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A 15-Year Review of Clinical Practice Patterns in Carpal Tunnel Syndrome Based on Continuous Certification by the American Board of Plastic Surgery. Plast Reconstr Surg 2022; 149:1140e-1148e. [PMID: 35404337 DOI: 10.1097/prs.0000000000009117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The American Board of Plastic Surgery has been collecting practice data on carpal tunnel syndrome treatment since 2004 as part of its Continuous Certification Program. These data allow plastic surgeons to compare their surgical experience to national trends and analyze those trends in relation to current evidence-based medicine. METHODS Data on carpal tunnel syndrome treatment from 2004 to 2014 were compared to those from 2015 to 2020. National practice trends observed in these data were evaluated relative to current literature regarding evidence-based practices. RESULTS A total of 11,090 carpal tunnel syndrome cases were included from 2004 to 2020. Electrodiagnostic and imaging studies were performed on most patients despite adding little sensitivity and specificity when physical examination tests are performed and not being considered cost-effective. An open "mini" approach has remained the most common surgical technique in carpal tunnel release for the last 15 years, with growing usage (53 percent versus 59 percent, p < 0.001). Splinting has decreased significantly over the last 15 years, from usage in 39 percent of patients to 28 percent (p < 0.001). Formal postoperative hand therapy has declined from 27 percent of patients to 22 percent (p < 0.001). Despite their low efficacy, 63 percent of patients received one or more perioperative doses of antibiotics. CONCLUSIONS Analysis of the Continuous Certification Program tracer data from the American Board of Plastic Surgery provides an excellent overview of current practice and its development over the 15 years since its inception. This analysis provides insight into how effectively plastic surgeons have remained aligned with developments in best practices in treating carpal tunnel syndrome.
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Cost Implications of Varying the Surgical Setting and Anesthesia Type for Dorsal Wrist Ganglion Cyst Excision Surgery. Plast Reconstr Surg 2022; 149:240e-247e. [PMID: 35077419 PMCID: PMC8797019 DOI: 10.1097/prs.0000000000008725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Minimizing expenses attributed to dorsal wrist ganglion cyst excisions, a common minor surgical procedure, presents potential for health care cost savings. Varying the surgical setting (operating room versus procedure room) and type of anesthesia (local-only, monitored anesthesia care, or monitored with regional or general anesthesia) may affect total operative costs. METHODS Patients who underwent an isolated unilateral dorsal wrist ganglion cyst excision between January of 2014 and October of 2019 at a single academic medical center were identified by CPT code. The total direct costs for each surgical encounter that met inclusion criteria were calculated. The relative total direct costs were compared between surgical setting and anesthesia type groups. Univariate and multivariable gamma regression models were used to identify factors associated with surgical costs. RESULTS A total of 192 patients were included; 26 cases (14 percent) were performed in the procedure room and 166 cases (86 percent) were performed in the operating room. No significant differences in demographic factors were identified between groups. Univariate analysis demonstrated that use of operating room/monitored anesthesia care, operating room/monitored anesthesia care with regional anesthesia, and operating room/general anesthesia groups, as compared to procedure room/local-only, yielded significantly greater median costs (1.76-, 2.34-, and 2.44-fold greater, respectively). Multivariable analysis demonstrated 1.80-, 2.10-, and 2.31-fold greater costs with use of operating room/monitored anesthesia care, operating room/monitored anesthesia care with regional anesthesia, and operating room/general anesthesia relative to procedure room/local-only, respectively. CONCLUSION Performing dorsal wrist ganglion cyst excisions in a procedure room with local-only anesthesia minimizes operative direct costs relative to use of the operating room and other anesthetic types.
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Cost Implications of Varying the Surgical Setting and Anesthesia Type for Trigger Finger Release Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2231. [PMID: 31333958 PMCID: PMC6571295 DOI: 10.1097/gox.0000000000002231] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 03/05/2019] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Trigger finger release (TFR) is a common surgical procedure, representing a financial burden to the healthcare system. Our null hypothesis is that the choice surgical setting [operating room (OR) versus procedure room (PR)] and anesthetic type [local-only or monitored anesthesia care (MAC)] do not affect surgical encounter costs for TFR. Methods: Adult patients undergoing isolated unilateral TFR between May 2014 and December 2017 by 5 fellowship-trained hand surgeons at a single academic medical center were identified by Current Procedural Terminology (CPT) code (26055). We excluded patients undergoing revision surgery, tenosynovectomy, or additional procedures. Using our institution’s information technology value tools, we calculated total direct costs for each surgical encounter, which were compared between groups. Univariate and multivariable gamma regression were used to model costs. Results: Of 210 included patients, 54% (113/210) of cases were performed in the PR and 46% (97/210) in the OR. No significant differences in demographics were observed between PR and OR groups. Compared to local-only in the PR, the OR with local-only, and OR with MAC, demonstrated 2.2- and 3.2-fold greater median costs. Multivariable models suggested that use of the OR independently led to 221% [95% Confidence interval: 137%–345%; P < 0.01] greater mean costs than the PR, and use of MAC was associated with 30% (95% confidence interval: 13%–49%; P < 0.01) greater mean costs for OR cases than local-only, while controlling for other confounders. Conclusion: Performing TFR in the PR setting under local-only anesthesia minimizes surgical encounter direct costs for this common procedure.
