Cost Implications of Varying the Surgical Setting and Anesthesia Type for De Quervain Release Surgery

Abstract

Background  First extensor compartment release is a common surgical procedure that represents a financial burden to the health care system.

Questions/Purposes  Study questions included (1) whether surgical encounter costs differ based upon surgical setting (operating room [OR] vs. procedure room [PR]) or (2) based upon anesthesia choice (local only, Bier's block [BB], monitored anesthesia care [MAC], or general [GA]) for De Quervain release (DQR).

Patients and Methods  Consecutive adult patients undergoing isolated unilateral DQR at a single academic medical center were identified retrospectively by Current Procedural Terminology code (25000). Using our institution's information technology value tools, we calculated total direct costs for each surgical encounter. Costs were adjusted to January 2016 dollars using the Consumer Price Index, normalized using each participant's surgical encounter cost divided by the median cost in the PR group, then compared across each group using Kruskal–Wallis and Nemenyi's post hoc pair-wise tests. Multivariable gamma regression analysis with a log link was performed to identify factors associated with surgical costs. QuickDASH (disabilities of the arm, shoulder, and the hand) scores were compared using a t -test at final follow-up.

Results  Among 58 included patients, 29% (17/58) were treated in the PR and 71% (41/58) in the OR. Compared with local only in the PR, all other groups were significantly more costly. Multivariable gamma regression indicated that use of OR/BB, OR/MAC, or OR/GA independently led to 211, 222, and 357% greater surgical costs as compared with the PR with local only while controlling for provider and patient age. Furthermore, QuickDASH scores were similar between PR and OR groups at final follow-up.

Conclusion  Performing DQR in the PR setting under local only anesthesia yields greater value than the OR, as patient-reported outcomes are similar despite significantly lower surgical costs. Level of Evidence This is a Level III, cost analysis study.

Given that the cost of health care delivery has come under great scrutiny over the past decade, in part, due to policy changes that have included value-based payment models in the United States, ^{1 2} it is clear that the consideration of treatment costs has become an important part of treatment selection. In other words, it is important for surgeons to understand the cost implications of their treatment decisions, particularly when clinical evidence is lacking to support one treatment choice over another.

First extensor compartment release, or De Quervain release (DQR), is a common surgical procedure that represents a financial burden to the health care system. DQR is reserved for selected patients with ongoing pain and decreased function despite maximized nonoperative treatment. ^{3 4 5} Substantial efforts have previously been made to assess clinical outcomes following DQR, ^{6 7 8 9 10} although prior work elucidating factors that influence surgical treatment costs is lacking in the current literature. Such information may help to guide treatment of patients with De Quervain tendinopathy, as the treating surgeon has several treatment choices to consider when surgically treating indicated patients. These factors include choice of a procedure room (PR) or operating room (OR) for the surgical setting, ^{11 12} and choice of a variety anesthetic types including local only, Bier's block (BB), monitored anesthesia care (MAC), regional anesthesia, and general anesthesia (GA). ^{10 12}

The choice of surgical setting and anesthesia type has not been proven to alter the clinical outcome following DQR, but these decisions may alter surgical treatment costs. Therefore, the discussion related to what constitutes appropriate treatment should focus on improving value through cost reduction. To this effect, our institution developed a “Value Driven Outcomes” (VDO) database that contains granular patient- and item-level total direct cost data for all health care services. This has successfully identified areas of high variability in cost, leading to improved value of care delivered ¹ and identification of sources of cost variation that may be targeted to improve value. ^{13 14 15 16 17 18} In the current study, the VDO tool was utilized to answer our primary study question of whether the choice of surgical setting (OR vs. PR), and anesthetic type (local only, BB, MAC, or GA) affect surgical encounter costs for DQR.

