Clinical Care Redesign to Improve Value for Trigger Finger Release: A Before-and-After Quality Improvement Study

Abstract

Background: Trigger finger release (TFR) is a commonly performed procedure. However, there is great variation in the setting, care pathway, anesthetic, and cost. We compared the institutional cost for isolated TFR before and after redesigning our clinical care pathway. Methods: Total direct cost to the health system (excluding the surgeon and anesthesiology costs) and time spent by the patient at the surgery center were collected for 1 hand surgeon’s procedures at an ambulatory surgery center over a 3-year period. We implemented a redesigned pathway that altered phases of care and anesthetic use by transitioning from intravenous (IV) sedation to wide awake local anesthesia with no tourniquet. Cost data were reported as percentage change in the median and compared both pre- to post-implementation and with 2 control surgeons using the traditional pathway within the same center. Power analysis was based on prior work on a carpal tunnel pathway. Significance was defined by a P-value < .05. Results: Ten TFRs (90% local with IV sedation) and 44 TFRs (89% local alone) were performed pre- and post-implementation, respectively. From pre- to post-implementation, the study surgeon’s total direct cost decreased by 18%, while the control surgeons decreased by 2%. Median time spent at the surgery center decreased by 41 minutes post-implementation with significantly shorter setup time in the operating room (OR), total time in the OR, and time spent in recovery prior to discharge. Conclusions: Redesigning the care pathway for TFR led to a decrease in institutional cost and patient time spent at the surgery center.

Introduction

Trigger finger (TF) or stenosing tenosynovitis is one of the most common conditions seen in a hand surgeon’s practice.¹ It is estimated to affect 2.2% of adults greater than 30 years old and up to 10% of patients with insulin-dependent diabetes.^2,3 While the surgical technique used in the management of TF differs little between hand surgeons, the setting (i.e. clinic procedure room, ambulatory surgery center, hospital-based operating room [OR]), care pathway on the day of surgery, and anesthetic choice (i.e. general anesthetic, local anesthetic with sedation, local anesthetic alone) differ widely between hand surgeons.¹ Hand surgeons may adjust these factors based on their own clinical acumen for each individual patient. As healthcare systems are focusing on the “quality of care” and the costs associated with the care provided (“value-based care”), there has been a drive to measure and track these metrics.^4-6 With the shift toward value-based reimbursement models, such as bundled payments, the cost incurred by all stakeholders (health system/hospital, surgeon, patient) will come under increased scrutiny. Thus, it is important to identify and remove unnecessary costs while maintaining quality of care. Cost can be defined from a number of different perspectives, including the “payer” (insurance company), institution (health system or hospital), surgeon, patient, or society in general.¹ Prior studies have evaluated the difference in cost or charges with isolated changes in anesthesia type^1,7,8 (i.e. local anesthesia with or without sedation) and/or location^1,7,9 (i.e. clinic vs. OR) from the payer and surgeon standpoint.^1,7-9 Few studies have evaluated it from an institution or health system perspective and even fewer studies have discussed a complete care pathway redesign including efforts to streamline aspects of care by partnering with other members of the care team to improve transitions, and move portions of care from areas with a time-based cost (i.e. OR) to those areas with a fixed cost (i.e. pre-operative holding). We identified 2 studies analyzing TF releases (TFRs) and utilizing the institutional cost perspective, but these studies may not be applicable to the general United States healthcare market place as they were performed in the British National Healthcare System⁹ and the United States military.⁷

This study reports the change in institutional total direct cost by redesigning our clinical care pathway for performing TFRs. In addition, we looked for a difference in patient time spent at the surgical center. We hypothesized that there would be a significant decrease in institutional cost after implementing a new care pathway emphasizing value-based care. A secondary hypothesis was that there would be a significant decrease in patient time spent at the surgery center.

