A Comparative Cost Analysis of Local Anesthesia versus Brachial Plexus Block for Complex Hand Surgery

Abstract

Background:

Local anesthesia has shown to be safe and cost-effective for elective hand surgery procedures performed outside of the operating room. The economic benefits of local anesthesia compared to regional anesthesia for hand surgeries performed in the operating room involving repair of tendons, nerves, arteries, or bones are unclear. This study aimed to compare costs pertinent to hand surgeries performed in the main operating room under local anesthesia (LA) or brachial plexus (BP) block.

Methods:

We performed a cross-sectional study on the first 70 randomized patients from a prospective controlled trial of anesthesia modalities for hand surgery. The primary objective was to determine the mean anesthesia-related cost, and the secondary objectives were to analyze block performance time, block onset time, duration of anesthesia, duration of surgery, and time in the recovery room.

Results:

The mean anesthesia-related cost of performing hand surgery under LA as a wrist and/or digital block was $236 ± 30, compared to $435 ± 43 for BP, a difference of $199 per case. The mean block performance time was shorter for LA (1.3 minutes) versus BP (7.0 minutes). The mean anesthesia-related time was longer in BP (30.7 ± 16 minutes) compared to LA (17.7 ± 6.7 minutes), and consequently the total anesthesia time was longer in BP.

Conclusions:

We demonstrated that local anesthesia compared to brachial plexus block achieved substantial cost savings in complex hand surgeries by decreasing major expenses. In an era of cost-consciousness, the use of LA represents an important modality for health systems to optimize patient flow and increase cost-effectiveness.

Introduction

As healthcare in North America continues to find more efficient and cost-effective treatment modalities, physicians must also evolve to meet the needs of the patient and healthcare system to make treatments better, faster, and cheaper. As an example of such an innovation, wide awake local anesthesia no tourniquet (WALANT) hand surgery was developed to improve access to hand surgery while optimizing medical resources,^1,2 resulting in considerable cost savings for the United States Military Health Care System and became a popular practice in North America.^3,4

Hand surgeries are some of the most commonly performed plastic and orthopedic procedures in North America. Over the past few years, detailed cost-efficiency analyses have been performed on the benefits of local anesthesia (LA) in minor hand procedures, for example carpal tunnel release ⁵ and trigger finger release. ⁶ However, detailed cost analyses comparing LA to other more established anesthetic modalities in more complex hand surgeries have yet to be conducted. These procedures involving the repair and reconstruction of bone, tendon, nerves, and arteries were classically performed under regional block or in some cases under general anesthesia.

The main objective of our study was to determine the cost-efficiency profile associated with performing LA compared to brachial plexus (BP) block in more complex hand surgeries. We hypothesized that for similar hand surgeries performed in the operating room (OR), the use of local anesthesia was cheaper, faster, and more cost-effective than the incumbent standard of care in our institution, the BP block.

Patients and Methods

Patient Selection

This was a retrospective study of prospectively collected data on 70 consecutive patients enrolled in a randomized controlled trial on the quality of recovery after hand surgery. The surgeries were performed at a single tertiary care trauma center. The study was conducted with approval of the Review Ethics Board at McGill University Health Center. Patients were randomized to receive local anesthesia (wrist and/or digital block) or brachial plexus block using computer generated randomization (www.random.org). The first 35 consecutive patients randomized to each group were included for analysis, for a total of 70 patients. All surgeries were performed by fellowship-trained hand surgeons in the main OR, with involvement of an anesthesiologist for monitoring, intravenous sedation, and performance of the brachial plexus block.

Inclusion and Exclusion Criteria

The study participants were adults (>18 years) who consented to participate, had a complex hand surgery defined as any surgical procedure involving bone, tendon, nerves, arteries, or soft tissue distal to the carpal bones, excluding carpal tunnel and trigger finger release; and estimated surgical time of less than 2 hours. Study participants were excluded if they did not meet inclusion criteria, if they had an allergy to local anesthetics, body mass index > 40 kg/m², neurological disorder of the upper extremity, chronic opioid use, or history of complex regional pain syndrome or severe anxiety. The complete summary of patient inclusion and exclusion criteria is listed in Table 1.

