Optimizing Costs and Outcomes for Carpal Tunnel Release Surgery: A Cost-Effectiveness Analysis from Societal and Health-Care System Perspectives

American Academy of Orthopaedic Surgeons/ASSH Clinical Practice Guideline Summary Management of Carpal Tunnel Syndrome

Management of Carpal Tunnel Syndrome Evidence-Based Clinical Practice Guideline is based on a systematic review of published studies with regard to the diagnosis and treatment of carpal tunnel syndrome in adult patients (≥18 years of age). The scope of this guideline addresses the diagnosis and treatment of carpal tunnel syndrome and contains nine recommendations to assist orthopaedic surgeons and all qualified clinicians managing patients presenting with signs and symptoms which may be attributable to carpal tunnel syndrome based on the best current available evidence. It is also intended to serve as an information resource for professional healthcare practitioners, health services researchers, and developers of practice guidelines and recommendations. In addition to providing pragmatic practice recommendations, this guideline also highlights gaps in the literature and informs areas for future research and quality measure development.

Direct Variable Cost Comparison of Endoscopic Versus Open Carpal Tunnel Release: A Time-Driven Activity-Based Costing Analysis

INTRODUCTION

To improve the delivery of value-based health care, a deeper understanding of the cost drivers in hand surgery is warranted. Time-driven activity-based costing (TDABC) offers a more accurate estimation of resource utilization compared with top-down accounting methods. This study used TDABC to compare the facility costs of open carpal tunnel release (OCTR) and endoscopic carpal tunnel release (ECTR).

METHODS

We identified 845 consecutive, unilateral carpal tunnel release (516 open, 329 endoscopic) surgeries performed at an orthopaedic specialty hospital between 2015 and 2021. Itemized facility costs were calculated using a TDABC algorithm. Patient demographics, comorbidities, surgical characteristics, and itemized costs were compared between OCTR and ECTR. Multivariate regression was used to determine the independent effect of endoscopic surgery on true facility costs.

RESULTS

Total facility costs were $352 higher in ECTR compared with OCTR ($882 versus $530). ECTR cases had higher personnel costs ($499 versus $420), likely because of longer surgical time (15 versus 11 minutes) and total operating room time (35 versus 27 minutes). ECTR cases also had higher supply costs ($383 versus $110). Controlling for demographics and comorbidities, ECTR was associated with an increase in personnel costs of $35.74 (95% CI, $26.32 to $45.15), supply costs of $230.28 (95% CI, $205.17 to $255.39), and total facility costs of $265.99 (95% CI, $237.01 to $294.97) per case.

DISCUSSION

Using TDABC, ECTR was 66% more costly to the facility compared with OCTR. To reduce the costs related to endoscopic surgery, efforts to decrease surgical time and negotiate lower ECTR-specific supply costs are warranted.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level II.

Registry cost description of carpal tunnel release in Finland in 2011-2015

OBJECTIVES

In this study, we evaluated the amount of public funds spent on the operative treatment of carpal tunnel syndrome (CTS) in Finland in 2011-2015.

DESIGN

A registry-based cost burden study.

SETTING

The data were collected in primary and secondary care in both private and public hospitals, covering the whole population of Finland.

PARTICIPANTS

We collected the total number of patients with new CTS diagnoses and the total number of patients undergoing surgery from the Care Register for Health Care, Finland's national register.

INTERVENTIONS

Open carpal tunnel release (OCTR).

OUTCOME MEASURES

We collected the costs of the OCTR procedure from diagnosis-related group prices. The Social Insurance Institution of Finland provided the total amount of euros reimbursed for sick leaves. We then combined the average amount of reimbursed sick leave with our estimated cost of the treatment chain to approximate the average cost per patient.

RESULTS

The average amount of public funds used for diagnosing and surgically treating new CTS in 2011-2015 in Finland, including reimbursements for sick leaves, was €2759 per patient in 2015 currency. The average direct procedure cost was €1020. We found no clear trend in total cost per patient, but the proportion of surgically treated patients rose from 63.14% to 73.09%. The total annual cost of these treatments was between €18 128 420 and €22 569 973.