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Kazmers NH, Presson AP, Xu Y, Howenstein A, Tyser AR. Cost Implications of Varying the Surgical Technique, Surgical Setting, and Anesthesia Type for Carpal Tunnel Release Surgery. J Hand Surg Am 2018; 43:971-977.e1. [PMID: 29784549 PMCID: PMC6218304 DOI: 10.1016/j.jhsa.2018.03.051] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 02/15/2018] [Accepted: 03/30/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE Carpal tunnel release (CTR) is a common surgical procedure, representing a financial burden to the health care system. The purpose of this study was to test whether the choice of CTR technique (open carpal tunnel release [OCTR] vs endoscopic carpal tunnel release [ECTR]), surgical setting (operating room vs procedure room [PR]), and anesthetic type (local, monitored anesthesia care [MAC], Bier block, general) affected costs or payments. METHODS Consecutive adult patients undergoing isolated unilateral CTR between July 2014, and October 2017, at a single academic medical center were identified. Patients undergoing ECTR converted to OCTR, revision surgery, or additional procedures were excluded. Using our institution's information technology value tools, we calculated total direct costs (TDCs), total combined payment (TCP), hospital payment, surgeon payment, and anesthesia payment for each surgical encounter. Cost data were normalized using each participant's surgical encounter cost divided by the average cost in the data set and compared across 8 groups (defined by surgery type, operation location, and anesthesia type). RESULTS Of 479 included patients, the mean age was 55.3 ± 16.1 years, and 68% were female. Payer mix included commercial (45%), Medicare (37%), Medicaid (13%), workers' compensation (2%), self-pay (1%), and other (3%) insurance types. The TDC and TCP both differed significantly between each CTR group, and OCTR in the PR under local anesthesia was the lowest. The OCTR/local/operating room, OCTR/MAC/operating room, and ECTR/operating room, were associated with 6.3-fold, 11.0-fold, and 12.4-16.6-fold greater TDC than OCTR/local/PR, respectively. CONCLUSIONS Performing OCTR under local anesthetic in the PR setting significantly minimizes direct surgical encounter costs relative to other surgical methods (ECTR), anesthetic methods (Bier block, MAC, general), and surgical settings (operating room). CLINICAL RELEVANCE This study identifies modifiable factors that may lead to cost reductions for CTR surgery.
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Affiliation(s)
| | - Angela P Presson
- Division of Public Health, University of Utah, Salt Lake City, UT; Department of Pediatric Research Enterprise, University of Utah, Salt Lake City, UT
| | - Yizhe Xu
- Division of Public Health, University of Utah, Salt Lake City, UT; Department of Pediatric Research Enterprise, University of Utah, Salt Lake City, UT
| | - Abby Howenstein
- Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | - Andrew R Tyser
- Department of Orthopaedics, University of Utah, Salt Lake City, UT
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Hermiz SJ, Kalliainen LK. Evidence-Based Medicine: Current Evidence in the Diagnosis and Management of Carpal Tunnel Syndrome. Plast Reconstr Surg 2017; 140:120e-129e. [PMID: 28654613 DOI: 10.1097/prs.0000000000003477] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Create a safe and effective plan for management of carpal tunnel syndrome. 2. Support his or her rationale for the use of diagnostic tests. 3. Discuss elements of management that have been controversial, including anesthesia, the use of a tourniquet, postoperative pain control, and cost of care. SUMMARY This is the fourth MOC-PS CME article on carpal tunnel syndrome. Each of the prior three has had a slightly different focus, and the reader is invited to review all to generate a comprehensive view of the management of this common, and often controversial, topic. The operative goal-to release the transverse carpal ligament-is straightforward: diagnosis, cause, and technique have generated more vibrant discussions.
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Affiliation(s)
- Steven J Hermiz
- Chapel Hill, N.C.,From the Division of Plastic Surgery, University of North Carolina
| | - Loree K Kalliainen
- Chapel Hill, N.C.,From the Division of Plastic Surgery, University of North Carolina
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Tulipan JE, Kim N, Abboudi J, Jones C, Liss F, Kirkpatrick W, Rivlin M, Wang ML, Matzon J, Ilyas AM. Open Carpal Tunnel Release Outcomes: Performed Wide Awake versus with Sedation. J Hand Microsurg 2017; 9:74-79. [PMID: 28867906 DOI: 10.1055/s-0037-1603200] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 04/21/2017] [Indexed: 12/14/2022] Open
Abstract
Background Carpal tunnel release (CTR) is the most common surgery of the hand, and interest is growing in performing it under local anesthesia without tourniquet. To better understand differences, we hypothesized that patients undergoing CTR under wide-awake local anesthesia with no tourniquet (WALANT) versus sedation (monitored anesthesia care [MAC]) would not result in a difference in outcome. Methods Consecutive cases of electrodiagnostically confirmed open CTR across multiple surgeons at a single center were prospectively enrolled. Data included demographic data, visual analog scale, Levine-Katz carpal tunnel syndrome scale, QuickDASH questionnaire, customized Likert questionnaire, and complications. Results There were 81 patients enrolled in the WALANT group and 149 patients in the MAC group. There were no reoperations in either group or any epinephrine-related complications in the WALANT group. Disability and symptom scores did not differ significantly between WALANT and sedation groups at 2 weeks or 3 months. Average postoperative QuickDASH, Levine-Katz, and VAS pain scales were the same in both groups. Both groups of patients reported high levels of satisfaction at 91 versus 96% for the WALANT versus MAC groups, respectively ( p > 0.05). Patients in each group were likely to request similar anesthesia if they were to undergo surgery again. Conclusion Patients undergoing open CTR experienced similar levels of satisfaction and outcomes with either the WALANT or MAC techniques. There was no statistically significant difference between either group relative to the tested outcome measures. These data should facilitate surgeons and patients' choosing freely between WALANT and MAC techniques relative to complications and outcomes.