Table 1.

Patient Inclusion and Exclusion Criteria.

Inclusion criteria	Exclusion criteria
Consents to research	Patient refusal
Patient age 18 and older	Allergy to local anesthetics
Hand surgeries distal to carpal bones	Surgery proximal to the carpal bones or concomitant surgery
Trauma or elective case	Minor procedure (ie, carpal tunnel and trigger finger release)
Under 2 hours estimated surgical duration	BMI > 40 kg/m2
	Neurological disease of the upper extremity
	Daily use of opioids for > 2 weeks prior to surgery
	History of complex regional pain syndrome (CRPS)
	High anxiety or severe post-traumatic stress disorder

Note. BMI = body mass index; CRPS = complex regional pain syndrome.

Local Anesthesia

The LA was administered by the operating hand surgeon or a senior resident under the surgeon’s direct supervision as a wrist block and/or digital block. The local anesthesia was given after the surgical check-in, directly outside of the OR before surgery. The LA administered was a 1:1 solution of lidocaine 2% with 1:100 000 epinephrine and bupivacaine 0.5% with 1:100 000 epinephrine. The dose is standardized to 3 mL per nerve block. For example, the total amount for a complete wrist block is 12 mL (median, ulnar, dorsal ulnar sensory, radial nerve). The number of nerve blocks varied according to the site of the surgery.

Brachial Plexus Block

The BP block was performed via the infraclavicular approach by a staff anesthesiologist with extensive experience in ultrasound-guided regional anesthesia, or an anesthesia fellow under their direct supervision. The brachial plexus block was performed in a dedicated anesthesia block room, usually during the completion of a preceding surgical case, in an effort to shorten the turnover time. The anesthetic solution used was a 1:1 mixture of 20 mL lidocaine 2% and 20 mL bupivacaine 0.5%, with the addition of epinephrine 5 mcg/mL. The minimum volume of anesthetic solution used per brachial plexus block was 35 mL; additional boluses are were given as needed to reach the anesthetic threshold. The total volume used and the need for intraoperative supplementation was recorded.

Billing Structure

The cost analysis for local anesthesia and brachial plexus included direct costs associated with the procedure and excluded any indirect cost. Direct costs are calculated from the sum of perioperative and operative resources, materials, and personnel required to conduct the surgery. Indirect costs are those shared with other procedures and specialties, such as transcriptionist fees, sterilization costs, and housekeeping wages. We did not take into account the surgeon’s remuneration in the calculations as this should remain the same for both groups. All costs were calculated in Canadian Dollars.

Data was collected on the block performance time, block onset time, duration of surgery, duration of anesthesia, and time in the recovery room. The anesthesiologist-administered anesthesia service fees based on the Quebec’s manual of reimbursement for specialists, ⁷ using standard procedural terminology codes. The reimbursement was calculated on the basis of time units, remunerated at a rate $16.70 /unit. Each surgery started with a base of 5 units ($83.50), with an additional unit for every 15 minutes of anesthesia time.

Differences existed between the block payment strategies for local anesthesia and brachial plexus groups, depending on who administered the anesthetic block. For example, in the local anesthesia group, the wrist block performed by the surgeon was remunerated at a $42 flat fee. In the brachial plexu group, there was no specific fee code for brachial plexus block administration. However, there was a fee for the dedicated block room used to accelerate turnover over time, for a rate of 6 units ($100.20) per patient.

Statistical Analysis

Statistical analyses were performed using the SPSS^® program version 26 (SPSS^®, Chicago, Illinois, USA). Variables with kurtosis of below + 1 and above -1 considered normally distributed. Quantitative variables such as duration of surgery, anesthesia time, and costs were compared with independent sample t-test; P-value of < .05 was considered significant.