Patients and Methods

This institutional review board (IRB)-approved retrospective cost analysis study included all consecutive adult (≥18 years of age) patients undergoing isolated unilateral DQR between January 2014 and August 2018, performed by five fellowship-trained hand surgeons, at a single tertiary academic institution. Patients were identified by Current Procedural Terminology code (25000) via a computerized search of the electronic medical record, and corresponding basic demographic and surgical data were tabulated. Manual chart review of all pertinent operative, anesthesia, and orthopaedic clinic notes was performed to confirm the diagnosis, surgical procedure performed, surgical location (PR vs. OR), and anesthesia type. All included patients had a chart-documented diagnosis of De Quervain tendinopathy in their operative note, and clinic records documenting a positive Finklestein's test. Patients undergoing additional simultaneous procedures including other surgeries or injections, and those undergoing bilateral simultaneous releases, were excluded. Also excluded were patients undergoing revision release, as these cases are not representative of primary surgeries and would be expected to cost more. Patients undergoing surgery prior to July 2014 (corresponding with initiation of wide-awake local only no tourniquet [WALANT] hand surgery at our institution) were also excluded. We did not exclude patients diagnosed with complications subsequent to the index procedure, and we did not adjust costs of the index procedure to include costs related to the treatment or evaluation of subsequent complications.

DQR was performed as previously described. ¹⁹ A 2-cm transverse radial-sided wrist incision, approximately 1-cm proximal to the radial styloid was utilized, and blunt dissection was used to identify the superficial radial nerve branches. The first extensor compartment was sectioned dorsally, and retraction on the tendons was performed to identify a separate extensor pollicis brevis subsheath which was then similarly sectioned as needed. Wounds were irrigated and then closed, and a bulky thumb spica splint versus a plaster splint was placed depending on surgeon preference.

The decision to perform DQR in the PR versus OR was based on patient preference using a shared decision-making model.

WALANT Protocol

As previously described, ²⁰ patients were not required to undergo preoperative medical or anesthesia evaluation regardless of their comorbidities. All WALANT surgery was performed in the PR setting, adjacent to the ambulatory surgery center ORs. Patients were brought directly from the surgical waiting room into the PR and placed supine on an OR table with an adjacent mobile hand table, where local anesthesia was administered to the operative site in standard sterile fashion using a formulation of 4.5 cc of 1% lidocaine and 4.5 cc of 0.5% bupivacaine with 1:100,000 epinephrine buffered with 1 cc of 8.4% sodium bicarbonate (10:1 ratio). ²¹ An injection of approximately 10 cc was administered prior to the subsequent formal preparation and draping of the surgical site to allow time for the epinephrine to fully act as a vasoconstrictor. Phentolamine was available for use if critical digital ischemia occurred. ²²

Patients were not asked to disrobe, and the arm was exposed and sterilized to the level of the elbow. All home medications including anticoagulation agents were neither held prior to nor discontinued after the procedure, and patients were not required to fast prior to the procedure. No cardiovascular monitoring was used, neither was an intravenous (IV) line placed. Staffing of the PR included an attending hand surgeon, medical assistant to assist with achieving field sterility, hand surgery fellow or resident, and a nurse assigned specifically to the PR setting. A sterile nonpneumatic tourniquet was available for use if requested by the attending surgeon. After the procedure, patients received postoperative care instructions and were discharged directly to home/self-care.

Operating Room Protocol

As previously described, ²⁰ patients receiving surgery in the OR, by comparison, were required to fast for at least 8 hours prior to the procedure, disrobed and placed into a surgical gown, had an IV placed, and underwent routine evaluation by an anesthesiologist in the preprocedural setting prior to being taken back by gurney to the OR. Choice of anesthesia performed in the OR was based on surgeon and anesthesiologist preference, and included local only anesthesia using a 1:1 mixture of plain lidocaine (1%) and bupivacaine (0.5%), or MAC supplemented with the same local anesthetic mix. A forearm tourniquet was used to minimize intraoperative bleeding. In accord with hospital policy, intraoperative cardiovascular monitoring was routinely supervised by an attending anesthesiologist. After the surgery, the patients were taken by gurney to the post–anesthesia care unit (PACU) where further cardiovascular monitoring and nursing services were utilized, and then they were discharged to the care of a companion after receiving postoperative care instructions.