CONCLUSIONS

The average amount of public funds used to surgically treat one patient with new CTS in 2011-2015 in Finland was €2759, making the total annual burden €20.7 million.

Trends in Open Versus Endoscopic Carpal Tunnel Release From 2010 to 2021

BACKGROUND

This study compared trends in use, predictive factors, and reimbursement of endoscopic carpal tunnel release (ECTR) withthose of open carpal tunnel release (OCTR) from 2010 to 2021 using a national administrative database.

METHODS

ECTR and OCTR patients were identified in the PearlDiver M151Ortho data set. Numeric and proportional utilization of these procedures was characterized for each year of study. Multivariate analysis was conducted to identify predictive factors for having ECTR performed. The average 90-day reimbursement of ECTR and OCTR was determined.

RESULTS

From 2010 through 2021, 441,023 ECTR and 1,767,820 OCTR procedures were identified. The proportional use of ECTR compared with OCTR rose from 2010 (15.7% of procedures) to 2021 (26.1%). Independent predictors of having ECTR performed rather than OCTR included geographic variation (compared with having surgery in the Midwest, Northeast odds ratio [OR], 1.53; West OR, 1.62; and South OR, 1.66), having Medicare or commercial insurance (compared with commercial, Medicare OR, 0.94, and Medicaid OR, 0.69), female sex, and fewer comorbidities. The average 90-day reimbursement for ECTR was $3,114.82, compared with $3,087.62 for OCTR.

DISCUSSION

As of 2021, over one-fourth of carpal tunnel releases are done endoscopically. Several factors independently predict whether patients receive ECTR or OCTR.

Optimization of Carpal Tunnel Syndrome Using WALANT Method

As surgical management of carpal tunnel release (CTR) becomes ever more common, extensive research has emerged to optimize the contextualization of this procedure. In particular, CTR under the wide-awake, local-anesthesia, no-tourniquet (WALANT) technique has emerged as a cost-effective, safe, and straightforward option for the millions who undergo this procedure worldwide. CTR under WALANT is associated with considerable cost savings and workflow efficiencies; it can be safely and effectively executed in an outpatient clinic under field sterility with less use of resources and production of waste, and it has consistently demonstrated standard or better post-operative pain control and satisfaction among patients. In this review of the literature, we describe the current findings on CTR using the WALANT technique.

Evaluation of Factors Affecting Return to Work Following Carpal Tunnel Release: A Statewide Cohort Study of Workers' Compensation Subjects

PURPOSE

Most randomized trials comparing open carpal tunnel release (OCTR) to endoscopic carpal tunnel release (ECTR) are not specific to a working population and focus mainly on how surgical technique has an impact on outcomes. This study's primary goal was to evaluate factors affecting days out of work (DOOW) following carpal tunnel release (CTR) in a working population and to evaluate for differences in medical costs, indemnity payments, disability ratings, and opioid use between OCTR and ECTR with the intent of determining whether one or the other surgical method was a determining factor.

METHODS

Using the Ohio Bureau of Workers' Compensation claims database, individuals were identified who underwent unilateral isolated CTR between 1993 and 2018. We excluded those who were on total disability, who underwent additional surgery within 6 months of their index CTR, including contralateral or revision CTR, and those not working during the same month as their index CTR. Outcomes were evaluated at 6 months after surgery. Multivariable linear regression was performed to evaluate covariates associated with DOOW.

RESULTS

Of the 4596 included participants, 569 (12.4%) and 4027 (87.6%) underwent ECTR and OCTR, respectively. Mean DOOW were 58.4 for participants undergoing OCTR and 56.6 for those undergoing ECTR. Carpal tunnel release technique was not predictive of DOOW. Net medical costs were 20.7% higher for those undergoing ECTR. Multivariable linear regression demonstrated the following significant predictors of higher DOOW: preoperative opioid use, legal representation, labor-intensive occupation, increasing lag time from injury to filing of a worker's compensation claim, and female sex. Being married, higher income community, and working in the public sector were associated with fewer DOOW.

CONCLUSIONS

In a large statewide worker's compensation population, demographic, occupational, psychosocial, and litigatory factors have a significant impact on DOOW following CTR, whereas differences in surgical technique between ECTR and OCTR did not.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.