Materials and Methods

Improving Our Health Systems Pathway

This study was exempt from institutional review board review as a quality improvement initiative. We started by creating a current-state process map of our health system’s pathway used for the management of TF and cross-referenced it with evidence from the literature (Table 1). Prior to this, the intervention surgeon (R.N.K.) performed TFR using local anesthesia administered in the OR after the patient received IV sedation administered by an anesthesiologist (monitored anesthesia care). Next, we identified areas within this pathway that we could modify to decrease institutional direct medical costs. These areas included: (1) offering local alone (without the presence of anesthesia staff, sedation, and/or regional anesthesia) with no tourniquet (commonly termed WALANT); (2) the surgeon performing local alone injections in the pre-operative holding area rather than in the OR where time is charged; (3) involving the perioperative staff to facilitate a streamlined process in the OR before and after the procedure; and (4) involving the recovery staff to decrease time spent in recovery (i.e. requiring only 1 set of vital signs for local alone cases). Using these identified areas, we constructed an evidence-based high-value clinical care pathway which was initiated in March 2016 (Figure 1). A team of stakeholders (study surgeon, hand fellow, OR manager, sterile processing staff, and hospital quality improvement staff) continuously reviewed the data during the study period and identified opportunities for improvement. An example fishbone diagram for root cause analysis is demonstrated in Supplemental Figure 1.¹⁰

Table 1.

Evidence-Based Support for the Post-Implementation Clinical Care Pathway.

Study/guideline	Domain (structure, process, outcome)	Aspect of care pathway
Döring et al,11 Codding et al8	Process	Assessment: Shared decision-making in preference sensitive conditions
Huisstede et al,12 Choudhury13	Process	Pre-operative: Non-steroidal anti-inflammatories in the treatment of trigger finger
Huisstede et al,12 Choudhury13 Colbourn et al,14	Process	Pre-operative: Splinting in the treatment of trigger finger
Peters-Veluthamaningal et al,15 Fleisch,16 Sheikh17	Process	Pre-operative: Corticosteroid injections for the treatment of trigger finger
Kerrigan1	Process	Pre-operative: Indications for trigger finger surgery (locked finger, ≥ 2 trigger finger injections)
Lalonde et al18	Process	Pre-operative: Lidocaine with epinephrine for local anesthesia, no monitored anesthesia care
Huisstede et al12	Outcome	Pre-operative/post-operative/follow-up: VAS pain
Huisstede et al12	Outcome	Post-operative: Trigger finger release should lead to improved patient-reported outcomes

Note. VAS = visual analogue scale.

Figure 1.

Clinical process map for the management of trigger finger at our health system.

Reviewing the Outcomes

We used a historically controlled cohort to compare the cost and time pre- and post-intervention. All patients treated with isolated TFR by the primary author (RNK), a fellowship-trained orthopedic hand surgeon, at a tertiary academic referral center from October 1, 2014 until December 1, 2017 were identified using the Current Procedural Terminology code for TFR (26055). All surgeries were performed at an outpatient surgery center owned by the academic institution. Patients were excluded if they were under 18 years of age, had any concomitant procedure (including the removal of retinacular cysts from the flexor tendon sheath), or had multiple TF addressed during the index surgery. Cost and time data were collected from the electronic health record in addition to separate systems used by the financial and peri-operative services department at our health system. Two main parameters were compared: (1) institutional total direct cost; and (2) patient time spent in each phase of care.

Cost: Cost was analyzed for each surgical encounter from the health system’s perspective (from the pre-operative holding area to discharge). This cost did not include the initial diagnostic work-up, non-operative management, anesthesiologist or surgeon bills, follow-up visits, or rehabilitation. Total direct costs were provided for each encounter by the hospital’s Financial Decision Support System staff. Due to health system confidentiality considerations, cost was reported as a percentage change rather than the actual value.

Patient time: Total (lead) time was defined as the time from the patient entering the pre-operative holding area to leaving the recovery unit. This period of time was further subcategorized by the following time stamps: (1) “pre-op time” (entering the pre-operative holding area to entering the OR); (2) “setup time” (entering the OR to making an incision); (3) “surgery time” (making an incision to completion of dressing application); (4) “wake & leave time” (completion of dressing application to leaving the OR); (5) “time in the OR” (entering the OR to leaving the OR); and (6) “recovery time” (leaving the OR to leaving the recovery unit). Prior to implementation, educational sessions were held with nursing managers in addition to pre-operative holding, OR, and recovery nurses regarding the revised pathway (Figure 1) and evidence (Table 1).