Total direct costs for each surgical encounter were extracted from the VDOs database. The VDO information technology tool draws prospectively collected cost data and patient- and item-level total direct cost data from our institution's data warehouse for specific patient encounters. VDO costing methods have been previously described, which allow access to total direct costs for materials used for patient care, facility utilization direct costs (including sterile processing costs), and time-based cost allocations including procedure/operative time and cost of staff involved in care (nursing, surgical technicians, and medical assistants). ^{1 13 14 16 20 23} As the outcome measure was total direct costs, rather than payments, reimbursement for the surgeon, anesthesiologist, and facility were not included; however, time-allocated costs for the surgeon, anesthesiologist, and facility use were captured by the database. All cost categories captured by the VDO tool are further illustrated in Appendix A . At our institution, the PR and OR are both located within an orthopaedic ambulatory surgery center, and the PR is considered a place of service 22 (a PR within a hospital). Both the PR and OR incur a facility cost (OR costs are 8.4-fold greater than the PR per minute of use). ¹⁴

Table 1. Baseline patient characteristics.

	OR n  = 41 (%)	PR n  = 17 (%)	Overall n  = 58 (%)	p -Value
Sex
Female	31 (75.6)	14 (82.4)	45 (77.6)	0.74 a
Male	10 (24.4)	3 (17.6)	13 (22.4)
Age
Mean (SD)	42.5 (14.9)	55.5 (16.2)	46.3 (16.3)	0.01 b
Median (min, max)	39.0 (18.0, 74.0)	53.0 (26.0, 82.0)	47.0 (18.0, 82.0)
Insurance type
Commercial	33 (80.5)	9 (52.9)	42 (72.4)	0.08 a
Medicaid	1 (2.4)	0 (0)	1 (1.7)
Medicare	6 (14.6)	6 (35.3)	12 (20.7)
Self-pay	1 (2.4)	2 (11.8)	3 (5.2)
Marital status
Divorced	2 (4.9)	0 (0)	2 (3.4)	0.09 a
Married	28 (68.3)	15 (88.2)	43 (74.1)
Single	11 (26.8)	1 (5.9)	12 (20.7)
Widowed	0 (0)	1 (5.9)	1 (1.7)
Race
American Indian and Alaska Native	2 (4.9)	1 (5.9)	3 (5.2)	0.16 a
Asian	0 (0)	1 (5.9)	1 (1.7)
Other	1 (2.4)	2 (11.8)	3 (5.2)
White or Caucasian	38 (92.7)	13 (76.5)	51 (87.9)
ASA class a
Missing	2 (4.9)	–	–
1. Healthy	12 (29.3)	–	–	N/A c
2. Mild systemic disease	24 (58.5)	–	–
3. Severe systemic disease	3 (7.3)	–	–

Abbreviations: ASA, American Society of Anesthesiologists; OR, operating room; PR, procedure room; SD, standard deviations.

^aFisher's exact.

^b t -Test.

^cASA class was only recorded for OR patients, and therefore a comparison cannot be made.

