Index cholecystectomy has been recognized as the standard of care for acute biliary complaints requiring hospital admission. The results of randomized control trials, meta-analyses, and organizational guidelines suggest patients with acute cholecystitis (AC) and gallstone pancreatitis (GSP), without signs of systemic illness, should undergo laparoscopic cholecystectomy during the initial hospital admission.1–3 Significant variability exists with respect to adherence to the available guidelines.4–6 In a large population based study, de Mestral et al7 found a 4-fold difference in the odds of undergoing an index cholecystectomy among hospitals, even when considering only young healthy patients with uncomplicated disease. This variation in practice, in the context of strong evidence supporting index cholecystectomy, underscores the need for quality measures to guide an improvement in care.
Variation in health care delivery is a well-accepted contributor to higher costs and less efficient care. With respect to acute biliary disease, patients who do not undergo an index cholecystectomy have higher rates of readmission and more emergency room visits.2,5,8 Not only does this represent increased health care resource use, but from a patient perspective it is a surrogate for more symptoms, more time away from work and an overall lower quality of life compared with a patient who had definitive care when in hospital. Importantly, limiting variation is not about practicing “cookbook medicine,” or designed to lay blame for those who practice outside guidelines, but rather it is meant to foster quality improvement and deliver the best patient care possible through efficient use of resources.
The first step in reducing variations in practice is deciding an appropriate measure of quality. The chosen measure is then assessed over time to allow benchmarking within and among institutions. When deciding on quality measurements and indicators, the Donabedian model of structure, process, and outcome is best used to organize the perspectives of multiple stakeholders.9 Many stakeholders (patients, surgeons, nurses, anesthesia, payers, and administration) can influence the timeliness of surgery and the Donabedian model can help guide the development of a strategy for quality in acute biliary disease. Using a process measure to assess quality confers a number of benefits: most importantly it can be used to directly measure the care delivered. The use of process measures to measure the quality of surgical care has previously been recognized by Birkmeyer et al10, however in their article, the authors acknowledge this approach to be limited by a lack of information on which processes are important for specific procedures. We believe the rate of index cholecystectomy, a process measure, is the most appropriate indicator of quality of care for acute biliary admissions (Table 1). Indeed, index cholecystectomy is directly linked with good outcomes without an increase in adverse event rates such as conversion to open surgery.1,2,5,8 The volume and quality of evidence supporting index cholecystectomy suggests this process measure is ideally suited to acute biliary disease. Although measures of structure and outcomes could be used for assessing quality in acute biliary disease, they suffer from significant drawbacks. With structure, for example, access to emergency operating room time could be used as a proxy measure of quality. However, this measure is not specific, and relies on a surgeon's acceptance of available guidelines to infer that an operation would be performed if indicated. As a corollary even if an institution has surgeons who are willing to perform index cholecystectomies (a structure measure), a lack of personnel resources (nursing and anesthesia staff) could preclude adequate care for acute biliary disease. Using an outcome measure such as complication or hospital readmission rate is equally problematic, largely because of the problem of attribution; a measured outcome can be challenging to directly attribute to delivered, or not delivered, care. Because of this, outcome measures are generally viewed as weaker when compared with process measures.9
In acute biliary disease, the time to index operation is also a potentially important quality indicator, though this metric has significant potential for confounding. A mandatory 72-hour cholecystecomy target has been advocated in multiple sources by numerous authors, though this is by no means the only time target identified.1,2,8 Although this may seem like a reasonable goal to manage the increasing difficulty of the procedure itself because of worsening inflammation over time, local resource limitations among the operating room and/or the on call general surgeons may make achieving this goal relatively challenging. It is also not specifically applicable to cases of gallstone-induced pancreatitis, where an additional delay/step of endoscopic stone extraction is commonly required.3 A time-based metric is not feasible in the present day due in part to the low rate of index cholecystectomy being performed. As the rate of index cholecystectomy improves; however, additional quality targets, such as time to operation, should be assessed and may be used to identify variable care at institutions with very high index cholecystectomy rates.4–6
At present, no guideline proposes an individual or institutional goal for the rate of index cholecystectomy. Recent literature would suggest that with appropriate resources and uptake by the necessary stakeholders, an index cholecystectomy rate of 75% for all admissions of acute biliary disease is realistic and achievable, and could be used as an indicator of the provision of good surgical care.5,6 Appropriate resources may include a dedicated day-time theater for urgent cases (including anesthesia and nursing support) and/or a dedicated acute care surgery model.5,6 Our institutional index cholecystectomy rate rose from 20% to 80% within a year of implementing an acute care surgery team with dedicated, daily access to the operating room, and has remained over 70% for 5 years.6 Similar results have been achieved in Australia.7 An index cholecystectomy rate of 100% is unrealistic given differences in patient comorbidities and personal patient preferences, and available hospital resources. However, it is the minority of patients who are not eligible or unwilling to undergo an index cholecystectomy. An institutional goal to have 75% of patients with acute biliary disease undergo an index cholecystectomy would require hospitals to innovate or learn from other institutions with regard to care delivery models. Index cholecystectomy rate as a metric is actionable both by the surgeon and institution, another advantage of process measures.10 Setting an institutional rather than surgeon specific goal would facilitate collaboration between surgical departments and the institution to achieve the metric. In addition to surgeons considering index cholecystectomy more often than not, institutions would need to provide resources to support and facilitate index cholecystectomy. Ultimately, this approach would lead to less variation between hospitals and providers, and improve care for patients with acute biliary disease.
Finally, a recognized drawback of setting a target is that a certain volume of acute biliary disease is required to reduce the influence of a single admission. To balance the applicability of this quality metric with the potential for variation, we believe an annual institutional volume of 50 admissions for acute biliary complaints should be required to use this metric as an indicator of quality. For example, in our regional health care system, an annual admission volume of 50 would include the majority of hospitals (>75%).7 This would allow benchmarking and reduce the variation of an individual patient to 2%.7 Fortunately, the process measure of index cholecystectomy is easy to capture retrospectively through modern medical records and could be measured on a quarterly basis to benchmark internally and published annually to benchmark nationally in centers meeting the minimum admission requirements.
Access to efficient and timely care is important not only for patients but also within the context of limited health care resources. The dollar cost of ineffective and inefficient care is completely realized within health care systems, particularly those with a single-payer. As such there has been a shift within health care, including surgery, to identify areas for quality improvement and to ensure appropriate and evidence based delivery of health care. The improvement of quality requires carefully chosen, appropriate and reflective indicators of quality, as well as accurate measurement. We believe the rate of index cholecystectomy for acute biliary admissions is an appropriate indicator of quality and readily available to measure and report. An index cholecystectomy rate of 75% could be used by surgical departments, hospitals, local and national bodies as a measure of surgical quality. This metric can be used to drive innovation and further develop quality improvement projects within general surgery.
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