Surgical Procedure

Local anesthetic consisted of either: (1) 5 to 10 mL plain 1% lidocaine when IV sedation was used; or (2) 1% lidocaine with 1:100,000 (10 µg/mL) epinephrine when local alone was used. For the local alone procedures, the injection around the A1 pulley was performed in the pre-operative holding area 20 to 25 minutes prior to surgery.¹ The surgical procedure for both cohorts was identical with the exception of tourniquet application, exsanguination, and tourniquet inflation for injections performed in the OR after IV sedation. For TFR of the index, middle, ring, or small fingers, a 1.5-cm oblique incision was made in the palm at or just proximal to the level of the A1 pulley (volar to the metacarpal phalangeal joint) at the base of the finger in question. For a trigger thumb release, a 1.5-cm transverse incision was made in the flexion crease over the thumb metacarpophalangeal joint. In all cases, the skin was incised before identifying and releasing the A1 pulley, while protecting the adjacent neurovascular bundles and flexor tendons.

Establishing Baseline Change/Control Group

We utilized data from 2 other fellowship-trained orthopedic hand surgeons at the same health system as a baseline for comparison to the intervention surgeons’ (RNK) data. This allows for control of changes that may have taken place at the health system’s surgical center during this time period. Both control surgeons’ practices predominantly used local anesthetic with IV sedation for TFR.

Statistical Analysis

Using G*Power software (Universität Mannheim, Mannheim, Germany), an a priori power analysis (effect size 3.0, β = 0.20) was performed with < 5 patients being needed in each group for significance based on effect sizes seen from our prior work in carpal tunnel surgery. For this calculation, we used the difference in lead time pre- and post-implementation (75 minutes). As our lead time difference was less than our prior study, a post hoc power analysis (effect size 1.6, β = 0.20) was performed, which found 8 patients would be needed in each group for significance.

Total direct cost was reported as a percentage change from pre-implementation to post-implementation regardless of method of anesthesia utilized. Time was reported in minutes. Data were reported using descriptive statistics (mean, median, range, 95% confidence intervals) and histograms with best fit curves. Times were compared using a Mann-Whitney test with statistical significance set at P < .05.

Results

Fifty-four patients were included in this study: 10 pre-implementation (90% local with IV sedation) and 44 post-implementation (89% local alone), who received TFR during the designated time period. Of note, 11% of the patients chose to receive IV sedation post-implementation and were included with local alone cases as “post-implementation” for data analysis. Four patients underwent 2 separate procedures (both single digit TFRs) by the intervention surgeon (or control surgeons) during the study period. Two received local alone both times, while 2 received local with IV sedation during the first procedure and local alone during the second procedure. No procedures were converted from local alone to include the use of IV sedation. In pe-implementation, 60% of the patients were women and the overall median age was 67 years old (range: 28-84). In post-implementation, 68% were women and the overall median age was 61 years old (range: 31-88). There was no significant difference in age (P = .500) or gender (P = .628) between groups.

Cost: Total direct costs decreased by 18% pre- to post-implementation (shown in Figure 2).

Figure 2.

Illustration of the total direct cost (1B) pre- and post- implementation.

Note. This demonstrates a best-fit curve to a histogram for the intervention surgeon (blue line) and the control surgeons (red line). The median value for the intervention surgeon (blue circle) and control surgeons (red triangle). The total direct cost decreased (shifted to the left) for the intervention surgeon.

Patient time: There was a significant decrease in total (lead) time by 41 minutes (P < .001). This was broken down into improvements in setup time by 5 minutes (P < .001), time in the OR by 7 minutes (P < .001), and time spent in the recovery unit by 21 minutes (P = 0.001) (Table 2). No learning curve (i.e. decrease in time with experience) was identified post-intervention for surgical time (P = .050).

Table 2.

Time Stamp Analysis Demonstrating the Intervention Surgeon’s Changes From Pre-Implementation to Post-Implementation.

Time (minute)a	Intervention surgeon, in minutes
	Pre-implementation			Post-implementation			Δ Mean (P-value)
	Median	Mean	Range	Median	Mean	Range
Pre-op time	77	76	40-115	61	62	19-174	14 (.079)
Setup time	15	15	10-20	9	10	5-20	5 (<.001)
Surgery time	13	13	10-17	11	11	4-21	2 (.050)
Wake and leave time	3	3	2-4	3	3	0-15	0 (.442)
Time in OR	31	31	25-36	23	24	16-39	7 (<.001)
Recovery time	49	53	23-80	27	32	14-87	21 (.001)
Total (lead) Time	158	159	141-185	118	118	65-225	41 (<.001)

Note. OR = operating room.