All reported cost data were normalized using each individual's cost divided by the average cost in the dataset, to comply with institutional guidelines prohibiting the public reporting of any financial data related to the details of nonpublically disclosed contractual agreements. Each unique combination of surgical location (PR or OR), and anesthesia type (local only, BB, MAC, and GA) was defined as a distinct group. Continuous variables were summarized as mean ± standard deviation (SD) or median ± interquartile range, as appropriate. Categorical variables were summarized as count and percentage (%). Relative costs were calculated relative to the lowest group by dividing each distinct group median by the lowest group median. Total direct costs and total combined payments were compared between groups using Kruskal–Wallis tests, followed by Nemenyi's post hoc tests to adjust for multiple comparisons. ²⁴ Univariate and multivariable gamma regression model with loglink was used to identify factors that are associated with surgical encounter total direct costs. Regression predictors of interest included patient demographic variables, American Society of Anesthesiologists (ASA) class, surgical setting, anesthesia type, and provider. For surgical cases performed in the OR, a separate regression model is built, including surgical time as additional predictor. Exponentiated gamma regression coefficients (eβ, synonymous with relative cost) and their 95% confidence intervals (CIs) were reported, describing relative percent change for each regression predictor. Statistical significance was assessed at the 0.05 level and all tests were two-tailed.

Complications and patient-reported functional outcomes were also compared between the OR and PR groups. Chart review was performed to identify any intraoperative surgical and medical complications or any postoperative complications. The abbreviated version of the Disabilities of the Arm, Shoulder and the Hand (QuickDASH) was used to assess the functional outcomes of patients at their latest follow-up visit. QuickDASH scores were excluded if a new or worsened upper extremity condition, injury or surgery occurred between the DQR and the collection of the QuickDASH to avoid confounding the interpretation of the postoperative outcome for the index surgery. A two-sided t -test at a significant level of 0.05 was used to compare QuickDASH scores between the two surgical settings.

Our a priori power calculation was based on an effect size of 1.0 in SD units. With a two-sided, two-sample t -test, we would need a total sample size of 51 (17 PR and 34 OR cases) to detect a medium effect size of 1 per SD unit for cost ratio between PR and OR groups with 90% of power at 0.05 significance level.

Results

Among 67 patients identified, who underwent DQR, 8 patients that underwent additional simultaneous surgeries or injections were excluded. We also excluded the one patient who received local only anesthesia in the OR, as formal statistical analysis could not be performed on this group due to low sample size. Therefore, a total of 58 patients were included for final analysis. Mean age was 46.3 ± 16.3 years, and 78% (45/58) were female. The majority of cases were performed in the OR (71% [41/58]), with 29% (17/58) in the PR. Additional baseline patient characteristics, as well as comparisons between PR and OR groups, are provided in Table 1 .

Given that only two patients were observed to have received regional anesthesia only, these patients were combined with the BB anesthetic group for the analysis. Therefore, our analysis was performed on four separate groups: (1) PR with local only anesthesia (PR/local), OR with MAC anesthesia (OR/MAC), OR with BB/regional anesthesia (OR/BB-regional), and OR with general anesthesia (OR/GA). Table 2 illustrates additional surgical details including the provider, anesthesia type, and surgery time for OR cases.

Table 2. Summary of surgical details.

	OR n  = 41 (%)	PR n  = 17 (%)	Overall n  = 58 (%)	p -Value
Provider
A	20 (48.8)	0 (0)	20 (34.5)	0.002 a
B	8 (19.5)	8 (47.1)	16 (27.6)
C	3 (7.3)	2 (11.8)	5 (8.6)
D	6 (14.6)	5 (29.4)	11 (19.0)
E	4 (9.8)	2 (11.8)	6 (10.3)
Anesthesia type
General	5 (12.2)	0 (0)	5 (8.6)	<0.001 a
MAC	19 (46.3)	0 (0)	19 (32.8)
BB/regional	16 (39.0)	0 (0)	16 (27.6)
Surgery time (min) b
Mean (SD)	17.1 (5.74)	–	17.1 (5.74)
Median (min, max)	17.0 (8.00, 35.0)	–	17.0 (8.00, 35.0)

Abbreviations: BB, Bier's block; MAC, monitored anesthesia care; OR, operating room; PR, procedure room; SD, standard deviations.

^aFisher's exact.

^bSurgery time was only recorded for OR patients, and therefore a comparison cannot be made.

