Use of Ultrasound in Patients With Carpal Tunnel Syndrome: A Cost-Effective Solution to Reduce Delays in Surgical Care.

PURPOSE: Currently, electrodiagnostic testing, which comprises electromyogram (EMG) and nerve conduction studies (NCS), is the most commonly used method for confirming the clinical diagnosis of carpal tunnel syndrome (CTS). Electromyogram and NCS can be costly, can require multiple visits, may induce anxiety, and may be painful for patients. The purpose of this study was to determine whether replacing EMG/NCS with ultrasound (US), performed by the treating surgeon, to diagnose CTS decreases time to surgery and the number of office visits. METHODS: We retrospectively reviewed a database that consisted of patients who presented to our department with numbness and/or tingling in the hand(s). We assessed the patients' histories for any subsequent carpal tunnel release, dates of diagnosis, dates of surgery, the number of CTS-related medical visits, and diagnostic methods employed. A fellowship-trained hand surgeon performed US examination, and the patients were referred for EMG/NCS testing. We collected data prior to surgery using the Boston Carpal Tunnel Questionnaire to evaluate symptom severity scale and functional status scale scores. We performed linear regression to assess differences in the time to surgery and the number of medical visits prior to carpal tunnel release. RESULTS: Patients who had the diagnosis confirmed by the surgeon using US (n = 34) underwent surgical intervention 3-4 weeks earlier, with 1.8 fewer medical visits on average than the number of medical visits for those who had their diagnosis confirmed using EMG/NCS (n = 98). CONCLUSIONS: If a confirmatory method for the diagnosis of CTS is required or desired by the treating surgeon, surgeon-conducted US might have an impact on the efficiency of care for patients with CTS. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Effect of Insurance Type on Access to Orthopedic Care for Pediatric Trigger Thumb.

PURPOSE: To assess the effect of type of insurance coverage on the ability of a pediatric patient to obtain an outpatient orthopedic appointment for trigger thumb. METHODS: A list of 200 orthopedic practices in 4 states were contacted and presented with a fictitious 3-year-old patient with trigger thumb. The patient was presented as having Blue Cross Blue Shield Insurance during the first call and Medicaid during the second call. Data regarding whether an appointment was offered or denied were recorded. RESULTS: Of the 200 practices, 81 were excluded, 22 because they did not answer the calls, 25 needed the patient's social security number, 19 needed medical records, 5 had no hand surgeon in the practice, and 10 would not see any children at all. Of the 119 practices included in the analysis, the private insurance patient was able to get an appointment 51.3% of the time whereas the Medicaid patient was able to get an appointment in 26.9% of instances. CONCLUSIONS: There is a significant effect of insurance status on the ability of pediatric patients with trigger thumb to obtain outpatient orthopedic appointments. CLINICAL RELEVANCE: Pediatric patients with Medicaid face greater barriers to accessing proper care for trigger thumb than patients with private insurance.

The Direct and Indirect Costs to Society of Carpal Tunnel Release.

Background: Carpal tunnel syndrome (CTS) is one of the most common compressive neuropathies and affects a large amount of individuals. We investigated the direct and indirect cost to society of operative versus nonoperative management of CTS. Methods: A Monte Carlo simulation model was used to estimate the lifetime direct and indirect costs associated with nonoperative and operative treatment of CTS, and its utility to patients. Results: Operative treatment of CTS had a lower total cost and a higher utility when compared with nonoperative treatment. Conclusions: CTS surgery is clearly a cost-effective treatment strategy that should be included in the societal perspective regarding evolving costs and savings associated with health care.

Ultrasound Measurement of the Cross-Sectional Area of the Median Nerve: The Effect of Teaching on Measurement Accuracy.

BACKGROUND: The purpose of this study was to determine the effect of concise instruction and guidance on the accuracy of measuring the cross-sectional area of the median nerve at the carpal tunnel inlet. METHODS: Seven orthopedic residents and 5 hand fellows obtained serial measurements of the median nerve at the carpal tunnel inlet using a 15-6 MHz ultrasound (US) probe. After a 5-minute teaching session, all participants repeated measurements. A single cadaveric specimen was used. Measurements were compared with the measurement of a fellowship-trained hand surgeon with extensive experience in US diagnosis of carpal tunnel syndrome. This was considered the reference standard. RESULTS: The rate of participants selecting the correct structure to measure on US was 36% before instruction and 97% after. Discarding the measurements of the incorrect structure, the average measurement was 4.8 mm2 before instruction and 5.2 mm2 after. The standard measurement was 6 mm2. The average deviation from the standard measurement -.2 mm2 before instruction and -0.8 mm2 after. The percent of measurements (of the correct structure) that fell within 1 mm2 of the standard measurement increased from 62% to 74%. Participant self-reported confidence in performing measurements elevated from 2.4/10 before instruction to 6.5/10 after. CONCLUSIONS: US of the median nerve cross-sectional area can be efficiently taught and results in measurements consistent with that of an experienced operator.

Comparison of ultrasound and electrodiagnostic testing for diagnosis of carpal tunnel syndrome: study using a validated clinical tool as the reference standard.

