Patient Benefits and Economic Value of InOffice Surgery for Hand Procedures

Patient Benefits and Economic Value of In-Office Surgery for Hand Procedures Nathan Lesley MD Joy Brewer| Sharon Cherian| Emily Moore

Table of Contents List of Figures ............................................................................................................................................ 3 Introduction ........................................................................................................................................... 4 Traditional Hand Surgery ...................................................................................................................... 5 Formal OR .......................................................................................................................................... 5 Anesthesia .......................................................................................................................................... 5 Cost ..................................................................................................................................................... 6 Benefits of WALANT ............................................................................................................................. 7 Decreases complications .................................................................................................................... 7 Decreases cost to patients and society ............................................................................................... 7 Improves patient satisfaction ............................................................................................................ 7 In-Office Patient Data ............................................................................................................................ 8 Methods .............................................................................................................................................. 8 Results ................................................................................................................................................ 8 Discussion ........................................................................................................................................ 12 Conclusion ........................................................................................................................................... 12 Appendix ...............................................................................................................................................13 References ............................................................................................................................................ 14 Patient Benefits and Economic Value of In-Office 2 Surgery for Hand Procedures

List of Figures Figure 1 : Percentage of female and male patients ................................................................................... 8 Figure 2: Age groups of patients ............................................................................................................... 8 Figure 3: Amount of time spent in-office .................................................................................................. 9 Figure 4: Pain scores during the injection of local anesthetic…………………………………………………………….9 Figure 5: Pain scores using WALANT…………………………………………………………………………………………. 9 Figure 6: Pain compared to dental procedure……………………………………………………………………………. 10 Figure 7: Patients experiencing nausea after surgery………………………………………………………………….. 10 Figure 8: Duration of anesthetic post-operation………………………………………………………………………….10 Figure 9: Reported anxiety levels before, during, and after surgery ....................................................... 11 Figure 10: Preferred method of anesthesia .............................................................................................. 11 Figure 11: Expectations of WALANT........................................................................................................ 11 Figure 12: Recommendation of WALANT to a friend ............................................................................. 11 Figure 13: Ten question questionnaire used to assess patient satisfaction………………………………………13 Table 1: Hand procedures of 48 patients performed in-office ................................................................. 8 Patient Benefits and Economic Value of In-Office 3 Surgery for Hand Procedures

Introduction Wide awake local anesthesia no tourniquet (WALANT) surgical technique is becoming more popular compared to the traditional method involving general anesthesia and applied tourniquet because of lower complication rates, elevated cost efficiency, and higher patient satisfaction in hand and wrist surgeries. WALANT has proven benefits in areas of patient satisfaction, significant cost-savings, and lower complications related to IV therapy, general anesthesia, and tourniquets. According to the “Wide Awake Hand Surgery Handbook,” WALANT uses a mixture of a local anesthetic agent (lidocaine) and low-dose epinephrine injected in a site. Epinephrine provides hemostasis without the use of a pneumatic tourniquet, which causes severe discomfort when insufflated for greater than 10 minutes (Brown et al. 2020). It was previously thought that an injection of adrenaline (epinephrine) would cause digital necrosis due to induced vasospasm (Neto et al. 2017). Critical literature reviews on cases that reported having finger necrosis from 1880 to 2000 have found the anesthetic agent, not the epinephrine, was the cause of tissue necrosis (Abdullah et al 2021). As a secondary safety measure, should revascularization of the digit be delayed, phentolamine acts as a reversal agent for vasoconstriction (Neto et al. 2017). In essence, it is safe to use local anesthesia and adrenaline together and will not put the patient’s well-being at risk, making WALANT a viable option for hand and wrist surgeries. WALANT has many benefits like a decrease in complications rates, cost efficiency, and patient satisfaction compared to traditional methods used for hand surgeries. Patient Benefits and Economic Value of In-Office 4 Surgery for Hand Procedures