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Affiliation(s)
- Jacob E Tulipan
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Nayoung Kim
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States.,Divison of Hand Surgery, Rothman Institute, Philadelphia, Pennsylvania, United States
| | - Jack Abboudi
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States.,Divison of Hand Surgery, Rothman Institute, Philadelphia, Pennsylvania, United States
| | - Christopher Jones
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States.,Divison of Hand Surgery, Rothman Institute, Philadelphia, Pennsylvania, United States
| | - Frederic Liss
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States.,Divison of Hand Surgery, Rothman Institute, Philadelphia, Pennsylvania, United States
| | - William Kirkpatrick
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States.,Divison of Hand Surgery, Rothman Institute, Philadelphia, Pennsylvania, United States
| | - Michael Rivlin
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States.,Divison of Hand Surgery, Rothman Institute, Philadelphia, Pennsylvania, United States
| | - Mark L Wang
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States.,Divison of Hand Surgery, Rothman Institute, Philadelphia, Pennsylvania, United States
| | - Jonas Matzon
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States.,Divison of Hand Surgery, Rothman Institute, Philadelphia, Pennsylvania, United States
| | - Asif M Ilyas
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States.,Divison of Hand Surgery, Rothman Institute, Philadelphia, Pennsylvania, United States
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Efficacy of Keyhole Approach to Carpal Tunnel Syndrome under Ambulatory Strategy. Neurol Res Int 2017; 2017:3549291. [PMID: 28484650 PMCID: PMC5397629 DOI: 10.1155/2017/3549291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 01/03/2017] [Accepted: 01/22/2017] [Indexed: 11/22/2022] Open
Abstract
The carpal tunnel syndrome is one of the most common entrapment neuropathies found in humans. Currently, the gold standard is surgical treatment using different modalities. The minimally invasive strategy with high resolution capacity and less morbidity is still a challenge. Methods. Prospective nonrandomised clinical trial in which a minimally invasive microsurgical approach was used following the keyhole principle in 55 consecutive patients and 65 hands under local anesthesia and ambulatory strategy. They were evaluated with stringent inclusion criteria with the Levine severity and functional status scale and with a 2-year follow-up. Results. 90% showed immediate improvement dropping to grades 1-2 in all items of the scale referring to pain and numbness. 97% reported improvement, as of the first month, and 3% reported persistence of symptoms, although at a lesser degree and with no functional limitation. No incidents were identified during the procedure and 98% of patients were discharged within an hour after the surgical procedure. Conclusions. The microsurgical approach described following the keyhole principle is a treatment option that, under local anesthesia and ambulatory management, may represent an alternative strategy of an effective treatment reducing the morbidity. This trial is registered with Clinical Trials Protocol Identifier NCT03062722.
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Symptoms During or Shortly After Isolated Carpal Tunnel Release and Problems Within 24 hours After Surgery. J Hand Microsurg 2014; 7:30-5. [PMID: 26078500 DOI: 10.1007/s12593-014-0157-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 08/21/2014] [Indexed: 10/24/2022] Open
Abstract
This study used the National Survey of Ambulatory Surgery (NSAS) database to measure the incidence of and risk factors for symptoms in the ambulatory surgery center and problems within 24 h after isolated carpal tunnel release (CTR). The NSAS contained records on 400,000 adult patients with carpal tunnel syndrome who were treated with CTR in 2006, based on ICD-9 codes. The type of anesthesia used and factors associated with symptoms and problems were sought in bivariate and multivariable statistical analyses. The mean duration of the procedure was 16 ± 8.8 min. Only 5 % were performed under local anesthesia without sedation, 45 % with IV sedation, 28 % regional anesthesia, and 19 % general anesthesia. Symptoms in the ambulatory surgery center or a problem within 24 h after discharge were recorded in 10 % of patients, all of them minor and transient, including difficulties with pain and its treatment. The strongest risk factors were male sex, age of 45 years and older, and participation of an anesthesiologist. Local anesthesia and regional anesthesia were associated with more perioperative symptoms and postoperative problems. Most CTR are performed with some sedation in the United States. CTR is a safe procedure: one in 10 patients will experience a minor issue in the perioperative or immediate postoperative period.
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