odds ratio [OR] 0.84; 95% CI 0.53–1.33; P=0.45). Risk of surgical site complications was 0.56% (12/2134) and 0.81% (616/76,216) for the PR and OR, respectively, with no difference in the multivariable analysis (OR 0.68; 95% C.I. 0.38–1.22; P=0.19). Iatrogenic complications were rarely observed (PR 1/2134 [0.05%], OR 71/76,216 [0.09%]), which precluded multivariable modeling.

Conclusion:

These results support a similar safety profile for both the PR and OR surgical settings following oCTR with similar pooled major medical complications, pooled wound/surgical site complications, and iatrogenic complications.

Evaluating the Safety of the Hand Surgery Procedure Room: A Single-Center Cohort of 1,404 Surgical Encounters

PURPOSE

Performing hand surgeries in the procedure room (PR) setting instead of the operating room effectively reduces surgical costs. Understanding the safety or complication rates associated with the PR is important in determining the value of its use. Our purpose was to describe the incidence of medical and surgical complications among patients undergoing minor hand surgeries in the PR.

METHODS

We retrospectively reviewed all adult patients who underwent an operation in the PR setting between December 2013 and May 2019 at a single tertiary academic medical center by 1 of 5 fellowship-trained orthopedic hand surgeons. Baseline patient characteristics were described. Complication rates were obtained via chart review.

RESULTS

For 1,404 PR surgical encounters, 1,796 procedures were performed. Mean patient age was 59 ± 15 years, 809 were female (57.6%), and average follow-up was 104 days. The most common surgeries were carpal tunnel release (39.9%), trigger finger release (35.9%), and finger mass or cyst excision (9.6%). Most surgeries were performed using a nonpneumatic wrist tourniquet (58%), whereas 42% used no tourniquet. No patient experienced a major medical complication. No procedure was aborted owing to intolerance. No patient required admission. No intraoperative surgical or medical complications occurred. Observed complications included delayed capillary refill requiring phentolamine administration after a trigger thumb release performed using epinephrine without a tourniquet (n = 1; 0.1%), complex regional pain syndrome (n = 3; 0.2%), infection requiring surgical debridement (n = 2; 0.2%), and recurrent symptoms requiring reoperation (n = 8; 0.7%).

CONCLUSIONS

In this cohort of patients in whom surgery was performed in a PR, there were no major intraoperative surgical or medical complications. There was a low rate of postoperative infection, development of complex regional pain syndrome, and a low need for revision surgery. These observations do not support the concern for safety as a barrier to performing minor hand surgery in the PR setting.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Evaluation of factors driving cost variation for distal humerus open reduction internal fixation

Background

Distal humerus fracture open reduction and internal fixation (ORIF) represents a substantial cost burden to the health care system. The purpose of this study was to describe surgical encounter cost variation for distal humerus ORIF, and to determine demographic-, injury-, and treatment-specific factors that influence cost.

Methods

We retrospectively identified adult patients (≥18 years) treated for isolated distal humerus fractures between July 2014 and July 2019 at a single tertiary academic referral center. For each case, surgical encounter total direct costs (SETDCs) were obtained via our institution's information technology value tools, which prospectively record granular direct cost data for every health care encounter. Costs were converted to 2019 dollars using the personal consumption expenditure indices for health and summarized with descriptive statistics. Univariate and multivariate linear regression models were used to identify factors influencing SETDC.

Results

Surgical costs varied widely for the 47 included patients, with a standard deviation (SD) of 33% and interquartile range of 76%-124% relative to the mean SETDC. Implant and facility costs were responsible for 46.2% and 32.6% of the SETDC, respectively. Implant costs also varied considerably, with an SD of 21% and range from 13%-36% relative to the mean SETDC. Multivariate analysis demonstrated that SETDC increased 24% (P < .001) on performing an olecranon osteotomy, and by 15% for each additional 1 hour of surgical time (P < .001). These findings were independent of age, sex, body mass index, open fracture, need for an additional small plate construct as a reduction aid, and fracture pattern (all insignificant in the multivariate analysis, with P >.05 for each factor).

Conclusion

Substantial variations in surgical encounter total direct costs for distal humerus ORIF exist, as do wide variations in associated implant costs that comprise nearly half of the entire surgical cost. Performing an olecranon osteotomy, and increased surgical time, significantly increased surgical costs. Although use of an olecranon osteotomy may not be a completely controllable factor as it is confounded by fracture severity and operative time, this may suggest that surgeons should try to use an olecranon osteotomy judiciously. Although complexity of the fracture pattern was statistically insignificant, it is confounded by the need for an olecranon osteotomy and increased surgical time and likely is a clinically relevant and nonmodifiable driver of surgical cost. These findings highlight opportunities to reduce cost variation, and potentially improve the value of care, for distal humerus ORIF patients.

A comprehensive analysis of medium-term outcomes of open first dorsal compartment release for de Quervain's syndrome

The primary aim of this study is to describe medium-term functional outcomes following first dorsal compartment decompression using a longitudinal incision in patients with de Quervain's syndrome. The secondary aims are to describe the improvement in health-related quality of life and patient satisfaction, and to determine the cost-effectiveness of this procedure. Pre- and postoperative QuickDASH, EQ-5D-5 L, and satisfaction scores were collected prospectively over five years. Paired data were available for 36 patients (90% at mean 32 months follow-up). The median QuickDASH score improved significantly from 50 to 9.1 (p < 0.01). Median EQ-5D-5L index scores improved from 0.65 preoperatively to 0.73 (p = 0.03). The satisfaction rate was 97% and there were no cases of superficial radial nerve injury or neuroma. The cost per quality-adjusted life year gained was £356 (€398; $449). First dorsal compartment release using a longitudinal incision results in a significant improvement in function, with high levels of patient satisfaction, and low complication rates. In addition, health economic analysis revealed that this is a cost-effective procedure for the treatment of de Quervain's syndrome. LEVEL OF EVIDENCE: III (cohort study).