Compared with PR/local, all other treatment strategies for DQR were significantly more costly ( Fig. 1 ). Univariate gamma regression analysis of surgical costs for the overall population (PR and OR cases) showed that age, surgical setting, anesthesia type, and surgical time (specific to OR cases) were significantly associated with surgical costs ( Table 3 ). Univariate analysis demonstrated lack of significance for patient sex, race, marital status, ASA class, insurance type, and provider.

Fig. 1.

Data represent median costs ± standard error of the mean (SEM). # Reference group, normalized to a cost of 1.0. * p  < 0.05 as compared with left-sided neighboring value per Kruskal–Wallis tests and Tukey's multiple pair-wise comparison tests. Values over graph bars represent fold-change differences relative to the reference group. The dotted line represents the normalized cost of the reference group. BB, Bier's block; GA, general anesthesia; MAC, monitored anesthesia care; OR, operating room; PR, procedure room.

Table 3. Univariate gamma regression analysis for surgical total direct costs.

Variable Names	Exponentiated regression coefficient (e β )	95% CI—lower	95% CI—upper	p -Value
Age	0.99	0.98	0.99	<0.05
Sex a	0.90	0.68	1.23	0.53
Race—white (vs. other) b	1.02	0.68	1.48	0.92
Marital status—not married c	1.16	0.88	1.55	0.32
ASA d —healthy	Reference	–	–	–
Mild systemic disease	0.90	0.76	1.05	0.19
Severe systemic disease	0.88	0.66	1.19	0.38
Insurance e	0.78	0.59	1.03	0.08
Provider f –A	Reference	–	–	–
B	0.76	0.53	1.07	0.12
C	1.00	0.61	1.73	>0.99
D	0.68	0.46	1.01	0.06
E	0.87	0.55	1.45	0.58
PR (vs. OR) g	0.31	0.25	0.39	<0.05
Surgical time (min)	1.02	1.01	1.03	<0.05 h
Anesthesia type i –GA	Reference	–	–	–
Local only	0.25	0.17	0.36	<0.05 j
MAC	0.79	0.53	1.13	0.22
BB/regional	0.70	0.47	1.01	0.07

Abbreviations: ASA, American Society of Anesthesiologists; BB, Bier's block; CI, confidence interval; GA, general anesthesia; MAC, monitored anesthesia care; OR, operating room; PR, procedure room.

Note: exponentiated coefficients (e ^β ) demonstrate relative costs of subgroups relative to the reference. For example, a value of 1.6 is interpreted as a 60% increase in costs with respect to the reference group, and a value of 0.80 is interpreted as a 20% decrease in costs.

^aMale vs. female as reference group.

^bWhite vs. non-White (including Asian, American Indian and Alaska Native, and Others) as the reference group.

^cNot married, versus married as the reference group.

^dASA for OR cases only; ASA1-Healthy used as the reference group.

^eNon-commercial Insurance, vs. commercial Insurance as reference group.

^fProvider A as the reference group.

^gPR/local only as the reference group.

^hSpecific to only OR cases.

ⁱGA was used as the reference group.

^jSpecific to only PR cases.

Multivariable gamma regression analysis of surgical costs for the overall population (PR and OR cases) indicated that use of OR/BB-regional, OR/MAC, and OR/GA independently led to 211–222, and 357% greater surgical costs as compared with the PR with local only, respectively, while controlling for provider and patient age ( Table 4 ).

Table 4. Overall population: multivariate gamma regression analysis results on relative total direct costs.

Variable	Exponentiated regression coefficient (e β )	95% CI	p -Value
Age	0.99	(0.99–1.01)	0.31
Provider a
B	0.97	(0.61–1.51)	0.91
C	1.53	(0.88–2.64)	0.12
D	0.93	(0.57–1.46)	0.75
E	1.30	(0.77–2.15)	0.32
Anesthesia type/surgery location b
OR/GA	4.57	(3.01–7.08)	<0.05
OR/MAC	3.22	(2.44–4.24)	<0.05
OR/BB-regional	3.11	(1.87–5.04)	<0.05

Abbreviations: BB, Bier's block; CI, confidence interval; GA, general anesthesia; MAC, monitored anesthesia care; OR, operating room.

