HIQA makes recommendations on referral thresholds for a range of common hand and back procedures

Date of publication:
HIQA has today published a series of reports outlining recommended referral and treatment thresholds for nine scheduled procedures to treat common hand and back conditions, such as chronic spinal pain, trigger finger and carpal tunnel. The reports set out the minimum criteria a patient should meet before being referred for such treatment, which should lead to a more streamlined referral process, standardise the care provided and ultimately improve patient access to beneficial interventions. 
 
These reports come at a critical time for Ireland’s health service, with demand for healthcare growing considerably over the last number of years. Demand for scheduled procedures in particular continues to exceed available capacity, with a 22% increase in demand for these services in 2011 compared to a year earlier. The Health Service Executive (HSE) is therefore continually striving to provide more with a finite, and reducing, budget. In light of this it is now more important than ever that access to services is governed in an equitable, transparent and evidence-based manner. This series of HTAs is one of a number of initiatives in progress to tackle waiting lists for outpatient appointments and for elective procedures in Ireland. 
 
Dr Máirín Ryan, Director of Health Technology Assessment in HIQA, said: “Following a public consultation process we have today published referral and treatment thresholds that can help identify those who stand to benefit most from each of the elective procedures we assessed, and those for whom more effective alternatives exist. This is the first step in a process that will require the combined efforts of a number of different parts of the health system to implement, and will ultimately help to improve the efficiency, equity of access and cost-effectiveness of these important services.”
 
The introduction of thresholds will help ensure a more efficient use of available resources and speedier access for those in greatest need of treatment, while also reducing regional variation in clinical practice and access to these procedures. Given that need and demand exceed existing capacity, it is unlikely that introduction of thresholds will result in a decrease in the number of these procedures undertaken in hospitals. Successful implementation of these thresholds will depend on timely access to primary care services, such as physiotherapy, for those who can be effectively managed in the primary care setting and who do not warrant referral to secondary care.
 
As well as reports on individual procedures, HIQA also today published a report outlining the background to the assessment and the methods used, as well as an analysis of relevant ethical issues.

Further Information: 

Please contact: Marty Whelan, Head of Communications and Stakeholder Engagement 01 814 7480 / 086 2447 623 mwhelan@hiqa.ie

Notes to the Editor: 

HIQA is the statutory organisation in Ireland with a responsibility to carry out national health technology assessments (HTAs) and to develop guidelines for the conduct of HTAs across our healthcare system. 

The procedures which are included in Phase II of a series of HTAs include: 

  • Release of Carpal tunnel
  • Surgery for Dupuytren’s Contracture
  • Ganglion Cyst Surgery
  • Surgery for trigger finger/thumb
  • Spinal injections for pain due to degenerative lumbar spine disease
  • Vertebroplasty and kyphoplasty for osteoporotic vertebral compression fractures
  • Radiofrequency lesioning for chronic spinal pain
  • Surgery for adult degenerative lumbar spine disease
  • Spinal Cord Stimulation for chronic pain.
  • Supporting documents include the ‘Background and Methods – Phase II’ and ‘Ethical Analysis’ documents. 

Carpal tunnel syndrome is caused by compression of the median nerve running through the wrist, resulting in numbness, weakness or tingling in the hand. It occurs in people of all ages, though peak incidence occurs between the ages of 50 and 60 years, with women more likely to be affected than men. Surgical release of the carpal tunnel can relieve carpal tunnel syndrome. 

Dupuytren’s contracture is a disorder characterised by the appearance of firm pits, nodules or cords in the palm of the hand. This may extend to the fingers and cause them to flex inwards, in which case the disease is known asDupuytren’s contracture. Surgery can restore function and correct deformity. 

Ganglion cysts are benign, fluid filled growths that usually form near a joint capsule, tendon or tendon sheath. Cysts can develop suddenly or over a period of time and some may resolve spontaneously. They can occur beside any joint in the body, but are most commonly associated with the wrist, hand and fingers. Ganglion cysts can be surgically excised. 

Trigger finger is a painful condition caused by the inflammation or thickening and narrowing of the sheath for the flexor tendon of a finger. If the condition worsens, the finger may get stuck in a bent position, then suddenly pop straight. Eventually, it may not straighten fully and instead become locked in flexion or extension. Surgical trigger finger release can provide a permanent cure. 

Spinal injections are one type of minimally-invasive interventional procedure used in managing back pain either as an independent procedure or in conjunction with other modalities of care. Typically for therapeutic purposes, drugs administered via these injections will include a mix of corticosteroids and local anaesthetics. These injections will result in some pain relief in the short term. 

Spinal cord stimulation delivers repetitive electrical impulses of varying width, duration and intensity to the spinal cord. This stimulation of the dorsal columns of the spinal cord aims to modify the patient’s perception of pain. 

Radiofrequency lesioning procedures are increasingly being used to provide long term pain relief in adults with chronic spinal pain. X-ray imaging is used to guide an electrode to the nerve supplying a painful joint. Classical RF ablation involves application of uninterrupted heat (60-80ºC) for a predetermined amount of time to destroy the sensory nervefibres. Pulsed RF uses short bursts of electrical current of a high voltage without heating the tissue enough to cause coagulation (less than 42ºC). Both procedures aim to interrupt the pain signals to provide relief. 

Vertebroplasty is a minimally-invasive surgical procedure that involves injection of a cement-like material, under X-ray guidance, into the vertebral body to stabilise and strengthen collapsed or crushed bone. During kyphoplasty, a balloon is inserted into the vertebral body and inflated, elevating the fracture and allowing return to a more normal position. A cavity is also created inside the vertebrae for cement injection. 

Surgical approaches to the management of degenerative lumbar spine disease include discectomy, decompression surgery and spinal fusion. Discectomy involves removal of disc material to relieve pressure on the nerve tissue. Decompression surgery can include a combination of procedures, including discectomy, designed to relieve pressure on the spinal cord or nerve roots caused by disc herniation or stenosis of the spinal canal. Where degenerative lumbar disease or prior decompression surgery has resulted in spinal instability, spinal fusion may be required to join two or more vertebrae together.