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Fig. 1 Average carpal tunnel surgery charge by health service area in New York
Courtesy of Peter Brodeur

AAOS Now

Published 9/3/2021
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Ariel DeMaio

Report Describes Factors That Drive Up Procedure-related Costs of Carpal Tunnel Release

In an analysis of carpal tunnel release (CTR) procedures performed in a large, diverse patient population, researchers identified several variables that increase the costs of surgery: use of general anesthesia, hospital setting, and the use of antibiotics and opioids. The findings will be presented today by lead author Peter Brodeur, a medical student at Brown University.

“Carpal tunnel syndrome has a prevalence of nearly 4 percent in the United States, leading to over 600,000 CTR procedures every year,” Mr. Brodeur told AAOS Now Daily Edition. “When considering the Medicare population alone, estimates of the economic impact reach up to $5 billion per year. Given the proportion of patients undergoing CTR, reducing the total costs can have large financial implications.”

Fig. 1 Average carpal tunnel surgery charge by health service area in New York
Courtesy of Peter Brodeur
Table 1 Natural log of amount billed per carpal tunnel surgery claim and surgical factors
Source: Patel et al., “Higher Surgical Costs Associated with Hospital Outpatient Carpal Tunnel Release.”
Peter Brodeur

The investigators reviewed the New York Statewide Planning and Research Cooperative System (SPARCS) database to identify adult patients with carpal tunnel syndrome (CTS) who underwent CTR between 2016 and 2017. They then performed a multivariable analysis to assess factors that contributed significantly to the total charge of claims. The relevant variables were patient age, sex, anesthesia method, whether the surgery took place in an ambulatory surgery center (ASC) versus a hospital outpatient department (HOPD), operation time in minutes, primary insurance type, race, ethnicity, Charlson Comorbidity Index (CCI), and categories for billed procedure codes.

A total of 10,173 claims were identified, with a mean charge per claim of $4,780. The use of general anesthesia was associated with higher charges compared to local anesthesia. The location of the surgery also affected costs: charges for surgeries performed in an HOPD were approximately 51 percent higher than those performed in an ASC. See Table 1 for other factors associated with higher surgical costs.

Operating time was less impactful, with a one-minute increase in operation time leading to a 0.56 percent increase in total charge. In addition, costs for open procedures were 47 percent lower than endoscopic procedures.

Claims with antiemetics, antihistamines, benzodiazepines, IV fluids, narcotic agents, or preoperative antibiotics were associated with higher total charge amounts compared to claims that did not bill for those agents.

Together, these findings suggest that using local-only anesthesia, performing surgeries in an ambulatory or office setting, and eliminating the use of superfluous medications may help reduce overall procedure-related costs, the authors concluded. “Both open and endoscopic CTR 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,” Mr. Brodeur said. “Despite the increased costs of the endoscopic approach and similar long-term outcomes, recent prospective, randomized trials have shown earlier return to work and better early (<3 months) improvement in scar tenderness. 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.”>

Regarding eliminating antibiotics to drive down costs, Mr. Brodeur cited “abundant evidence that preoperative antibiotics do not affect surgical site infection rates in clean hand surgery, even in diabetic patients. The decision to administer preoperative antibiotics should weigh the risks and benefits for each patient.”

The findings from this analysis are limited by the retrospective design. He added, “The nature of the database prevents evaluation of the details and circumstances surrounding each case and decision,” Mr. Brodeur said. “It is possible that noncontributory comorbidities were not completely documented for all carpal tunnel releases.”

Although this study was not designed to elucidate the higher costs associated with HOPD versus ASC, Mr. Brodeur noted several possible explanations for this finding, including slower turnover time, more OR and perioperative staff, and greater use of equipment. “We also found that increased time in the OR increased overall costs, which fits with the higher costs of hospital-based surgery,” he added. “A financial benefit could be realized if volume was shifted toward ASC- and office-based procedures.”

Because this study evaluated only patients in New York, the results may not be generalizable to other states with different payer mixes or different billing and payment structures. The authors even noted great regional variability in the study, as illustrated in Fig. 1. “Health service areas in southern New York had average charges that differed by upward of $6,000 when compared to western New York,” Mr. Brodeur explained.

Asked about future directions for this research, Mr. Brodeur noted, “The patient population in this study was predominantly white, and although we do not anticipate the costs of the operating room, anesthesia, etc., would vary based on ethnicity, the costs associated with other patient ethnicities cannot fairly be evaluated.” He added, “An analysis could be performed to evaluate the complication rates in hospital outpatient departments versus ASC settings to understand the momentum to shift volume toward ASCs.”

The study will be presented today as Paper 716 at 2:20 p.m. in Ballroom 6A.

Mr. Brodeur’s coauthors of “Higher Surgical Costs Associated with Hospital Outpatient Carpal Tunnel Release” are Devan Patel, MD; Joseph Andrew Gil, MD; and Aristides Ignacio Cruz, MD, MBA.

Ariel DeMaio is the managing editor of AAOS Now. She can be reached at ademaio@aaos.org.