Open versus endoscopic carpal tunnel release: A decision analysis

doi:10.1053/jhsu.1999.1109

The Journal of Hand Surgery

Volume 24, Issue 5, September 1999, Pages 1109-1117

https://doi.org/10.1053/jhsu.1999.1109 Get rights and content

Abstract

The endoscopic technique for the surgical treatment of carpal tunnel syndrome was developed to decrease postoperative morbidity and accelerate a patient's return to normal activities and work. We used the methods of decision analysis to compare the total cost of the open versus the endoscopic technique. We adopted a societal perspective and included estimates of the costs of medical procedures and complications, as well as lost wages. Our base case analysis showed that the 2 techniques have similar total costs, given the assumptions of our model. The endoscopic approach is more costly if the complication rate of endoscopic surgery exceeds 6.2% (base case estimate, 5.0%). The endoscopic technique is more costly if the risk of career ending injury exceeds 0.001 (base case estimate, 0.0004) and if the average work absence following a complication exceeds 15.5 months (base case estimate, 12 months). In addition, the endoscopic technique is more costly if the difference between the 2 techniques in mean time to return to work is less than 21 days (base case estimate, 26 days). These findings have different implications for recipients and nonrecipients of workers' compensation. If endoscopically treated patients return to work an average of 42 days faster than patients treated with the open technique (24 days vs 66 days), as was documented for nonrecipients of workers' compensation in one large study, the endoscopic strategy would be less costly ($5,599 for endoscopic release vs $7,340 for open surgery). If endoscopically treated patients return to work an average of just 10 days sooner (103 days vs 113 days), however, as was documented for workers' compensation recipients in the same study, the open technique would be less costly ($11,353 for open release vs $11,959 for the endoscopic technique). The relative costs are not sensitive to the direct medical costs of complications. These findings allow prediction of the costs of endoscopic and open surgery under a range of assumptions concerning key parameters. The analyses also emphasize the need for more precise data on risks and costs of surgical treatments for carpal tunnel syndrome. (J Hand Surg 1999;24A:1109–1117. Copyright © 1999 by the American Society for Surgery of the Hand.)

Section snippets

Specification of the model

We designed a decision—analytic model to examine the differences between the open and endoscopic methods, incorporating all the major possible outcomes of each procedure. Since the cost of care before surgery should not differ between the open and endoscopic methods, a decision—analytic model was developed beginning at the point of surgical intervention. An end point of 1 year was established to allow patients to reach a medical end result. The model consists of branches for each possible

Base case estimate

Using the base assumptions of the model, the overall cost of the open technique was $6,315 compared with $5,896 for the endoscopic technique. Thus, the approaches had similar total costs, with endoscopic technique approximately 7% less costly than the open technique in the base case.

Sensitivity analyses

Sensitivity analyses were performed to examine the effects of varying values of individual cost components and probabilities on total cost. The analyses varied one variable while holding the other variables constant

Discussion

The purpose of this decision analysis was to use data obtained in prior clinical studies to examine whether the potential savings in lost wages due to the faster return to work often associated with the endoscopic technique are outweighed by the costs of a higher complication rate. The principal findings of the analysis are that the costs of the procedures are similar and that the cost differential is highly sensitive to 2 key variables: the rate of complications associated with endoscopic

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Cited by (54)