^aTime stamps included total (lead) time (entering the pre-operative holding area to leaving the recovery unit), pre-op time (entering pre-operative holding area to entering the operating room [OR]), setup time (entering the OR to making an incision), surgery time (making an incision to completion of dressing application), wake & leave time (completion of dressing application to leaving the OR), time in OR (entering the OR to leaving the OR), and recovery time (leaving the OR to leaving the recovery unit).

Control: The control surgeons performed 117 TFRs (47 pre-intervention and 70 post-intervention). Pre-implementation, the intervention surgeon’s total direct costs were 10% less than the control surgeons and the intervention surgeon had significantly faster setup time (P = .001), time in the OR (P < .001), and total (lead) time (P = .002) (Table 3). The control surgeons’ total direct costs decreased by 2% pre- to post-intervention. They showed significant improvement in time spent in recovery by 15 minutes (P = .038) and total (lead) time by 33 minutes (P = .008) (Table 4). Post-intervention, the intervention surgeon’s total direct costs were 25% less than the control surgeons and the intervention surgeon was significantly faster in all 7 times (Table 5).

Table 3.

Time Stamp Analysis Comparing the Control Surgeons to the Intervention Surgeon Prior to Implementation.

Time (minute)a	All surgeons pre-implementation, in minutes
	Control surgeons			Intervention surgeon			Δ Mean (P-value)
	Median	Mean	Range	Median	Mean	Range
Pre-op time	103	115	17-317	77	76	40-115	39 (.050)
Setup time	20	20	13-32	15	15	10-20	6 (.001)
Surgery time	14	14	9-21	13	13	10-17	2 (.102)
Wake and leave time	3	4	1-16	3	3	2-4	1 (.240)
Time in OR	38	39	29-60	31	31	25-36	9 (<.001)
Recovery time	57	66	16-218	49	53	23-80	13 (.425)
Total (lead) Time	201	221	117-398	158	159	141-185	62 (.002)

Note. OR = operating room.

^aTime stamps included total (lead) time (entering the pre-operative holding area to leaving the recovery unit), pre-op time (entering pre-operative holding area to entering the OR), setup time (entering the OR to making an incision), surgery time (making an incision to completion of dressing application), wake and leave time (completion of dressing application to leaving the OR), time in OR (entering the OR to leaving the OR), and recovery time (leaving the OR to leaving the recovery unit).

Table 4.

Time Stamp Analysis Demonstrating the Control Surgeons’ Changes From Pre-Implementation to Post-Implementation.

Time (minute)a	Control surgeons, in minutes
	Pre-implementation			Post-implementation			Δ Mean (P-value)
	Median	Mean	Range	Median	Mean	Range
Pre-op time	103	115	17-317	84	98	32-307	17 (.133)
Setup time	20	20	13-32	18	19	8-50	2 (.098)
Surgery time	14	14	9-21	14	15	7-39	0 (.989)
Wake and leave time	3	4	1-16	4	4	1-7	1 (.865)
Time in OR	38	39	29-60	36	37	26-65	2 (.141)
Recovery time	57	66	16-218	51	51	9-156	15 (.038)
Total (lead) Time	201	221	117-398	176	188	100-404	33 (.008)

Note. OR = operating room.

^aTime stamps included total (lead) time (entering the pre-operative holding area to leaving the recovery unit), pre-op time (entering pre-operative holding area to entering the OR), setup time (entering the OR to making an incision), surgery time (making an incision to completion of dressing application), wake and leave time (completion of dressing application to leaving the OR), time in OR (entering the OR to leaving the OR), and recovery time (leaving the OR to leaving the recovery unit).

Table 5.

Time Stamp Analysis Comparing the Control Surgeons to the Intervention Surgeon Post Implementation.

Time (minute)a	All surgeons post-implementation, in minutes
	Control surgeons			Intervention surgeon			Δ Mean (P-value)
	Median	Mean	Range	Median	Mean	Range
Pre-op time	84	98	32-307	61	62	19-174	36 (.001)
Setup time	18	19	8-50	9	10	5-20	9 (.001)
Surgery time	14	15	7-39	11	11	4-21	4 (.001)
Wake and leave time	4	4	1-7	3	3	0-15	1 (.004)
Time in OR	36	37	26-65	23	24	16-39	14 (.001)
Recovery time	51	51	9-156	27	32	14-87	19 (.001)
Total (lead) Time	176	188	100-404	118	118	65-225	70 (.001)

Note. OR = operating room.

