Delivering Quality and Value Focus on: Cholecystectomy A Guide for Commissioners
Introduction This document will help commissioners and local health communities improve the quality and value of care for cholecystectomy patients 1. This guide is supplementary to the Focus On Cholecystectomy document produced by the Delivering Quality and Value team at the NHS Institute for Innovation and Improvement as part of the high volume Healthcare Resource Groups (HRG) programme. Figure 1 Healthcare Resource Groups (HRGs) Cumulative % FCEs by HRG for England (2003/04) 100 90 80 70 60 % 50 40 30 20 10 0 HRG Source Hospital Episode Statistics HRGs are groups of clinically similar activities for which a similar quantity of resources is needed. They are also the basis for the NHS Payment by Results system. 01 50 HRGs account for 50% of all bed days. 50 different HRGs (however, there is overlap) account for 50% of all finished consultant episodes (FCEs). As the graph shows, a relatively small number of HRGs account for a large proportion of NHS resources. The programme is based on the concept that by focusing on a limited range of high volume HRGs (or related care groups), the NHS Institute can help the NHS to make the maximum impact on improving the quality and value of care for NHS patients. The initial series of HRGs were chosen on the basis that they were high volume, and hence high resource consumers, and also represented a range of clinical areas. 1 Based on HRG codes G13 and G14 The series of HRGs chosen were: acute admissions in adult mental health acute stroke Caesarean section fractured neck of femur cholecystectomy (removal of gall bladder) short stay emergency care (length of stay two days or less) urinary tract infections (as a tracker condition for frail older patients) primary hip and knee replacement. This guide has been developed in conjunction with commissioners, acute NHS Trusts and clinicians to aid adoption of the recommended cholecystectomy care pathway by commissioners. This pathway will lead to high quality care for patients and significant financial savings for both commissioners and providers.
02 By following the recommended pathway commissioners can expect to save up to 190 per patient by: reducing emergency readmissions with acute cholecystitis/biliary colic (based on HRG codes G18 & G19 Biliary Tract Disorders) preventing unnecessary primary care attendances whilst waiting for elective surgery reducing primary care prescribing costs for symptom control whilst waiting for elective surgery avoiding routine postoperative out-patient follow-up. The majority of improvements are applicable and easily transferable to other surgical procedures. Implementation will have numerous benefits not only for the patient but also for the wider health and social economy by freeing up resources and enabling patients to return to normal activities sooner. The document covers: a background to the cholecystectomy pathway (for the benefit of commissioners with a non-clinical background) the current national cholecystectomy performance key messages for commissioners the recommended cholecystectomy patient pathway examples of potential cost savings further information.
Background to the cholecystectomy pathway Gallstones are stones that form in the gallbladder. The liver produces bile that is concentrated by and stored in the gallbladder and gallstones can form within this fluid. Gallstones are quite common but increase with age and in people who eat a diet rich in fat. They can cause severe symptoms with repeated attacks of abdominal pain being the most common. Pain is due either to stones blocking the cystic duct and preventing the gallbladder from emptying (biliary colic) or to inflammation of the gallbladder (cholecystitis). The pain can be severe enough to need admission to hospital. If the stones move out of the gallbladder into the common bile duct, they can cause jaundice, severe infection of the bile ducts (cholangitis) or inflammation of the pancreas (acute pancreatitis). These complications can be very serious but rarely fatal. The two main investigations for patients with suspected gall bladder disease are an ultrasound scan of the upper abdomen and a blood test for liver function. right hepatic duct liver Biliary System left hepatic duct pancreas 03 gallbladder stomach cystic duct common bile duct duodenum common hepatic duct pancreatic duct Traditionally the gallbladder was removed by an open operation requiring admission to hospital for several days and resulted in a prolonged and often complicated postoperative recovery for the patient. Nowadays, the surgery is performed using a minimally invasive technique (laparoscopic cholecystectomy) in up to 90% of cases and can be done safely as a day case procedure in the majority of cases.