Results

The analysis involved 70 patients recruited between August 2018 and January 2020, randomized to receive local anesthesia (n = 35) or brachial plexus block (n = 35) with intravenous sedation. Basic demographic data such as median age, gender, American Society of Anesthesiologists (ASA) class, and worker’s compensation status are stated in Table 2. The local anesthesia and brachial plexus groups had similar patient demographics.

Table 2.

Patient Demographics.

Variable	Local anesthesia (n = 35)	Brachial plexus block (n = 35)	P-value
Age, mean years (SD)	40 (15)	43 (15)	.45
Gender, male n (%)	19 (54%)	25 (71)	.11
ASA class, median (n)	1 (18)	1 (22)	.27
CSST (worker’s compensation), n (%)	6 (17)	5 (14)	.74
Surgery type
ORIF	7	11	.43
CRPP	16	13
Soft tissue	9	9
Hardware removal	3	2

ASA: American Society of Anesthesiologists; CRPP: Closed reduction percutaneous pinning; CSST: (Quebec provincial workers compensation: comité des normes de l’équité de la santé et de la sécurité du travail); ORIF: Open reduction internal fixation.

The surgeries involved single and multi-digit procedures distal to carpal bones. These included surgeries on bone (fusion, k-wire pinning, open reduction internal fixation) and soft tissues (ulnar collateral ligament repair, tenolysis, fasciotomy, microsurgery on arteries and nerves). The variety of surgical procedures is described in Table 2. The type of surgery did not differ significantly between groups.

Block Performance Time

The block performance time was defined as the time used by the operator to administer the block. For the local anesthesia group, the block performance time was defined as when the needle touched the patient’s skin until the last nerve block was completed and the needle removed. For the brachial plexus group, it was defined as when the ultrasound probe touched the patient’s skin until the catheter was removed. No patients received any continuous brachial plexus infusions for intra-operative or post-operative analgesia. The block performance time was significantly longer for the brachial plexus group (7.0 minutes, SD = 5.4) compared to local anesthesia (1.3 minutes, SD = 0.4; P < .001).

Block Onset Time

The block onset time is defined as the time elapsed from the end of block performance until the patient loses pinprick sensation of the surgical area. The patient is tested every 5 minutes over the surgical area using a dull needle, and more frequently as surgical anesthesia is reached. The block onset time is significantly longer for the brachial plexus group (24 minutes, SD = 12) compared to local anesthesia (17 minutes, SD = 6.6; P = .002).

Anesthesia-Related Time

The anesthesia-related time is defined as the sum of the block performance and block onset time. It is a measure of the wait time required before achieving surgical anesthesia and being able to start the surgery. A longer anesthesia-related time may lead to slower OR turnover and increased costs to the hospital. The mean anesthesia-related time was significantly longer for the brachial plexus group (30.7 minutes, SD:16) compared to local anesthesia (17.7 minutes, SD:6.7; P < 0.001). Further, a comparison of total surgical time and time in the recovery room did not reveal any significant differences between the 2 groups (Table 3).

Table 3.

Variables.

Variable	Local anesthesia	Brachial plexus block	P-value
Block performance, mean minutes (SD)	1.3 (0.4)	7.0 (5.4)	<.001
Block onset, minutes (SD)	17 (6.6)	24 (12)	.002
Anesthesia-related time, minutes (SD)	17.7 (6.7)	30.7 (16)	<.001
Total anesthesia time, minutes (SD)	88 (27)	105 (38)	.03
Surgical time, mean minutes (SD)	43 (19)	50 (26)	.16
Recovery room time, mean minutes (SD)	96 (66)	105 (54)	.53

Total Anesthesia Time

The total anesthesia time is a reflection of the total time required to provide anesthetic care to the patient. It starts when the anesthesiologist first come into contact with the patient until after the patient is officially transferred to the recovery room. Regardless of their randomization, all patients received intra-operative sedation and immediate post-operative analgesics. The anesthesia time cannot overlap between 2 concurrent patients, for example 1 patient in the OR undergoing surgery while another patient is being anesthetized in the block room. The total anesthesia time differed significantly between local anesthesia (88 minutes, SD = 27) and brachial plexus groups (105 minutes, SD = 38; P = .034).

Cost Analysis

The total average cost for performing hand surgery under local anesthesia or brachial plexus block is tabulated in Table 4. The total cost is calculated from the sum of direct costs: cost of block administration, cost of anesthesia, and cost of equipment (Table 5). As described previously, the cost of anesthesia is calculated on the basis of 15-minute time units, with each unit remunerated at a rate $16.70. Each surgery started with a base of 5 units, or $83.50. We calculated the average cost of anesthesia for brachial plexus block to be ($210, SD = 43) compared to a lower cost for local anesthesia block ($190, SD = 30; P = .02). By the summation of the cost of anesthesia services, block administration fee and equipment fee (Table 4), we found that local anesthesia ($236, SD =30) was associated with a significantly smaller overall cost compared to the brachial plexus block ($435, SD =43; P < .001), a difference of $199.

Table 4.

Direct Costs of Performing Hand Surgery Under Local Anesthesia or Brachial Plexus.

Variable	Local anesthesia	Brachial plexus block	P-value
Fee to administer block, CAD	42	184	N/A
Cost of anesthesia, CAD (SD)	190 (30)	210 (43)	.023
Cost of equipment, CAD	4.4	40.8
Total, CAD (SD)	236 (30)	435 (43)	<.001

CAD = Canadian dollars.

Table 5.

Basic Consumed Materials and Their Costs.

	LA	BP
Perioperative Equipment, CAD
	Alcohol swab: 0.01	Tray: 9.95
	18G needle: 0.03	Long needle: 14
	25G needle: 0.02	Sterile ultrasound probe cover and rubber bands: 3.09
	Syringe (10 cc): 0.10	Sterile gel: 1.84
		Sterile towels x3: 4.95
Medications, CAD
	Bupivacaine: 2.76	Bupivacaine: 5.52
	Lidocaine: 1.46	Lidocaine: 1.46
Total, CAD	4.38	40.81

Note. LA = local anesthesia; BP = brachial plexus; CAD = Canadian dollars.

Discussion

This cost analysis was derived from data collected in a randomized controlled trial comparing 2 commonly utilized anesthetic modalities in hand surgery and assessed their economic impact in a single-payer, universal healthcare system. We demonstrated the cost-effectiveness of local anesthesia compared to brachial plexus block in an OR-based hand surgery program. At our tertiary trauma center, we observed considerable cost savings in various hand surgeries performed distal to the carpal bones by using local anesthesia.

We found that equipment fees were almost considerably more costly in brachial plexus compared to local anesthesia, $40.81 and $4.38 respectively (Table 5). We determined the pharmaceutical and consumable costs from the hospital’s inventory and each item’s price. Billing and charging practices may differ in other institutions across provinces and countries, and therefore slightly alter the cost data.

This, in addition to the cost for block administration and cost of anesthesia services rendered, showed a $199 cost difference, or approximately a doubling of the cost, between the 2 groups.

The block performance time, block onset time, and total anesthesia time charted by the anesthesiologist were significantly shorter in the local anesthesia group. We noticed that the most clinically important measurement is the anesthesia related time (block performance time plus the block onset time), as this is how long a surgeon needs to wait prior to starting a surgery.

At our institution, a dedicated anesthesia block room is used to hasten case turnover and increase OR efficiency. However, in the province of Quebec, the anesthesiologist cannot bill for concurrent patient care, for example when 1 patient undergoes surgery, and another is undergoing a brachial plexus block in the block room. Despite the use of an anesthesia block room at our institution, the total anesthesia time charted for anesthesia services rendered was still shorter for the local anesthesia group. Evidently, in institutions where no separate anesthesia block room exists, the total anesthesia time could be even longer and more costly for surgeries completed under brachial plexus block.

According to the Quality Chasm report published by the Institute of Medicine (US) Committee on Quality of Health Care in America, one cornerstone of healthcare is efficiency. ⁸ In 2017, the average expenditure per capita was $4178 ⁹ in the province of Quebec, with an increase to $6935 by the year 2019. ⁹ Strategies to reduce costs to the system can be found in every corner. As an example, one study found that if US physicians’ administrative costs were similar to those of Canadian physicians, the result would be $27.6 billion in yearly savings. ¹⁰ To help achieve the goal of reducing costs, the National Health Service in the U.K. introduced methodology such as Lean and Six Sigma. These programs helped multidisciplinary health care professionals identify unnecessary costs in their different industries and streamline their work. ¹¹ Cost reduction demonstrated in our study is meaningful when brought down to this level, showing how strong an optimization can benefit the healthcare budget.

As reinforced by Health Canada, “since 2000, the number of beds per capita has decreased, part of the decrease can be attributed to advances in medical technology, allowing for more surgery to be performed on a same-day basis.” ¹² The time and cost reduction in hand surgeries by using local anesthesia instead of the brachial plexus block may allow for more cases to be completed in one day and improve surgical access to care. Particularly in the hand trauma population, where operative timing is crucial for improved outcomes, the use of local anesthesia in hand surgeries may allow for a faster time to surgery while maintaining a low cost. In the future, it is fathomable that select complex hand surgeries will be increasingly performed outside of the OR under local anesthesia, similar to the current model for carpal tunnel and trigger finger releases. In many centers in Canada, many hand surgeries are already being performed under the WALANT method without the presence of an anesthesiologist, and this study supports this practice from a cost-effectiveness perspective.

In a separate prospective, randomized controlled, multicenter study, the authors demonstrated the safety and non-inferiority of local anesthesia to brachial plexus in complex hand surgeries. ¹³ Authors showed that the quality of recovery (QoR-15) of local anesthesia was non-inferior to brachial plexus and opioid consumption on postoperative days 1 and 3 were similar. ¹³ Parallel to other studies in the literature, there were no intra-operative or periprocedural adverse events in this study sample. ¹⁴

Local anesthesia has become a well-accepted method of anesthesia for surgeries distal to carpal bones in our institution by both surgeons and anesthesiologists. With the BP block, there is a need for additional usage of resources with the presence of an anesthesiologist performing the block, an anesthesia assistant, and a separate block room. On the other hand, LA can be performed quickly and effectively by the operating surgeon, directly outside of the as the patient is waiting for surgery, which decreases overall non-surgical time. LA can incentivize the anesthesiologist as well by allowing for more surgeries to be performed during a single operative day and increase the case volume for the hospital.

It is a general limitation of most cost studies that specific costs for services billed, medications, and supplies are institution-dependent and might be different from region to region. Although we listed all directs costs for both arms of the study, another limitation was the exclusion of all indirect costs, which may make the comparison more comprehensive and help relativize the cost savings to the total expenditure of the surgery. Next, although all patients were given with sedation during the surgery, dosing was at the discretion of the anesthesiologist to tailor based on patient’s need and provide optimal comfort. Furthermore, the definition of “complex hand surgery” is variable based on the center, while some perform percutaneous pinning in the main OR, others conduct in the office and do not consider them as complex.

This study demonstrates that local anesthesia compared to brachial plexus block achieves substantial cost savings in hand surgeries by decreasing major expenses. In an era of cost-consciousness and evidence-based medicine, the use of local anesthesia represents an important modality for health systems to optimize patient flow and increase cost-effectiveness.