Surgical versus non-surgical treatment for carpal tunnel syndrome

Verdugo, Renato J.; Salinas, Rodrigo; Castillo, José Luís; Cea, Gabriel

doi:10.1002/14651858.cd001552.pub2

Cited by 198 publications

(162 citation statements)

References 21 publications

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“…We also used unpublished data from an additional RCT 119 that had been previously obtained by a Cochrane review. 120 We used a forest plot to graphically display the results of primary studies. Visual inspection of the graphs and the I 2 statistic 121 were used to investigate statistical heterogeneity between primary studies.…”

Section: Search Strategymentioning

confidence: 99%

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Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Hollingworth

Rooshenas

Busby

et al. 2015

Health Services and Delivery Research

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BackgroundNHS expenditure has stagnated since the economic crisis of 2007, resulting in financial pressures. One response is for policy-makers to regulate use of existing health-care technologies and disinvest from inefficiently used health technologies. A key challenge to disinvestment is to identify existing health technologies with uncertain cost-effectiveness.ObjectivesWe aimed to explore if geographical variation in procedure rates is a marker of clinical uncertainty and might be used by local commissioners to identify procedures that are potential candidates for disinvestment. We also explore obstacles and solutions to local commissioners achieving disinvestment, and patient and clinician perspectives on regulating access to procedures.MethodsWe used Hospital Episode Statistics to measure geographical variation in procedure rates from 2007/8 to 2011/12. Expected procedure numbers for each primary care trust (PCT) were calculated adjusting for proxies of need. Random effects Poisson regression quantified the residual inter-PCT procedure rate variability. We benchmarked local procedure rates in two PCTs against national rates. We conducted rapid systematic reviews of two high-use procedures selected by the PCTs [carpal tunnel release (CTR) and laser capsulotomy], searching bibliographical databases to identify systematic reviews and randomised controlled trials (RCTs). We conducted non-participant overt observations of commissioning meetings and semistructured interviews with stakeholders about disinvestment in general and with clinicians and patients about one disinvestment case study. Transcripts were analysed thematically using constant comparison methods derived from grounded theory.ResultsThere was large inter-PCT variability in procedure rates for many common NHS procedures. Variation in procedure rates was highest where the diffusion or discontinuance was rapidly evolving and where substitute procedures were available, suggesting that variation is a proxy for clinical uncertainty about appropriate use. In both PCTs we identified procedures where high local use might represent an opportunity for disinvestment. However, there were barriers to achieving disinvestment in both procedure case studies. RCTs comparing CTR with conservative care indicated that surgery was clinically effective and cost-effective on average but provided limited evidence on patient subgroups to inform commissioning criteria and achieve savings. We found no RCTs of laser capsulotomy. The apparently high rate of capsulotomy was probably due to the coding inaccuracy; some savings might be achieved by greater use of outpatient procedures. Commissioning meetings were dominated by new funding requests. Benchmarking did not appear to be routinely carried out because of capacity issues and concerns about data reliability. Perceived barriers to disinvestment included lack of collaboration, central support and tools for disinvestment. Clinicians felt threshold criteria had little impact on their practice and that prior approval systems would not be cost-effective. Most patients were unaware of rationing.ConclusionsPolicy-makers could use geographical variation as a starting point to identify procedures where health technology reassessment or RCTs might be needed to inform policy. Commissioners can use benchmarking to identify procedures with high local use, possibly indicating overtreatment. However, coding inconsistency and limited evidence are major barriers to achieving disinvestment through benchmarking. Increased central support for commissioners to tackle disinvestment is needed, including tools, accurate data and relevant evidence. Early engagement with patients and clinicians is essential for successful local disinvestment.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Section: Search Strategymentioning

confidence: 99%

“…126 However, our search identified all RCTs included in a previous Cochrane review on the topic. 120 We also retained the Cochrane risk of bias tool in order to describe the quality of the RCTs included in our review.…”

Section: Strengths and Weaknessesmentioning

confidence: 99%

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Hollingworth

Rooshenas

Busby

et al. 2015

Health Services and Delivery Research

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“…Although surgical treatment is generally accepted in severe cases, it is not clear if surgical treatment overweighs the non -surgical approaches such as steroid injection in the treatment of CTS patients with mild to moderate symptoms (12).…”

Section: Discussionmentioning

confidence: 99%

Comparison of the Efficacy of Carpal Tunnel Release vs. Local Steroid Injection in the Management of Mild to Moderate Carpal Tunnel Syndrome: A Clinical Trial

et al. 2018

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“…20 When compared with surgical management however, splinting is less effective in treating CTS. 21 Therapeutic US involves delivering sound impulses to the median nerve within the carpal tunnel in an attempt to relieve the intra-compartmental pressure, improve perfusion and relieve pain through thermal action. The reported frequencies used, range from 1 to 3 MHz and have been administered over short or prolonged periods, in the published literature.…”

Section: Current View On Non-surgical Treatment Of Ctsmentioning

confidence: 99%

Carpal tunnel syndrome – current controversies

Raja¹,

Carlos²

2015

Orthopaedics and Trauma

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Surgical versus non-surgical treatment for carpal tunnel syndrome

Abstract: Surgical treatment of carpal tunnel syndrome relieves symptoms significantly better than splinting. Further research is needed to discover whether this conclusion applies to people with mild symptoms and whether surgical treatment is better than steroid injection.

Cited by 198 publications

References 21 publications

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Comparison of the Efficacy of Carpal Tunnel Release vs. Local Steroid Injection in the Management of Mild to Moderate Carpal Tunnel Syndrome: A Clinical Trial

Carpal tunnel syndrome – current controversies

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