Medicare Spending and Evidence-Based Approach in Surgical Treatment of Thumb Carpometacarpal Joint Arthritis: 2001 to 2010

Background: Despite equivalent outcomes among surgical treatments of thumb carpometacarpal arthritis, little is known about the variation in spending. Because of its complexities, the authors hypothesized that trapeziectomy with ligament reconstruction and tendon interposition incurs the greatest cost to Medicare compared with other surgical procedures. Methods: Using a random 5 percent sample of Medicare beneficiaries diagnosed with thumb carpometacarpal joint arthritis, the authors examined total and out-of-pocket spending for 3530 patients who underwent a surgical treatment between 2001 and 2010. The authors used generalized linear regression models, controlling for patient characteristics and place of surgery, to examine variations in spending. Results: Eighty-nine percent of patients who underwent surgery received trapeziectomy with ligament reconstruction and tendon interposition, with total and out-of-pocket spending of $2576 (95 percent CI, $2333 to $2843; p < 0.001) and $436 (95 percent CI, $429 to $531; p < 0.001), respectively. Simple complete trapeziectomy was the least expensive procedure, performed in 5 percent of patients, with total and out-of-pocket spending of $1268 (95 percent CI, $1089 to $1476; p < 0.001) and $236 (95 percent CI, $180 to $258; p < 0.001), respectively. Because of increasingly higher facility costs, performing the same procedure in a hospital outpatient setting compared with an ambulatory center would increase Medicare spending by more than two-fold (p < 0.001). Conclusions: With a consistent rise in health care spending, adherence to an evidence-based approach in medicine is more important than ever. Most surgeons continue to perform trapeziectomy with ligament reconstruction and tendon interposition, the most expensive surgical option. Medicare could potentially save $7.4 million annually if simple complete trapeziectomy was the procedure of choice.