Traditional Hand Surgery Formal OR Unlike hand surgeries performed in formal operating rooms, WALANT surgeries utilize fewer materials, require less staffing, and can be performed outside of the hospital operating room. This makes expenses associated with hand and wrist surgeries lower compared to mainstream surgical techniques. A study on the application of a WALANT circuit showed that 24% of people preferred the surgery outside of the orthodox operating room mostly due to the outpatient procedure being less timely and complicated (Far-Riera et al. 2019). Complications associated with IV therapy, anesthesia, and tourniquets will lower patient satisfaction while also adding to the overall cost of the surgery when resolving such complications. WALANT surgeries in a non-traditional operating room with field sterility have similar associated low-infection rates comparable to standard sterilization procedures and main operating room surgeries (Avoricani et al. 2021). Anesthesia The use of general or regional anesthesia in traditional methods for hand surgeries can exacerbate preexisting comorbidities in patients and cause many health issues related to IV placement, age, the respiratory system, and other complications. IV Complications When utilizing general or regional anesthesia, a peripheral intravenous line (IV) is necessary for the administration of medication. While IV placement is common and generally well-tolerated, multiple complications have been described. These include phlebitis, thrombophlebitis, infiltration, extravasation, nerve damage, and risk of infection (Dychter et al. 2012). Venous access decreases with age, obesity, past IV drug abuse, hypotensive patients, darker pigmented skin, and often with young children, increasing the likelihood of these complications (Dychter et al. 2012). Phlebitis, inflammation of the vessel, is the most common complication with an average incidence rate of 20% to a high of 50%, while people with infectious diseases have an incidence rate of 75% (Dychter et al. 2012). Infiltration (medication leaking into surrounding tissue of the vessel) and extravasation (leakage of bodily fluid [often blood] into surrounding tissue) incidence rates are hard to determine but increase with age and can have serious consequences like skin loss, muscle necrosis, and tendon necrosis (Dychter et al. 2012). Similar to infiltration and extravasation, infection rates associated with IV therapy are hard to determine; however, 5%-25% of peripheral catheters have shown skin organisms at the time of removal (Dychter et al. 2012). Nurses’ knowledge and execution of IV therapy have a strong influence on these complications occurring, which is why certification and/or relevant experience in infusion therapy is required (Dychter et al. 2012). Respiratory Complications Relevant respiratory complications associated with anesthesia are atelectasis, aspiration, and bronchospasms. Atelectasis, collapsing of the lung or part of the lung, has a maximum incidence rate of 70% in severe postoperative hypoxemia which can lead to pneumonia and acute lung injury (Harris and Chung 2013). Aspiration, breathing in foreign substances, is the most common reason for airway- related death and has an incidence rate of 0.025% associated with general anesthesia; this incidence rate increases to 0.1% when specific to emergency surgery (Harris and Chung 2013). Bronchospasms, constriction of the airways, occur in 0.2% of people that have received general anesthesia and can lead to hypoxia, hypertension, or death (Harris and Chung 2013). Patient Benefits and Economic Value of In-Office 5 Surgery for Hand Procedures

Age-Related Complications According to the American Society of Anesthesiologists (ASA), elderly patients are prone to more severe complications due to the aging brain being more vulnerable to general anesthesia. The two anesthesia-related surgery risks that are more common in older people are postoperative delirium and postoperative cognitive dysfunction (POCD). Moreover, anesthesia can increase the risk factor for the development of neurodegenerative disorders such as dementia, Alzheimer’s disease, and Parkinson's disease (Papon et al. 2010). In 2018, a study by Mahanna-Gabrielli et al. found that among patients aged 65 years and older, up to an estimated 65% experience delirium and 10% develop long-term cognitive decline after noncardiac surgery. The complications associated with delirium include longer hospitalization, more days with mechanical ventilation, and functional decline. POCD is associated with a decrease in quality of life, loss of function, and increased mortality (Vacas, Cole, and Cannesson 2021). Other Complications Other side effects/complications of general and regional anesthesia include nausea and vomiting, sore throat, dental damage, as well as more serious complications like myocardial infarction, lung mechanics interference, and exacerbation of preexisting comorbidities. The incidence reports of nausea and vomiting, when using general anesthesia, are up to 24% (Harris and Chung 2013, report 70% – 80% in high-risk individuals). Alongside postoperative nausea and vomiting, dental damage incidence rates are up to .05% and 12.2% of patients experience a sore throat after general anesthesia (Harris and Chung 2013). Cardiac complications have been recorded and about 5% of people who receive general anesthesia will have myocardial infarction as well as heart failure in 1% - 6% of people (Harris and Chung 2013). Cost While difficult to quantify, the myriad complications associated with general IV sedation are responsible for a sizable portion of the healthcare expenditure. Avoiding these complications can therefore reduce costs to society overall. In an economic analysis of monitored anesthesia care (MAC) versus WALANT, 78 single trigger finger release procedures performed in the same environment by the same surgeon were analyzed (Codding et al. 2016). Components of surgery like total time spent in the operating room, time of the actual procedure, recovery time, and costs associated with anesthesia were the main contributing factors to this analysis (Codding et al. 2016). 47 WALANT and 31 MAC cases were studied; it was found that WALANT averaged lower operating room time by 2.0 minutes, less recovery time by 42.1 minutes, and eliminated the expense of anesthesia (Codding et al. 2016). Some of these hidden costs are staffing to ensure proper management, administering the drug itself, set-up, equipment, maintenance, and pre-operative evaluation for clearance of the surgery (Codding et al. 2016). The authors concluded that by using the WALANT surgical technique, patients receive a very similar procedure resulting in the same outcome while obtaining costs savings from a variety of factors. Patient Benefits and Economic Value of In-Office 6 Surgery for Hand Procedures