^aTime stamps included total (lead) time (entering the pre-operative holding area to leaving the recovery unit), pre-op time (entering pre-operative holding area to entering the OR), setup time (entering the OR to making an incision), surgery time (making an incision to completion of dressing application), wake and leave time (completion of dressing application to leaving the OR), time in OR (entering the OR to leaving the OR), and recovery time (leaving the OR to leaving the recovery unit).

Discussion

This study reports on an evidence-based clinical care pathway redesign for value improvement for TFR at our health system by comparing institutional cost difference pre- and post-implementation—in addition to evaluating patient time spent at the surgical center. Post-implementation, there was an 18% decrease in total direct cost for TFR with a significant decrease in time spent in the OR and in the post-anesthesia care unit.

This study required coordination of multiple stakeholders within our health system, including the finance department, perioperative administration, nursing staff, and anesthesia. Education and purposeful engagement of the nursing staff involved in all phases of care led to significant improvements in the time spent in the OR and in recovery. Cost savings were obtained by shifting certain interventions (local anesthetic injection) from high-cost locations (OR; time-based cost) to low-cost locations (pre-operative holding; set cost regardless of time). Local without sedation avoids the possible complications and morbidity associated with sedation including time-based cost in recovery, while improving patient satisfaction and quality of life by allowing patients to maintain a diet and drive themselves to/from the surgery center.^19-21 The benefits and low risk with local anesthesia alone have been well described.^22,23 The intervention surgeon did not experience a notable learning curve (i.e. decrease in time with experience) post-intervention in terms of surgical time—despite the significant change in practice. This suggests that beneficial decreases in cost can be obtained as soon as the clinical care pathway changes are instituted. In terms of the timing of cases, the intervention surgeon scheduled local alone cases at the start of the operative day followed by anesthesiology-assisted cases. Because local alone cases can be reliably completed in their allotted times (without delays), they are not subject to OR delays. As such, these patients undergo surgery more efficiently than if they were scheduled at the end of the day where delays and scheduling miscalculations are more likely. Scheduling local alone patients at the start of the day, while representing a patient-centered approach, can be a point of contention with anesthesia as they may prefer to complete the cases they are involved in earlier in the day. Despite this, we have continued to schedule local alone cases this way as it has the advantage of minimizing wait times and improving the experience for patients. Educating all stakeholders on the patient-centered benefits of completing local alone cases at the start of the day can help other surgeons to implement this care pathway in their health systems. In order to maintain efficiency and prevent delay of turn-over, the injection of the next patient was performed immediately after the previous patient had their dressing applied and before talking to the previous patient’s family. As part of streamlining the entire clinical care pathway, significant pre-operative counseling with pre- and post-operative instructions were discussed with the patient and, if available, their family in clinic during their pre-operative visit—in addition to giving them written instructions. If insufficient time is available for the hemostatic effect of epinephrine to take place (i.e. less than 20-25 minutes), some surgeons may elect to forgo the epinephrine and utilize a tourniquet.

