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September Featured Article

A Cost, Profit, and Efficiency Analysis of Performing Carpal Tunnel Surgery in the Operating Room versus The Clinic Setting in the United States

Authors:  Chatterjee A, McCarthy JE, Montagne SA, Leong K, Kerrigan CL

Source: Ann Plast Surg  66(3): 245-8, 2011.

Link to Abstract: Annals of Plastic Surgery

Summary: 

The authors performed a detailed cost analysis of all carpal tunnel surgeries performed among 5 surgeons at a single institution over one year with 225 procedures total. The authors included both single port endoscopic and open techniques and both were performed in the clinic procedure room and the operating room settings.  Total, direct, indirect, and net costs were calculated. Opportunity costs, being costs associated with the loss of ability to be performing another procedure during an inefficient time period, such as OR turnover, were also calculated.  Their results demonstrated that the total cost per case of endoscopic CTR in the procedure room was $985 and total profit was $2710 versus total cost of the same procedure in the operating room of $2273 and total profit of $1139.  For open CTR, total cost per case was $670 and net profit per case was $1186 in the procedure room versus $3469 with a net loss of $650 per case performed in the operating room.  When opportunity costs were factored in (assuming procedures could be done every 30 min in the procedure room versus every 60 min the OR), the true profit per case in the procedure room was $2710 per endoscopic CTR and $1186 per open CTR versus a loss of $1562 and $3349, respectively, for endoscopic and open CTR’s performed in the operating room. 
 
 Thus, the authors demonstrated that, at their institution, using a clinic based procedure room, endoscopic and open CTR’s were much more profitable, with endoscopic CTR being the most profitable, when compared to the same procedures performed in the OR which lost money in direct costs when performing the open technique and for which both procedures resulted in a net loss when the theoretical opportunity costs were included.  While this article provides excellent data related to the operating costs in 2 different environments for 2 different procedures at their institution, the authors also point out several weaknesses of their study.  They immediately discuss that this paper only addresses cost effectiveness and not clinical efficacy of the procedures performed in different environments. Costs related to complications of each procedure and “societal costs” are also not included.  The data is specific to their institution, and overhead costs and reimbursements may change depending on region and site.  Also, the cost utility of surgery centers is not included as the only 2 sites analyzed are hospital OR’s and clinic procedure rooms.  The opportunity cost calculation assumes that every extra minute spent in the more time consuming OR procedure could be used to perform another procedure in the less time consuming procedure room.  This assumes a never ending abundance of patients available for surgery and perfect efficiency.  The assumption also requires that procedures occur like clockwork, 1 per hour in the OR and 1 per 30 minutes in the procedure room, which would certainly vary from institution to institution.  Nonetheless, this is an insightful article which demonstrates the theoretical yet substantial cost savings and increased profitability of performing endoscopic and open carpal tunnel operations in a clinic procedure room without an anesthetist which makes up approximately 60% of the authors’ carpal tunnel experience.
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Welcome to the interactive Online Journal Club.  I will play the role of provocateur in order to get the discussion going and the members of the ASSH Evidence Based Practice Committee that I chair along with Joy MacDermid, who will help moderate the discussion. 

- David Ring, MD, PhD

Feature Article Discussion by David Ring, MD PhD
Evidence Based Practice Committee, Chair
 

This analysis is interesting since changes in the way that health care is organized and paid for in the United States seem inevitable.  I read the full article and do not understand what is meant by “the clinic”, but it must be some form of outpatient operating room.  It seems like a foregone conclusion that efficient use of resources is less costly.  When we discuss open vs. endoscopic carpal tunnel release (CTR) these issues arise because endoscopic CTR generally takes longer to set up and execute, uses a more costly apparatus, and most surgeons use some sedation or anesthesia services with endoscopic, but not with open carpal tunnel release.  To start discussion on this topic, I would therefore offer the provocation that open CTR under local anesthesia performed in an efficient outpatient operating room with a scalpel ought to be the standard against which all other forms of CTR are judged.  That means that other types of surgery would have to show some valuable benefit to be considered a good use of resources.  I hope I can provoke some discussion with that one!

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Actual Cost Effectiveness Not Easy to Calculate

​I was only able to read the abstract, as I do not have access to this journal.  There are probably legal issues regarding posting the entire article for us to read, so selection of an article from JHS may be the only method to make sure everyone has access. 

I agree the efficient use of resources being the most efficient and cost effective as Mather et al also demonstrated regarding distal radius fractures (July issue of JHS). 