Benefits of WALANT Decreases complications There are many complications associated with IV therapy, general anesthesia, and tourniquets. These complications will not apply to WALANT because this surgical method uses local anesthesia and epinephrine to create a bloodless field. Local anesthesia used in WALANT is administered through injection(s) near the surgery area and creates numbness in a small region, like a lower arm, to allow for painless surgery. Decreases cost to patients and society One of the cost-saving factors is the utilization of local anesthesia instead of general or regional anesthesia, which allows a procedure room to be used instead of a traditional operating room, lowering the financial cost of the surgery, preventing excess surgical waste from being produced, and easier flow for the team conducting the surgery (Nolan et al. 2020). A study published in The Journal of Hand Surgery by Rhee et al. in 2017 demonstrated a cost savings of $6,275 per case when comparing the cost of the surgical procedure performed in an in-office setting vs a traditional operating room (1,111.09 vs $7,386.09). According to the National Institute of Occupational Health, in quarter 3 of 2015, 2,445,000 employed Americans were estimated to have carpal tunnel syndrome. If only 25% of these individuals required surgical intervention, WALANT represents a potential societal cost savings of $3,835,593,750. Additionally, when researchers looked at trigger finger release procedures to analyze cost savings and efficiency of the WALANT technique in an out-of-hospital procedure room compared to traditional methods performed in a hospital operating room (Maliha et al. 2019). WALANT trigger finger release surgeries also showed 1/3 fewer costs than hospital operating room procedures by calculating expenses with total operating room time, medical instruments used, and necessary staffing (Maliha et al. 2019). Improves patient satisfaction Multiple features of WALANT are associated with increased patient satisfaction. These include, decreased expenses, more cost efficiency, fewer complications (which will also lead to greater cost savings), improved intraoperative and postoperative pain levels, and equivalent or superior surgical outcomes. Intraoperative and postoperative pain levels have been proven to be lower in WALANT procedures (Kir et al. 2021). The convenience of patients being able to drive themselves to and from the procedure (due to no general anesthetic being administered), not being required to stop eating/drinking the night before the procedure, not having to change into a surgical gown, and being allowed to continue taking prescribed medications are all additional factors increasing patient satisfaction. Patient Benefits and Economic Value of In-Office 7 Surgery for Hand Procedures

In-Office Patient Data Methods A total of 48 responses were collected from patients who underwent hand surgery in-office (The Hand to Shoulder Center – Fort Worth, TX) using WALANT. Patient satisfaction was assessed using a 10- question (see Appendix) survey adapted from Teo et al. (2013), Davidson, Cobb, and Lalonde (2012), and Ayhan et al. (2020). The questions were based on four main categories: time spent, pain, anxiety, and overall experience. Results Twenty patients were male twenty-eight female with a mean range of 62 [range 25-95] years (Figure 1). 71 % of the patients were 55 years and or older with 50% being 65 or older (Figure 2). Forty-eight patient responses to the questionnaire and the number of responses per procedure are shown in Table 1. Sex Age Group 4% 12% 42% 50% 13% 58% 21% Female Male 25-34 35-44 45-54 55-64 65+ Figure 1 : Percentage of female and male patients Figure 2: Age groups of patients Procedure Number of patients Carpal Tunnel Release (CTR) 17 Trigger Finger Release (TFR) 14 deQuervain release (DQR) 3 Tendon repair 3 Nerve repair 5 Excision of deep mass of hand 2 Removal of implanted hardware 3 Cubital tunnel release 1 Table 1: Hand procedures of 48 patients performed in-office Patient Benefits and Economic Value of In-Office 8 Surgery for Hand Procedures