Evaluation of Factors Affecting Return to Work Following Carpal Tunnel Release: A Statewide Cohort Study of Workers' Compensation Subjects
2022, Journal of Hand Surgery
Citation Excerpt :
Net medical costs over the first 6 months after surgery were 20.7% greater for individuals undergoing ECTR, which is consistent with multiple studies.47–50 A 1999 cost-effectiveness analysis found that DOOW after ECTR would need to be 21 days less than OCTR to be less costly to the patient.51 If that conclusion were to hold, our findings would indicate that ECTR may not be cost effective in a WC population.
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.
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.
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.
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.
Therapeutic III.
Endoscopic Versus Open Carpal Tunnel Release: A Detailed Analysis Using Time-Driven Activity-Based Costing at an Academic Medical Center
2019, Journal of Hand Surgery
Citation Excerpt :
Unfortunately, extrapolation of fee and charge data do not result in an accurate definition of patient level costs owing to the intricate involvement of third-party payer systems. One further study identified that the societal cost burden of CTR was sensitive to the incidences of perioperative complications as well as the duration of work absence secondary to lost wages; however, the study was completed with certain assumptions—including a lack of cost differential between the 2 procedural interventions—which can reasonably be called into question.19 Altogether, the existing body of cost analysis literature comparing endoscopic versus open CTR has not yet been able to define detailed costs across all phases of a patient’s care cycle as can be achieved with TDABC.
In order to effectively improve value in health care delivery, providers must thoroughly understand cost drivers. Time-driven activity-based costing (TDABC) is a novel accounting technique that may allow for precise characterization of procedural costs. The purpose of the present study was to use TDABC to characterize costs in a high-volume, low-complexity ambulatory procedure (endoscopic vs open carpal tunnel release [CTR]), identify cost drivers, and inform opportunities for clinical improvement.
The costs of endoscopic and open CTR were calculated in a matched cohort investigation using TDABC. Detailed process maps including time stamps were created accounting for all clinical and administrative activities for both the endoscopic and the open treatment pathways on the day of ambulatory surgery. Personnel cost rates were calculated accounting for capacity, salary, and fringe benefits. Costs for direct consumable supplies were based on purchase price. Total costs were calculated by aggregating individual resource utilization and time data and were compared between the 2 surgical techniques.
Total procedural cost for the endoscopic CTR was 43.9% greater than the open technique ($2,759.70 vs $1,918.06). This cost difference was primarily driven by the disposable endoscopic blade assembly ($217), direct operating room costs related to procedural duration (44.8 vs 40.5 minutes), and physician labor.
Endoscopic CTR is 44% more expensive than open CTR compared with a TDABC methodology at an academic medical center employing resident trainees. Granular cost data may be particularly valuable when comparing these 2 procedures, given the clinical equipoise of the surgical techniques. The identification of specific cost drivers with TDABC allows for targeted interventions to optimize value delivery.
Economic Analysis II.
Our Surgical Experience: Open Versus Endoscopic Carpal Tunnel Surgery
2018, Journal of Hand Surgery
Citation Excerpt :
There was a marginal benefit (for all age groups) of cost for ECTR versus OCTR, which was feasible in the hypothetical case in which the rate of median nerve injury was 1% lower for ECTR versus OCTR surgery (this has not been reported in the literature). Vasen et al12 acknowledged societal costs associated with ECTR versus OCTR and cited complication rates of 5% for ECTR versus 0.1% for OCTR and the return to work time of 28 days for ECTR versus 54 for OCTR. They presented an algorithm highlighting the cost of outcomes, from $6,288 for an open surgery without complication to $701,609 for an endoscopic surgery that resulted in severe nerve laceration.
Carpal tunnel release is one of the most common hand operations in the United States and every year approximately 500,000 patients undergo surgical release. In this article, we examine the argument for endoscopic carpal tunnel release versus open carpal tunnel release, as well as some of the literature on anatomical variants in the median nerve at the wrist. We further describe the experience of several surgeons in a large academic practice. The goals of this article are to describe key anatomic findings and to present several cases that have persuaded us to favor offering patients open carpal tunnel release.
Update on carpal tunnel syndrome
2013, FMC Formacion Medica Continuada en Atencion Primaria
Open Versus Endoscopic Carpal Tunnel Release
2012, Orthopedic Clinics of North America
Citation Excerpt :
However, the incidence of major nerve complications, as discussed earlier, is likely similar when comparing the 2 groups outright. Vasen and colleagues39 performed a decision analysis that used a direct cost basis, and applied data to a model using assumptions of risks for complications. Using their model, a complication rate of greater than 6.2% would favor OCTR, a return-to-work difference of less than 21 days would favor OCTR, and a greater than 0.1% incidence of major nerve injury would favor OCTR.
Endoscopic Versus Open Carpal Tunnel Release
2009, Journal of Hand Surgery
Citation Excerpt :
This argues that ECTR is more cost-effective for employed patients. Vasen et al. estimated the costs of the ECTR versus the OCTR procedures, also accounting for differences in lost wages from time off work and the cost of complications and their treatment.38 A decision analytic model was used, incorporating the outcomes and rates of various complications from existing literature.

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^*: Supported by National Institutes of Health Grant No. AR36308 and the Arthritis Foundation.

^{* *}: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

^*: Reprint requests: Jeffrey N. Katz, MD, Rheumatology Division, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.

^{* *}: J Hand Surg 1999;24A:1109–1117.

^♢: 0363-5023/99/24A05-0016$3.00/0

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Original CommunicationsOpen versus endoscopic carpal tunnel release: A decision analysis*,* *,*,* *,♢

Abstract

Section snippets

Specification of the model

Base case estimate

Sensitivity analyses

Discussion

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

Arthroscopy

J Hand Surg

J Hand Surg

J Hand Surg

Original Communications
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