Note: exponentiated coefficients (e ^β ) demonstrate relative costs of subgroups relative to the reference. For example, a value of 1.6 is interpreted as a 60% increase in costs with respect to the reference group, and a value of 0.80 is interpreted as a 20% decrease in costs.

^aProvider A as the reference group.

^bPR/local only as the reference group.

The secondary multivariable gamma regression analysis of surgical costs specific to cases done in the OR revealed that the use of BB-regional or MAC anesthesia was associated with 30 and 24% reductions in surgical costs as compared with GA, respectively, while controlling for other confounders ( Table 5 ). Increased surgical time was associated with significantly greater surgical costs such that each additional 1 minute led to 2.7% greater surgical costs.

Table 5. OR only population: multivariate gamma regression analysis results on relative total direct costs.

Variable	Exponentiated regression coefficient (e β )	95% CI	p -Value
Age	1.00	(0.99–1.00)	0.41
Provider a –A	Reference	–	–
B	1.06	(0.88–1.26)	0.53
C	1.20	(0.96–1.51)	0.12
D	1.03	(0.85–1.25)	0.73
E	1.11	(0.89–1.37)	0.37
Anesthesia b –GA	Reference	–	–
OR/MAC	0.76	(0.65–0.89)	<0.05
OR/BB-regional	0.70	(0.57–0.86)	<0.05
Surgery time (min)	1.03	(1.02–1.03)	<0.05

Abbreviations: BB, Bier's block; CI, confidence interval; GA, general anesthesia; MAC, monitored anesthesia care; OR, operating room.

Note: exponentiated coefficients (e ^β ) demonstrate relative costs of subgroups relative to the reference. For example, a value of 1.6 is interpreted as a 60% increase in costs with respect to the reference group, and a value of 0.80 is interpreted as a 20% decrease in costs.

^aProvider A as the reference group.

^bOR/GA as the reference group.

The number of complications for the OR and PR groups were 7 (17%) and 1 (6%), respectively. Four OR patients experienced continued radial-sided wrist pain postoperatively, 1 had late return of symptoms, 1 had subjective stiffness, and 1 patient had decreased sensation in the superficial radial distribution. One PR patient had return of radial-sided wrist pain symptoms. No intraoperative complications were observed in either cohort. The OR and PR mean QuickDASH scores were 32.4 ± 19.6 ( n  = 19) and 31.6 ± 20.6 ( n  = 12) at an average follow-up of 6.0 ± 10.0 and 2.7 ± 2.7 months, respectively. These QuickDASH scores were no different between OR and PR groups ( p  = 0.91).

Discussion

Our main finding was that performing DQR in the OR was associated with 211 to 357% greater surgical encounter direct costs depending on the anesthesia type used, as compared with performing the surgery in the PR setting with local anesthetic only. Therefore, we rejected our null hypothesis that there are no cost differences for DQR based on surgical setting. Secondarily, we found that OR and PR settings yielded similar patient-reported outcomes (QuickDASH scores). Therefore, we conclude that performing this common surgical procedure under WALANT is a reasonable option in terms of improving the value of care for operative De Quervain patients.

This finding is unique, as we were unable to identify a single published study in the literature describing factors affecting surgical costs for DQR specifically. However, our main finding is consistent with prior literature. Rhee et al described substantial cost reductions related to performing small hand surgeries in the PR setting with local only anesthesia, 4% of which were DQRs. ¹¹ The authors projected nearly $400,000 in savings to the Military Health Care System by performing 100 minor hand surgeries in a clinic-based PR rather than the OR. In another study evaluating costs associated with anesthesia services for small hand surgeries, Kamnerdnakta et al concluded that such services may not be medically indicated but account for substantial costs for low-risk patients undergoing minor hand surgeries, including DQRs. ²⁵ Although not specific for DQR, other studies have demonstrated significant and substantial cost savings associated with performing carpal tunnel release ^{14 26} and trigger digit release ²⁰ in the PR setting as opposed to the OR.