BACKGROUND: Ultrasound examination is both accurate and cost-effective for the confirmation of a clinical diagnosis of carpal tunnel syndrome. Previous studies have shown electrodiagnostic testing and ultrasound to be similar with regard to sensitivity and specificity. The purpose of this study was to compare the sensitivity and specificity of ultrasound and electrodiagnostic testing by using a validated clinical diagnostic tool as the reference standard. METHODS: All consecutive patients referred to an upper-extremity practice for electrodiagnostic testing for any reason over a three-month period were recruited to participate in this study. All patients were evaluated with the use of the Carpal Tunnel Syndrome 6 (CTS-6) clinical diagnostic tool, and a score of ≥12 was considered positive for carpal tunnel syndrome. A positive finding on ultrasound was considered to be a cross-sectional area of the median nerve, measured just proximal to the level of the pisiform, of ≥10 mm(2). A positive finding on electrodiagnostic testing was a distal motor latency of ≥4.2 ms and/or a distal sensory latency of ≥3.2 ms. Sensitivity, specificity, and accuracy were calculated for ultrasound and electrodiagnostic testing with use of the CTS-6 as the reference standard. RESULTS: With use of the CTS-6 as the reference standard, ultrasound had a sensitivity of 89% and a specificity of 90% in our series of eighty-five patients. Electrodiagnostic testing had a sensitivity of 89% and a specificity of 80%. The positive predictive value of ultrasound was 94% compared with 89% for electrodiagnostic testing. The negative predictive value of ultrasound was 82% compared with 80% for electrodiagnostic testing. Ultrasound was accurate in seventy-six (89%) of the eighty-five cases whereas electrodiagnostic testing was accurate in seventy-three (86%) of the eighty-five cases (p = 0.5). CONCLUSIONS: While ultrasound will not replace electrodiagnostic testing in complicated or unclear cases, in a select group of patients with a positive CTS-6, ultrasound can be used to confirm the diagnosis of carpal tunnel syndrome with better specificity and equal sensitivity as compared with those of electrodiagnostic testing. LEVEL OF EVIDENCE: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Patient perception of physician reimbursement for common hand surgical procedures.

Health care-related costs have been the focus of intense scrutiny in politics and in the media. However, public perception of physician reimbursement is poorly understood. The purpose of this study was to determine patient perception of physician reimbursement for 2 common hand surgery procedures: carpal tunnel release and open reduction and internal fixation of a distal radius fracture. Anonymous surveys were completed by 132 patients in an outpatient hand and upper-extremity practice. The surveys asked patients to estimate reasonable surgeon fees and actual Medicare reimbursement for 2 common hand surgery procedures (carpal tunnel release and internal fixation of a distal radius fracture) and 2 common surgical procedures (coronary artery bypass and appendectomy). On average, patients estimated that a reasonable surgeon fee for carpal tunnel release and 90 days of postoperative care was $2629 and that actual Medicare reimbursement was $1891. Patients estimated that a reasonable surgeon fee for internal fixation of an extra-articular distal radius fracture and 90 days of postoperative care was $3874 and that actual Medicare reimbursement was $2671. Higher level of education, annual household income, and insurance status had no statistically significant effect on patient estimates of reimbursement. Patients in an outpatient hand and upper extremity practice believe that surgeons are reimbursed at a rate 3.6 to 4.7 times greater than actual reimbursement. These misperceptions highlight the lack of understanding and transparency in health care costs and may interfere with the ability of patients to make well-informed decisions about health care.

Ultrasound as a first-line test in the diagnosis of carpal tunnel syndrome: a cost-effectiveness analysis.

BACKGROUND: The American Academy of Orthopaedic Surgeons (AAOS) recommends that surgeons obtain a confirmatory test in patients for whom carpal tunnel surgery is being considered. The AAOS, however, does not specify a preferred test. Ultrasound reportedly causes less patient discomfort and takes less time to perform, while maintaining comparable sensitivity and specificity to electrodiagnostic testing (EDX). QUESTIONS/PURPOSES: We determined whether ultrasound as a first-line diagnostic test is more cost-effective than using EDX alone or using ultrasound alone: (1) when used by a general practitioner; and (2) when used by a specialist. METHODS: A fictional population of patients was created and each patient was randomly assigned a probability of having true-positive, false-positive, true-negative, and true-positive ultrasound and EDX tests over an expected range of sensitivity and specificity values using Monte Carlo methods. Charges were assigned based on Medicare charges for diagnostic tests and estimates of missed time from work. RESULTS: The average charge for the use of ultrasound as a first-line diagnostic test followed by EDX for confirmation of a negative ultrasound test was $562.90 per patient in the general practitioner scenario and $369.50 per patient in the specialist scenario, compared with $400.30 and $428.30 for EDX alone, respectively. CONCLUSIONS: The use of diagnostic ultrasound as a first-line test for confirmation of a clinical diagnosis of carpal tunnel syndrome is a more cost-effective strategy in the specialist population and results in improved false-negative rates in the generalist population despite increased cost. LEVEL OF EVIDENCE: Level III, economic and decision analyses. See the Guidelines for Authors for a complete description of levels of evidence.