title: Implementation of a critical pathway for complicated gallstone disease: translation of population-based data into clinical practice.
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.
  
  
  METHODS
  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.
authors.affiliation: Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA. kmsheffi@utmb.edu
authors.forename: Kristin M
authors.initials: KM
authors.lastname: Sheffield
authors.forename: Kenia E
authors.initials: KE
authors.lastname: Ramos
authors.forename: Clarisse D
authors.initials: CD
authors.lastname: Djukom
authors.forename: Carlos J
authors.initials: CJ
authors.lastname: Jimenez
authors.forename: William J
authors.initials: WJ
authors.lastname: Mileski
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Kimbrough
authors.forename: Courtney M
authors.initials: CM
authors.lastname: Townsend
authors.forename: Taylor S
authors.initials: TS
authors.lastname: Riall
mesh_terms: D000328:Adult; D016009:Chi-Square Distribution; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002763:Cholecystectomy / Q000706:statistics & numerical data*; D015897:Comorbidity; D019091:Critical Pathways; D019317:Evidence-Based Medicine; D005260:Female; D042882:Gallstones / Q000150:complications* / Q000601:surgery*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010195:Pancreatitis / Q000209:etiology* / Q000601:surgery*; D010359:Patient Readmission / Q000706:statistics & numerical data; D011183:Postoperative Complications; D013997:Time Factors