As a secondary finding, we observed significant differences in surgical encounter direct costs for DQR based on anesthesia choice. In our multivariable regression analysis of patients treated in the OR, we observe that use of BB/regional or MAC anesthesia significantly reduced surgical costs by 30 and 24%, respectively, as compared with general anesthesia. Although no prior literature exists to our knowledge that is specific to DQR, these results mirror those for carpal tunnel release ^{14 27} and trigger digit release. ²⁰

Limitations

This study has several limitations that deserve mention. Although the diagnosis and surgery performed for each surgical encounter were verified with chart review, the identification of patients by procedure code, the retrospective study design, and our single-center study design introduce potential for selection bias. Likely due to our nonrandomized study design, a significant difference in age PR, and OR groups was observed. However, it is unclear if this difference would affect procedural costs. Generalizability of our results may be limited by our unique pricing agreements between suppliers and our institution, which may affect total direct costs of disposable surgery supplies, pharmaceuticals, and time-allocated costs of perioperative services related to the surgical encounter. However, these trends likely exist in other care systems, as previously documented for moving minor hand surgeries out of the OR and into the PR in the United States military ¹¹ and nonmilitary populations, ^{14 20 23 28 29} for the National Healthcare System, ³⁰ and in Canada. ²⁶ The VDO database does not include indirect cost data such as housekeeping, electricity, or property rent/depreciation. Additionally, the study was not designed to evaluate indirect costs related to missed work. Although we believe this limitation does not hinder the primary aim of the study, which is to evaluate factors that affect costs of DQR, a cost-effectiveness analysis study combining such data with health utilities would be informative. Finally, complications were so infrequent that a sound statistical comparison between OR and PR groups was not possible.

Conclusion

In conclusion, we observed that performing DQR in the OR independently led to 211–357% greater surgical costs depending on the anesthesia type used, as compared with surgery in the PR setting with local only anesthesia. Furthermore, OR and PR settings yielded similar QuickDASH outcome scores. Taken together, performing this surgery in the PR setting yields greater value of care than the OR. For surgeons preferring the OR setting, use of monitored anesthesia care or regional anesthesia was associated with significant cost savings, as compared with general anesthesia. These cost drivers should be considered when indicating appropriate patients for DQR. In our current practice, all patients are candidates for DQR in the PR, and we reserve the OR for those with anxiety issues or those undergoing multiple other simultaneous surgeries.

Appendix A Breakdown of Value-Driven Outcomes Database Categories for Total Direct Costs

• Imaging costs: all imaging, scans, and radiology services used.

• Supply costs: all supplies and devices used, excluding implants.

• Implant costs: all supply costs related to surgical implants.

• Pharmacy costs: total cost of all medication used during the patient encounter.

• Laboratory costs: all lab work associated with the visit, including blood work, urinalysis, hematology, and all other lab or chemistry related costs.

• Other services costs: services that do not fall into one of the other categories. Services include physical therapy, occupational therapy, speech pathology, respiratory service, EKG, recovery room nursing/staff, and other therapeutic services.

Facility utilization costs: time and labor costs for patients stay in each unit (excluding professional costing such as time-allocated estimates of physician costs). Cost is mapped to the individual patient level based on time spent on specific unit (surgery minutes, patient hours) or by completed visit.

Funding Statement

Funding A.P. received funding from the NIH in the form of a grant, this investigation was supported by the University of Utah Study Design and Biostatistics Center, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant 5UL1TR001067-02 (formerly 8UL1TR000105 and UL1RR025764).