Cholecystectomy pathway Context A total of 49,077 cholecystectomy procedures took place in England between 1 April 2005 and 31 March 2006. Of these, 86% were elective admissions (42,402) and 14% (6,675) were operated on during an emergency admission. Overall, 84% of cholecystectomies were undertaken laparoscopically. There is large variation between trusts, with high performers achieving over 90% laparoscopic rates (includes day case and inpatient cholecystectomy) compared with some low performers where the rate of laparoscopic cholecystectomy is under 50%. 2 This variation is likely to be due to experience and sub-specialisation of surgeons in the technique of laparoscopic cholecystectomy. The national average day case cholecystectomy rate is only 6.4%. The highest performing organisations achieve rates of between 40 and 50%, but aim to achieve at least 70% as day cases. There is evidence of no increase in complications or readmission rates in units that perform a high number of day case laparoscopic cholecystectomy. A well designed day surgery and short stay service will ensure that patients and carers needs are met in the early postoperative period which will minimise demand on primary and community care services. 04 Figure 2 Day case rates for laparoscopic cholecystectomy for acute trusts Day April case 2005 March rates for laparoscopic 2006 (excluding cholecystectomy specialist trusts for or acute those trusts performing from April fewer 2005 than to March 2006 (excluding specialist trusts or those performing less than 20 cases per annum) 20 cases per annum) Figure 2 demonstrates national variation, highlighting that almost half of trusts have a day case rate of less than 5% for cholecystectomy, with many doing no day cases at all. 2 This may include some highly specialised units doing complex surgery, and therefore 50% may be an appropriate rate in this setting
Key Messages for Commissioners Encourage your acute trusts to perform laparoscopic cholecystectomy during the initial emergency admission for cholecystitis/biliary colic rather than discharging the patient home and operating electively at a later date. At first glance this may appear to be the more costly option for the commissioner, but repeat emergency admissions whilst on the waiting list for elective surgery is a significant cost that may go unnoticed (see page 9 for worked example of potential cost savings). Case study Patient interview Jeremy (a 23-year-old male), had undergone a laparoscopic cholecystectomy. He had returned from theatre about two hours previously and was awake and drinking water. He was being cared for in the 23- hour unit but was hoping to go home later that evening. His father and girlfriend were with him and were also prepared to take him home. I got acute cholecystitis five months ago while abroad. I was hospitalised and investigated there and then transferred back to the UK once I was fit to travel. I was seen in the outpatient department and told I would need to have my gall bladder removed. I tried a lowfat diet to keep the symptoms at bay. I had several uncomfortable episodes, as well as having three episodes of acute cholecystitis which required me to be admitted to hospital. The pain was awful and you feel so ill. I felt very well prepared for the operation today. The pre-assessment was useful and I have been prepared to go home this evening. I am a bit sore, which I expected, but the pain is not anything like the acute cholecystitis pain. If there was one thing I would change about my experience it would be to have had my operation as soon after diagnosis as possible. That way I would have suffered less and I wouldn t have needed to be admitted to hospital several times or have had to take time off work. 05
06 It is more cost effective to operate on the patient admitted as an emergency with acute cholecystitis/biliary colic as soon as possible after the initial presentation and preferably during the same admission. However, some commissioners may impose a minimum wait of up to five months for those patients admitted with acute cholecystitis/biliary colic and discharged home for later elective surgery. It is not uncommon for a patient to be readmitted as an emergency with a flare-up of symptoms up to three times during a prolonged waiting period. They will also have multiple visits to their GP during this time and may require significant time off work. This is poor quality care and often leads to a more difficult laparoscopic operation, increased operative risk and a greater likelihood of conversion to open surgery. Repeat acute admissions prior to surgery will significantly increase costs to commissioners and waste NHS resources. Early surgical intervention is therefore recommended, preferably during the acute admission, for patients with cholecystitis / biliary colic and also for patients diagnosed in primary care with symptomatic gallstones on both quality and value grounds. Laparoscopic cholecystectomy performed during the acute admission is safe in the hands of sub-specialised laparoscopic surgeons. Conversion from laparoscopic to open cholecystectomy, a significantly more invasive operation for the patient, is halved (8% versus 16%) when operating in the acute phase of the disease, as opposed to allowing the acute episode to settle and being operated on at a later date. Commissioners should ensure that laparoscopic surgeons performing cholecystectomy are sufficiently skilled and are performing adequate numbers regularly to ensure high quality outcomes (evidence suggests surgeons should perform a minimum number of 200 cases in 5 years - 40 cases per year).
