title: Clinical pathway implementation improves outcomes for complex biliary surgery.
abstract: BACKGROUND
  Complex biliary surgery is associated with significant morbidity, prolonged hospital stay, and high cost. Clinical pathway implementation has the potential to standardize treatment and improve outcomes. Therefore the aim of this analysis was to determine whether clinical pathway implementation and/or feedback of outcome data would alter hospital stay, charges, and mortality rates for complex biliary surgery at an academic medical center
  
  
  METHODS
  Pre- and postoperative length of stay, hospital charges, and mortality rates were monitored for 36 months before (period 1) and for 2 18-month periods (periods 2 and 3) after implementation of a clinical pathway for hepaticojejunostomy. Outcome data were provided to the surgeons 18 months after pathway implementation to determine whether further clinical practice improvement was possible.
  
  
  RESULTS
  From 1991 to 1997, 339 patients underwent hepaticojejunostomy at The Johns Hopkins Hospital for malignant and benign biliary obstruction. Total length of stay was 13.3 +/- 0.9 days for period 1 compared with 12.5 +/- 0.8 days for period 2 (not significant) and 10.1 +/- 0.3 days for period 3 (P < .01 vs period 1; P < .03 vs period 2). Hospital charges averaged $24,446 during period 1 compared with $23,338 during period 2 and $20,240 during period 3 (P < .01 vs periods 1 and 2). Hospital mortality rate was 4.5% during period 1 compared with 0.7% during periods 2 and 3 (P < .05).
  
  
  CONCLUSIONS
  These data suggest that implementation of a clinical pathway for hepaticojejunostomy reduces hospital mortality rates and that feedback of outcome data to surgeons results in further clinical practice improvement. Thus clinical pathway implementation and feedback are effective methods to control costs at an academic medical center.
authors.affiliation: Department of Surgery, Johns Hopkins Medicine, Baltimore, MD, USA.
authors.forename: H A
authors.initials: HA
authors.lastname: Pitt
authors.forename: K P
authors.initials: KP
authors.lastname: Murray
authors.forename: H M
authors.initials: HM
authors.lastname: Bowman
authors.forename: J
authors.initials: J
authors.lastname: Coleman
authors.forename: T A
authors.initials: TA
authors.lastname: Gordon
authors.forename: C J
authors.initials: CJ
authors.lastname: Yeo
authors.forename: K D
authors.initials: KD
authors.lastname: Lillemoe
authors.forename: J L
authors.initials: JL
authors.lastname: Cameron
mesh_terms: D000046:Academic Medical Centers / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data; D000713:Anastomosis, Roux-en-Y; D001649:Bile Duct Diseases / Q000191:economics / Q000401:mortality / Q000601:surgery*; D002768:Choledochostomy / Q000592:standards*; D003142:Communication; D019091:Critical Pathways; D017721:Hospital Costs; D017052:Hospital Mortality; D006801:Humans; D007582:Jejunostomy; D007902:Length of Stay / Q000706:statistics & numerical data; D008505:Medical Staff, Hospital; D009741:Nursing Staff, Hospital; D017063:Outcome Assessment, Health Care; D013527:Perioperative Nursing; D019555:Physician-Nurse Relations; D011787:Quality of Health Care