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September Featured Article
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
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.
Feature Article Discussion by David Ring, MD PhD
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
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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