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A Direct Cost Comparison Study of Open Carpal Tunnel Surgery
Brad Morrow, MD, Logan Carr, MD, William Albright, MD, Brett Michelotti, MD, Randy M. Hauck, MD.
Penn State Hershey Medical Center, Hershey, PA, USA.

Background: The recent trend in hand surgery to perform procedures with patients wide awake under local anesthesia has led many surgeons to move their practice away from the operating room (OR) or outpatient surgery center (OSC) and into the clinic. A multicenter prospective study reported no increase in surgical-site infections with this technique.
With the cost of health care continuing to rise, it is imperative that procedures are performed in the most cost effective manner. As facility fees and the surgeon's professional fee are reimbursed as a flat rate based on a CPT code, then the venue with the lowest cost should be utilized to maximize profits.
Objective: We performed a direct costs analysis of a single surgeon performing an open carpal tunnel release as an isolated procedure at a tertiary referral center OR, OSC and clinic.
Methods: Four treatment groups were prospectively studied, the OR with monitored anesthesia care (MAC) (OR), OSC with MAC (OSC-MAC), OSC with local anesthesia (OSC-local) and clinic with local anesthesia (clinic). To determine direct costs, a detailed inventory of all supplies opened during each procedure and the price per unit was recorded including the weight and disposal of medical waste.
Indirect costs such as support-staff salaries and equipment depreciation were not included as a quantitative number could not be objectively assigned.
Results: Five cases in each treatment group were prospectively recorded. Average direct costs, in descending order, were OR (\.55), OSC-MAC (\.12), OSC -local (\.16) and clinic (\.09). Using ANOVA, there was a statistically significant decrease in the clinic versus every other setting (p<0.005).
The surgical waste per case was collected and weighed. The average weight, in descending order, was the OR (4.78kg), OSC-MAC (2.78kg), OSC-local (2.6kg) and the clinic (0.65kg). Using ANOVA, there was a statistically significant decrease in the clinic versus every other setting (p<0.005).
Conclusions: The direct costs of an open CTR with local anesthesia were two times more expensive in the OSC compared to the clinic. The increased costs were the result of full disposable draping which is reflected by a five-fold increase in medical waste. Conversely, in the clinic, field sterility with re-usable sterile surgical towels is utilized.
The direct costs in the OR were seven times more expensive than the clinic. The increased costs were due to full sterility and an eight-fold increase in medical waste. Increased costs were also incurred as all patients in the OR received MAC or general anesthesia while all patients in the clinic were satisfactorily managed with local anesthesia. Anesthetic agents were included in the direct costs analysis but the anesthesiologist's professional fee was not included which would significantly increase the overall cost in the OR.
A limitation is the exclusion of indirect costs, however, one can argue that indirect costs are more substantial in the OR and OSC than the clinic and thus the overall cost would be increased and the profit margin decreased.
Open carpal tunnel release is more cost effective and generates less medical waste when performed in the clinic.

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