A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome

Hui, Andrew; Wong, Simon; Leung, Constant; Tong, Po-Yee; Mok, Vincent; Poon, Darren M.C.; Li‐Tsang, Cecilia W. P.; Wong, Lawrence K.S.; Boet, R.

doi:10.1212/01.wnl.0000169017.79374.93

Cited by 197 publications

(137 citation statements)

References 35 publications

Supporting

Mentioning

118

Contrasting

Unclassified

Order By: Relevance

“…Fourteen papers that described the results of six RCTs met our inclusion criteria (see Appendix 4). 118,119,122,123 recruited from a single centre while two trials 117,124 were multicentre. All participants had a clinical diagnosis of CTS including electrophysiological diagnostic criteria although electrophysiological parameters measured and diagnostic thresholds varied between RCTs (see Appendix 5).…”

Section: Resultsmentioning

confidence: 99%

“…Although many studies reported electrophysiological measurements at baseline, it was difficult to compare findings between studies because of the plethora of different protocols used and measures reported. There were three comparisons between surgery and splinting; 118,122,124 two comparisons of surgery versus corticosteroid injections; 119,123 one comparison of surgery versus splinting and injection; 118 and one comparison of surgery versus a combination of non-steroidal anti-inflammatory drugs (NSAIDs), hand therapy and exercises. 117 Open surgery was used in five trials, 118,119,[122][123][124] with the sixth allowing either open or endoscopic surgery.…”

Section: Resultsmentioning

confidence: 99%

“…There were three comparisons between surgery and splinting; 118,122,124 two comparisons of surgery versus corticosteroid injections; 119,123 one comparison of surgery versus splinting and injection; 118 and one comparison of surgery versus a combination of non-steroidal anti-inflammatory drugs (NSAIDs), hand therapy and exercises. 117 Open surgery was used in five trials, 118,119,[122][123][124] with the sixth allowing either open or endoscopic surgery. 117 Splint use varied: the oldest RCT 122 used a plaster splint completely immobilising the hand for 1 month; such splinting is no longer advocated.…”

Section: Resultsmentioning

confidence: 99%

“…118 The type of steroid and frequency of injection also varied. Two trials evaluated a single injection of methylprednisalone 119 or triamcinolone, 118 while the third evaluated one or two (if symptoms persisted) injections of paramethasone. 123 Participants in the non-surgical arm of the final trial 117 had a multimodal intervention including NSAIDs, hand therapy, splint use and, if symptoms did not improve, therapeutic ultrasound.…”

Section: Resultsmentioning

confidence: 99%

“…Loss to follow-up rates varied between 0% 119 and 25% 123 at final follow-up. In some trials the reasons for excluding patients from follow-up appear to be inappropriate, relating to lack of compliance with randomly allocated treatment or lack of satisfaction with treatment results.…”

Section: Case Studymentioning

confidence: 99%

See 4 more Smart Citations

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

View full text Add to dashboard Cite

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.

show abstract

Section: Resultsmentioning

confidence: 99%