Prior studies have analyzed the cost of TFR by anesthesia type from a payer and surgeon standpoint, but few have discussed a complete care pathway redesign.¹ Kerrigan and Stanwix¹ used a cost comparison model to find the most cost-effective pathway to treat TF from a payer (insurance company) perspective based on institutional/surgeon/anesthesiologist charges. Their model included TFR either performed in the clinic (with local alone) or in the OR (with an anesthesiologist); they found a 48% lower institutional charge with release in clinic with local alone.¹ However, dramatic differences exist between charges and actual direct costs which limits the impact of charge-based analyses. Webb and Stothard⁹ looked at the institutional cost for a number of common hand procedures, including percutaneous TFR either performed in the clinic or the OR in Britain. However, their analysis was limited to local anesthesia alone and their national healthcare system limits comparison of costs with our study. Rhee et al⁷ used a similar design to our study (historically controlled) comparing total cost (sum of indirect and direct costs) for TFR with IV sedation in the OR to local alone in the clinic demonstrating a 70% decrease in cost using local anesthetic alone in the clinic. This decrease in cost was much higher than our study, but comparison is limited by the use of total cost (rather than direct cost) and change in location (i.e. OR versus clinic) as an additional variable. This study was performed within a military system making it less generalizable to a privately insured non-military population. Finally, Codding et al⁸ compared the patient time spent in each phase of care for TFR using local with and without IV sedation similar to our study. They showed no significant change in total OR time (25 minutes for local alone vs. 27 minutes for local with IV sedation).⁸ This differs from our results, where there was a significant decrease from 31 minutes to 24 minutes with local alone. This discrepancy between studies could be explained by the injection of patients in the pre-operative holding area in our study, thereby eliminating the delay associated with the initiation of sedation. Their lack of change in surgical time (10 minutes vs. 10 minutes) and significant decrease in time spent in recovery (72 minutes vs. 30 minutes) was in line with our findings. They also reported a cost savings with local alone, but their cost (for the anesthesia provider) was based on data extrapolated from national Medicare reimbursement rates, rather than actual institutional expenses.

Our study does have some limitations. We believe the greatest limitation here is the lack of reporting on quality. When evaluating value (as a product of quality and cost), quality must be accounted for. Visual analogue pain scale scores were collected for the intervention group both pre- and post-implementation and showed no difference. However, they were not collected for the control group thereby limiting our ability to make a comparison of quality between our control and intervention groups. There is a trend toward performing smaller soft tissue only procedures (including TFR) in the office, rather than in a surgery center or OR; however, these procedures are still commonly completed in the OR.⁷ Many surgical centers have minimal turn-over time or allow the use of multiple ORs by 1 surgeon. This may not allow enough time for adequate hemostasis to take place and a tourniquet may be beneficial for visualization. Although the cost and time results of this study would not apply to these systems or surgical techniques, the method used for clinical pathway improvement is applicable (Supplemental Figure 1). In addition, we chose only to look at the cost difference for the day of surgery, rather than the entire treatment course (i.e. clinic visits, therapy, injections, pre-operative testing). The study surgeon did not perform purely local with IV sedation or local alone pre- and post-implementation. We believe that by presenting the data “as treated” it is more reflective of an actual change in practice. This pathway allows for patient preferences to be represented in the treatment plan by incorporating shared decision-making.¹¹ Changes to the health system itself or the Hawthorne effect from staff training and knowledge of the intervention may have improved costs or time pre- to post-implementation. However, the control surgeons were used as a baseline for comparison to minimize this and efforts for continued quality improvement could lead to long-term behavior change. Patients with significant anxiety regarding the procedure, who may be at risk of poorer outcomes, may have elected to forgo local alone anesthesia.^24-26 Because the care pathway allows for patient preferences to inform which type of anesthesia to use for surgery, the results are thus more pragmatic for actual care. Unfortunately, only 1 intervention surgeon was utilized and only 10 cases were available pre-intervention for the intervention surgeon, however, the time spent was similar (although shorter) when compared to the control surgeons pre-implementation. Although all isolated (single) TFRs performed by the intervention surgeon were included, we were limited by a small pre-implementation sample. The use of the control surgeons’ data, however, helps mitigate this limitation. The care pathway should be tested in other health systems to ensure the generalizability of our results. Finally, the use of percentage change in cost rather than actual values is a limitation of this study; however, the use of direct medical costs is informative to health systems, as opposed to charges that are often inflated and not meaningful for improvement efforts.

Hand surgeons have the opportunity to be at the forefront in improving quality and value for our most commonly treated diseases.⁴ As healthcare moves toward a value-based payment model, patients and health systems will benefit from decreasing cost (such as time, labor, supplies) while maintaining quality by improving efficiency and cultivating buy-in from all stakeholders. While prior studies have evaluated the cost of TFR from the standpoint of the “payer” (usually the insurer), less attention has been paid to institutional costs. By implementing an evidence-based clinical care pathway, our health system significantly decreased the institutional total direct cost and patient time spent at the surgery center for TFR. Future studies could evaluate other factors that can affect the cost of TFR including the setting where the surgery is performed (hospital, surgery center, clinic) and supplies utilized (reducing surgical instrument set sizes for minor procedures).