In the study by Zhang et al., the costs of open and endoscopic carpal tunnel release are compared. The authors report that the overall costs were significantly higher for the endoscopic approach, while there is no strong evidence supporting better clinical outcomes for either technique. This study addresses an important topic regarding the economics associated with a commonly performed orthopaedic surgical procedure.
In today’s ever-changing health-care environment, there is increasing emphasis on value-based care. The value of a surgical procedure is assessed by relating the clinical benefit to the potential cost1. If the clinical benefits of 2 techniques are equivalent, then the more costly procedure is contrary to the concept of value-based health care. This can result in a decision-making dilemma for the surgeon with respect to the many conditions for which different operative techniques produce similar outcomes.
However, there is some concern regarding the conclusion of Zhang et al. that endoscopic carpal tunnel release costs more with no established clinical superiority. This could be misconstrued by insurance carriers as a justification to deny authorization of, or reimbursement for, the procedure. As surgeons, we all know that surgical decision-making is a complex, multifactorial process that is rarely black and white. Patient preference and the societal cost from missed work must also be considered. In a randomized controlled trial, Kang et al. found that patients preferred endoscopic to open surgery, despite similar outcomes2. Patient satisfaction is an important factor in determining successful surgical outcomes. A prospective randomized trial comparing the outcomes and costs of endoscopic and open carpal tunnel release found an earlier median return to work of 20 days with endoscopic release3, while a 2015 meta-analysis of randomized controlled trials found that endoscopically treated patients had an average earlier return to work of 8.7 days4.
Zhang et al. provide an excellent detailed analysis of various cost centers associated with carpal tunnel care, such as electromyography (EMG), nerve conduction studies (NCS), magnetic resonance imaging (MRI), ultrasound, and hand therapy, and they found that these costs were not significantly different between open and endoscopic release. While this study attributed most of the difference in cost between the 2 procedures to facility fees, the more important question of what specifically led to higher cost reported for the endoscopic approach remains unanswered. We can speculate that factors such as the type of facility (hospital versus surgical center) or the additional equipment requirements of endoscopic treatment could play a role in the cost difference between endoscopic and open carpal tunnel release. The authors acknowledge as a limitation that their database methodology did not allow them to provide more specific details.
This study is an important step in understanding the economics associated with endoscopic and open carpal tunnel release. As mentioned in the article, an issue worth exploring in future studies is an analysis of the potential economic gain of an earlier return to work and whether it is enough to compensate for the additional cost of endoscopic release. More information is needed to make a definitive statement regarding the economics of endoscopic and open carpal tunnel release.
↵* The author indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest form, which is provided with the online version of the article, the author checked “yes” to indicate that he had a relevant financial relationship in the biomedical arena outside the submitted work.
- Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated