Wide-Awake Palmar Fasciectomy for Dupuytrenâ€™s Contracture: A Nationwide Analysis of Reimbursement and Adverse Events
Alexander J Kammien, BS1, K Lynn Zhao, MD1, Catherine T Yu, BS1, Jonathan N Grauer, MD1 and David L Colen, MD2, (1)Yale School of Medicine, New Haven, CT, (2)Yale University School of Medicine, New Haven, CT
Palmar fasciectomy is commonly considered for Dupuytrenâ€™s contracture and two institutional studies have reported reduced cost and similar outcomes for wide-awake palmar fasciectomy compared to those performed with monitored anesthesia care (MAC) or sedation. The current study examines these findings on a national level, comparing cost and adverse events for palmar fasciectomy performed wide-awake versus with MAC/sedation.
Adults with outpatient palmar fasciectomy (CPT-26121, CPT-26123) for Dupuytrenâ€™s contracture were identified in 2010-2021 administrative dataset (PearlDiver M157Ortho). Exclusion criteria included multi-finger fasciectomy (CPT-26125), prior needle aponeurotomy (CPT-26040) or collagenase injection (CPT-20527) and fewer than ninety days of follow-up. Patients were stratified by anesthesia type (MAC/sedation, wide-awake) using CPT codes, then matched 1:1 based on age, sex, Elixhauser Comorbidity Index (ECI) score and geographical region.
Total and physician reimbursements were determined by insurance type (commercial, Medicaid, Medicare) and analyzed with Wilcoxon rank-sum tests and linear regressions. Ninety-day wound complications, emergency department visits and readmissions were identified and analyzed with chi-squared tests and logistic regressions.
A total of 40,680 patients met inclusion criteria for the study: 16,824 (41%) with MAC/sedation and 23,856 (59%) with wide-awake surgery. After matching for age, sex, ECI score and geographic region, there were 15,711 patients in each group. Insurance coverage was not one of the matching criteria and differed significantly (p<0.001); more wide-awake patients had Medicare (32% vs 21%) and fewer had commercial insurance (66% vs 80%).
When considered by insurance type, MAC/sedation was associated with greater total reimbursement for commercial, Medicaid, and Medicare insurance (p<0.001) and greater physician reimbursement for commercial (p=0.021) and Medicare (p=0.003) insurance (Table 1). On multiple linear regression, wide-awake surgery was associated with reduced total reimbursement (regression coefficient -$463, p<0.001) and physician reimbursement (-$62, p<0.001).
Regarding clinical outcomes, patients with wide-awake surgery had fewer ninety-day wound complications (1.1% vs 1.6%; OR 0.69, p<0.001) and emergency department visits (5.2% vs 7.1%, OR 0.76, p<0.001), with no difference in readmissions (1.1% vs 1.2%, OR 0.88, p=0.124).
Performing wide-awake palmar fasciectomy may increase its healthcare value by reducing cost without sacrificing outcomes. Increasing payments to physicians for wide-awake surgeries may provide greater incentive for surgeons to incorporate the wide-awake approach in their practices.
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