Implementation of a critical pathway for complicated gallstone disease

Translation of population-based data into clinical practice

Kristin M. Sheffield, Kenia E. Ramos, Clarisse D. Djukom, Carlos Jimenez, William Mileski, Thomas Kimbrough, Courtney Townsend, Taylor S. Riall

Research output: Contribution to journalArticle

24 Citations (Scopus)

Abstract

Background: Evidence-based guidelines recommend cholecystectomy during initial hospitalization for complicated gallstone disease. Previous studies and quality initiative data from our institution demonstrated that only 40% to 75% of patients underwent cholecystectomy on index admission. Study Design: In January 2009, we implemented a critical pathway to improve cholecystectomy rates for all patients emergently admitted for acute cholecystitis, mild gallstone pancreatitis, or common bile duct stones. We compared cholecystectomy rates during initial hospitalization, time to cholecystectomy, length of initial stay, and readmission rates in prepathway (January 2005 to February 2008) and postpathway patients (January 2009 to May 2010). Results: Demographic and clinical characteristics were similar between prepathway (n = 455) and postpathway patients (n = 112). Cholecystectomy rates during initial hospitalization increased from 48% to 78% after pathway implementation (p < 0.0001). There were no differences in operative mortality or operative complications between the 2 groups. For patients undergoing cholecystectomy on initial hospitalization, the mean length of stay decreased after pathway implementation (7.1 days to 4.5 days; p < 0.0001), primarily due to a decrease in the time from admission to cholecystectomy (4.1 days to 2.1 days; p < 0.0001). Thirty-three percent of prepathway and 10% of postpathway patients required readmission for gallstone-related problems or operative complications (p < 0.0001), and each readmission generated an average of $19,000 in additional charges. Conclusions: Implementation of a multidisciplinary critical pathway improved cholecystectomy rates on initial hospitalization and lowered costs by shortening length of stay and markedly decreasing readmission rates for gallstone-related problems. Broader implementation of similar pathways offers the potential to translate evidence-based guidelines into clinical practice and minimize the cost of medical care.

Original languageEnglish (US)
Pages (from-to)835-843
Number of pages9
JournalJournal of the American College of Surgeons
Volume212
Issue number5
DOIs
StatePublished - May 2011

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Critical Pathways
Cholecystectomy
Gallstones
Population
Hospitalization
Length of Stay
Guidelines
Patient Readmission
Acute Cholecystitis
Common Bile Duct
Pancreatitis
Health Care Costs
Demography
Costs and Cost Analysis
Mortality

ASJC Scopus subject areas

  • Surgery

Cite this

Implementation of a critical pathway for complicated gallstone disease : Translation of population-based data into clinical practice. / Sheffield, Kristin M.; Ramos, Kenia E.; Djukom, Clarisse D.; Jimenez, Carlos; Mileski, William; Kimbrough, Thomas; Townsend, Courtney; Riall, Taylor S.

In: Journal of the American College of Surgeons, Vol. 212, No. 5, 05.2011, p. 835-843.

Research output: Contribution to journalArticle

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abstract = "Background: Evidence-based guidelines recommend cholecystectomy during initial hospitalization for complicated gallstone disease. Previous studies and quality initiative data from our institution demonstrated that only 40{\%} to 75{\%} of patients underwent cholecystectomy on index admission. Study Design: In January 2009, we implemented a critical pathway to improve cholecystectomy rates for all patients emergently admitted for acute cholecystitis, mild gallstone pancreatitis, or common bile duct stones. We compared cholecystectomy rates during initial hospitalization, time to cholecystectomy, length of initial stay, and readmission rates in prepathway (January 2005 to February 2008) and postpathway patients (January 2009 to May 2010). Results: Demographic and clinical characteristics were similar between prepathway (n = 455) and postpathway patients (n = 112). Cholecystectomy rates during initial hospitalization increased from 48{\%} to 78{\%} after pathway implementation (p < 0.0001). There were no differences in operative mortality or operative complications between the 2 groups. For patients undergoing cholecystectomy on initial hospitalization, the mean length of stay decreased after pathway implementation (7.1 days to 4.5 days; p < 0.0001), primarily due to a decrease in the time from admission to cholecystectomy (4.1 days to 2.1 days; p < 0.0001). Thirty-three percent of prepathway and 10{\%} of postpathway patients required readmission for gallstone-related problems or operative complications (p < 0.0001), and each readmission generated an average of $19,000 in additional charges. Conclusions: Implementation of a multidisciplinary critical pathway improved cholecystectomy rates on initial hospitalization and lowered costs by shortening length of stay and markedly decreasing readmission rates for gallstone-related problems. Broader implementation of similar pathways offers the potential to translate evidence-based guidelines into clinical practice and minimize the cost of medical care.",
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AU - Kimbrough, Thomas

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