Comparison of different techniques (mini open, one or two portal endoscopic techniques, use of instruments such as the Indiana tome, stryker knife light,…) will all have their advocates for various reasons.  While OR or facility costs can be compared, it is much harder to compare overall costs to society, such as time away from work and other activities, and utilization of post operative therapy (even though it has been shown that it is not cost effective (Pomerance and Fine – JHS 2007), is often used.  In addition, the cost to society is variable, depending on profession (desk job vs repetitive manual labor, ability of co-workers to cover,...) and insurance (compensation vs private vs Medicaid).

Many of these issues are more patient dependent than procedure dependent and in light of that, one could make a strong argument for the least expensive procedure.  But, I think it is more complicated than that.  Depending on the above factors, a slightly more expensive procedure with a shorter convalescent period could be equally or more effective from an overall cost standpoint.  In addition, those who perform endo CTR would also argue that that patients have less difficulties returning to many activities sooner following endo ctr and most patients who have had one side done with open CTR and the other side with endo prefer the endo side, so early patient satisfaction may be higher and justify a slightly increased expense (Level V evidence).  Better evidence would help answer this question, but the difficulty evening setting up a clinical trial to answer this question, with geographical differences as far as economics and the number of patients required to reach statistical significance, and the difficulty completing a trial of this magnitude, make this highly unlikely and will leave this topic and others open for debate.    ​


Warren C. Hammert

carpal tunnel cost analysis paper

​ A very interesting article that makes me think about setting up a small procedure room in our clinic. Unfortunately there are regional differences that may limit how applicable this is. In our hospital the main barriers to performing an open carpal tunnel or trigger finger release in the clinic setting have been:

1) organizing the staff and equipment. in order to have adequate safety, an RN would be needed in the room, a hand tray and drapes would be needed and the logistics of sterilizing and disposing of the used equipment. 

2) Clinic space is also at a premium and having a room set up as a procedure room would be difficult. Unless that room is being used everyday of the week by surgeons doing procedures, keeping a clinic room empty is inefficient

3) the maintenance and sterilization of endoscopic equipment would also have to be handled by the OR, in our setting the clinics are a few blocks away from the main hospital, and getting the equipment to Central sterile and back would take some work.

Although the operating room has some inherent inefficiencies, at least the set up and equipment is taken care of and I can just show up and do the case. In some hospitals this would be a great idea. In our hospital surgi-center carpal tunnels can be done every half an hour if you are doing them under straight local without an anesthesiologist.

this article does point out that an endoscopic carpal tunnel release is more expensive. although not the focus of this article I kept thinking that unless the results of endoscopic carpal tunnel release are that much better, why do them instead of an open procedure.

Nader Paksima

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A Cost, Profit, and Efficiency Analysis of Performing Carpal Tunnel Surgery in the Operating Room versus The Clinic Setting in the United States

​This article continues to be one of many challanging long held concepts of treatment of common conditions in the United States. There have been recent publications in numerous journals questioning the cost effectiveness of therapy in common procedures such as ACL reconstruction in recent sports medicine journals and therapy for CTS in our own JHS. As resouces become limited the question of how best to allocate them to do the most amount of good will be important. What the study does not address is the legal ramifications should a complication occur. Kevin Chung had published a cost effective analysis on open vs. ECTRA years ago. While the ECTRA was an effective procedure at reducing symptoms, its cost effectiveness was rapidly reduced when a nerve injury occurred when the outcomes were measures in Quality Adjusted Life years. While a carpal tunnel release done open is about as straightforward as it gets for well trained hand surgeons, a number of precautions must be planned out ahead of time to ensure the procedure is completed safely. As with most clinical studies, patient selection is key and those patients with multiple co-morbidities, especially those patients with anxiety having the procedure done under local, may be ones where the added cost of a hospital outpatient setting may well be worth it. The issue of tort reform in many states has come up over the years and this paper may well be able to reduce some of the anxiety practitioners have when performing procedures in an office setting to point to efficacy without the added cost.

Chronic carpal lunate luxation. treatment.

​I have a 70 year old very sport active man, whom suffer

a chronic carpal lunate luxation since september 15- 2012.

I need journal articles of treatment and follow up.

Thank you very much.

Oscar F. Orozco,M.D.

office carpal tunnel release

There is one situation where I will perform a carpal tunnel release in the office: the patient without insurance. Texas is a state with no safety net for the uninsured. Even though I live in a relatively wealthy county which is home to a major state university, one third of our population is uninsured.

If a self pay patient comes to see me with a straight forward history and physical exam, has failed conservative treatment and is not diabetic, I will perform an open carpal tunnel release in my treatment room using local anesthetic. It takes me about 40 minutes to set up and do the procedure. One of my x-ray techs is my assistant. My charge is $1000 which includes the initial office visit, and follow up.I don't do this often, but find it pretty easy and have not had any problems. I have not calculated the actual 'profit' but the staff are there anyway and at least one of my partners is working at the same time.   ​