Time Spent On average, patients spent a little more than an hour for their hand surgery at the clinic. Approximately, 96% of patients spent 30 minutes to 2 hours (See Figure 3). Time Spent 2% 2% 45% 51% 30 min - 1hr 1hr - 2 hrs 2hrs - 3 hrs 3hrs+ Figure 3: Amount of time spent in-office Pain Patients were asked to rate their level of pain during the injection of the local anesthetic and during the operation, with 0 being no pain at all and 10 being the worst pain. 96% reported a pain score of 5 or less during the injection of local anesthetic (Figure 4). 69% reported a pain score of 0 during their WALANT operation (Figure 5). 98% of patients felt that the pain they experienced with WALANT was much the same or less than having a dental procedure (Figure 6). Postoperatively, 98% stated they did not have any nausea or vomiting, and 2% reported some nausea and vomiting (Figure 7). 52% of patients reported that the local anesthetic only lasted 1 – 2 hours post-operation (Figure 8). Pain during injection of local Pain during WALANT anesthetic 35 33 18 30 16 ients25 ents16 at iat14 f p20 12 10 o 15 f po10 8 8 er er 8 mb10 6 6 Nu 5 3 3 mbu4 2 2 2 1 1 0 0 1 0 0 N 2 0 0 0 0 0 0 Pain score Pain Scores Figure 4: Pain scores during the injection of local anesthetic Figure 5: Pain scores using WALANT Patient Benefits and Economic Value of In-Office 9 Surgery for Hand Procedures

. Pain Comparision: In-office hand Nausea surgery vs. dentist procedure 2% 17% 2% 81% 98% Less pain More pain The same No Yes Figure 6: Pain compared to dental procedure Figure 7: Patients experiencing nausea after surgery Duration of anesthetic 3% 45% 52% 1-2 h 3-6 h 6-10 h Figure 8: Duration of anesthetic post-operation Anxiety Patients also rated their level of anxiety before, during, and after surgery, with 0 being not anxious and 10 being extremely anxious. The general trend showed decreasing levels of anxiety sequentially with pre-, intra-, and post-operation as shown in Figure 9. Patient Benefits and Economic Value of In-Office 10 Surgery for Hand Procedures

Before During After 45 40 TS40 EN35 IT30 PA 26 25 OF 20 16 BER15 MU10 56 4 56 5 4 N 5 3 3 1 1 1 1 0 1 1 000 3 1 1 300 1 20 1 0 0 0/10 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10 ANXIETY LEVELS Figure 9: Reported anxiety levels before, during, and after surgery Overall Experience 96% of patients felt that, if they needed to have hand surgery again, they would prefer to be wide- awake, 4% would prefer a different method (Figure 10). In terms of the overall experience, 81% felt it was better than what they had expected while 19% believed it was about what they had expected (Figure 1-11). 89% would recommend WALANT to a friend needing hand surgery (Figure 12). Anesthesia Method Expectations 4% 0% 19% 81% 96% About what you expected Better than expected Yes No, I prefer a different anesthesia method Worse than you expected Figure 10: Preferred method of anesthesia Figure 11: Expectations of WALANT Recommendations 9% 2% 89% Definitely Probably Not sure Figure 12: Recommendation of WALANT to a friend Patient Benefits and Economic Value of In-Office 11 Surgery for Hand Procedures

Discussion The results show high patient satisfaction with the use of WALANT in an in-office setting. Most patients only spent 30 minutes to an hour at the facility. Most patients also rated their pain during the injection of the local anesthetic and during the operation as minimal to none. Similarly, anxiety levels decreased as the status of the surgery progressed, and almost all the patients did not experience any nausea after the surgery. Overall, the majority of patients felt WALANT exceeded their expectations, preferred using WALANT over traditional anesthesia methods, and would recommend WALANT to another friend. These findings support that WALANT provides high patient satisfaction and considering that 50% of the patients were 65 or older, this shows that WALANT is also able to offer a safe and comfortable experience to the elderly population. Conclusion Traditional wrist and hand surgical methods that utilize general anesthesia and tourniquets have higher complications rates, more overall expenses, and lower patient satisfaction rates. IV-associated complications include phlebitis, thrombophlebitis, infiltration, extravasation, and risk of infection; general anesthesia complications consist of nausea, vomiting, sore throat, dental damage, myocardial infarction, lung mechanics interference, and exacerbation of preexisting comorbidities. WALANT is particularly beneficial and a safer alternative to the elderly population who are more vulnerable to the complications of general anesthesia. In addition, by using fewer materials, decreased staffing, reducing pain levels, and avoiding complications related to general anesthesia, WALANT allows surgeries to be more cost-efficient. In conclusion, WALANT procedures have higher satisfaction rates because patients receive similar surgery outcomes while lowering complication rates, costs, and pain levels. Patient Benefits and Economic Value of In-Office 12 Surgery for Hand Procedures

Appendix Figure 13: Ten-question questionnaire used to assess patient satisfaction Patient Benefits and Economic Value of In-Office 13 Surgery for Hand Procedures

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