Routine post-operative outpatient appointments after uncomplicated laparoscopic cholecystectomy are unnecessary. All too often outpatient follow-up after routine surgery is arranged irrespective of need. In the majority of cases (80%) this is unnecessary and a waste of valuable outpatient resources. It is also an unnecessary cost paid for by commissioners ( 87 per visit) and should be the exception rather than the norm. Commissioners should work with the acute providers to avoid unnecessary outpatient follow-ups and to provide alternative cost-effective patient support (e.g. telephone 24- hour follow-up advice and support) Patients should be educated in primary care to expect the operation to be performed laparoscopically as a day case. Basic investigations should be performed in primary care to confirm diagnosis (abdominal ultrasound scan and blood test for liver function) and the results should be available for the hospital outpatient appointment to prevent unnecessary duplication of tests, patient inconvenience and repeat outpatient appointments. Commissioners should work with providers to develop patient information that is consistent across primary and secondary care. 07 If I had been an inpatient then I would have had the mentality that I was ill. The whole outlook of day surgery can really help you with your recovery. I was able to recover with family and friends, all in the comfort of my own home. I could return to normality almost straightaway. It s a shame more people don t know about it. Day case patient
Figure 3 Recommended patient pathway for cholecystectomy Elective GP referral for suspected biliary disease Start of patient education process to prepare them for day case procedure Emergency primary care referral or acute hospital admission with suspected acute biliary disease Investigations completed prior to Out Patient Appointment (OPA) ideally by primary care ie ultrasound and Liver Function Tests (LFTs) Each day spent in hospital waiting for tests or surgery costs 225 08 Specialist OPA Added to waiting list for surgery at OPA Date of pre-assessment and operation offered to patient Lack of effective pre-assessment can lead to DNAs and on the day cancellations. Patient s expectations are also unlikely to have been properly managed for day case operation Ideally all three processes occur at same attendance Pre-assessment clinic Rapid diagnostic assessment (within 24 hours) Emergency patients also go through preassessment process to ensure consistency of pre-operative assessment and patient information Admit on day of surgery SURGERY Same day / 23 hour discharge Post-operative support via telephone helpline with rapid access to surgical assessment if appropriate. No routine OP follow-up Staggered or semi block arrival times (patient focus) Admission day or more before surgery costs 225 per day No routine use of: Antibiotics saves 5 and reduces patient risk On-table cholangiography saves 50 (+30 mins radiographer time) Specimen catch bag saves 30 Histopathology saves 50 Savings also around standardising disposable equipment Nurse-led discharge Use of standard post-operative analgesia regimes minimising use of opiates Avoiding unnecessary outpatient follow-up saves 87 per visit Emergency patients undergo surgery on acute admission if appropriate This avoids commissioning contractual delays of up to five months for elective surgery. Patients have been known to require three emergency admissions for biliary colic/cholecystitis whilst on waiting lists for elective surgery Specialist laparoscopic surgeon performing >40 laparoscopic cholecystectomies per annum reduces rates of conversion to open surgery Each admission (>69 or with complications) Cholecystitis/biliary colic = 2,271 As above + cholecystectomy = 4,478 Elective cholecystectomy = 1,875 N.B. Each additional admissions = 2,271 with Cholecystitis/biliary cholic whilst on waiting list for elective surgery
Example of potential cost savings if emergency admissions were operated on during the acute episode. An acute trust performs 300 laparoscopic cholecystectomies per year. If 100 patients are admitted to hospital as an emergency and are brought back for elective cholecystectomy at a later date, a third of these patients may be readmitted as an emergency due to a further attack of acute cholecystitis / biliary colic whilst on the waiting list (evidence suggests patients have been readmitted up to three times). Patient attendance Number of patients Tariff cost per patient Total cost Admitted with acute cholecystitis / biliary colic, treated conservatively and discharged then added to a routine waiting list to be admitted for surgery at a later date (HRG codes G18 & G19, plus G13 & G14) 100 4,146 414,600 Cost of readmission as an emergency while waiting for elective cholecystectomy (G18 & G19) 33 1,875 61,875 Total cost for emergency admission plus elective surgery plus associated primary care costs = 476,475 (A) Admitted with acute cholecystitis / biliary colic and operated on during that admission (G13 & G14) 100 4,478 447,800 (B) 09 Cost savings per annum to commissioners for patients operated on during initial acute admission A - B = 28,675 Other Potential Cost Savings Number of patients Estimated cost per patient Total cost Reducing outpatient follow-up by 80% (Outpatient specialty code 100) 240 87 20,880 GP visit whilst on waiting list 100 22 2,200 GP prescribing costs prior to surgery 100 50 5,000 Total potential savings 56,755 In this example there is a potential saving to commissioners of 56,755 based on 300 patients, equivalent to 190 per patient undergoing cholecystectomy. In addition, following the recommended pathway will support achievement of the 18 week target. Other benefits include less time off work for patients, early return to normal activities and reduced GP prescribing for symptoms whilst waiting for surgery. There are also significant savings for the acute trust by following the recommended pathway. These include reduced duplication of diagnostic tests, standardisation of disposables, use of routine pathology, radiology, antibiotics, DVT prophylaxis and freeing up bed and outpatient capacity.
Questions for commissioners to consider: Pathway Step Referral Questions to ask Are commissioners working with providers to develop patient information that is consistent across primary and secondary care? How many of your patients are aware they can have a laparoscopic cholecystectomy as a day case? Admission How many acute emergency admissions occur for cholecystitis/biliary colic? Do you know how many patients are readmitted as an emergency whilst waiting for surgery? Do commissioning rules delay surgery for patients admitted as an acute emergency then discharged home for later elective surgery? 10 Operation How many cholecystectomy operations is your PCT paying for each year? How many are elective and how many are emergency? How many patients are operated on during the emergency admission? Are surgeons specialised in laparoscopic cholecystectomy as per recommendations (200 cases over 5 years equivalent to 40 cases per annum)? Post operative care, discharge and follow-up characteristics What percentage of elective laparoscopic cholecystectomies are done as day cases? What percentage of your patients have routine post operative follow up outpatient appointments? What percentage of your patients have contact with 24-hour telephone support service? General What other high volume surgical procedures would benefit from the same approach?
Summary: The benefits of following the recommended pathway for laparoscopic cholecystectomy should be discussed with acute providers, i.e. to prevent emergency readmissions during the waiting period and understand the financial and quality benefits of operating during the acute admission vs later surgery Routine follow-up outpatient appointments after uncomplicated laparoscopic cholecystectomy are unnecessary GPs should prepare the patient to expect day case laparoscopic cholecystectomy and start the education process prior to referral Commissioners should be aware of the quality and value aspects related to day case laparoscopic surgery and encourage local providers to develop sub-specialist teams i.e. recommended minimum number per surgeon per year/sub-specialisation of surgeon Use the commissioning process to specify, in discussion with providers, an appropriate day case rate for procedures. Consider other high volume surgical procedures that would benefit from the same approach. 11
Acknowledgements Bradford PCT Kensington and Chelsea PCT Southwark PCT Windhill Green Medical Centre, Shipley Yorkshire and Humber SHA References 1. Carty, N. (28th September 2006), Clinical Hot Topics Surgery, Hospital Doctor, p.28. 2. O Boyle, C.J., Murphy, C., May, J.C., and Kapadia, C.R. (1999), Immediate versus delayed laparoscopic cholecystectomy for acute cholecystitis, British Journal of Surgery, Vol. 86, p. 57 12 3. Hobbs, M.S., Mai, Q., Knuiman, M.W., Fletcher, D.R. and Ridout, C.S. (2006), Surgeon experience and trends in intraoperative complications in laparoscopic cholecystectomy, British Journal of Surgery, Vol. 93, No. 7, pp. 844 53 For further information please refer to the Focus on: Cholecystectomy publication (2006).
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