Delays contribute to unnecessary ER visits and additional imaging services in symptomatic gallstone treatment

Getting patients to the operating room more quickly could cut by half the amount paid for hospital treatment of painful gallstones, researchers reported today at the 2009 Clinical Congress of the American College of Surgeons.

According to a study of 383 patients who underwent surgical treatment for gallstones at the University of North Carolina in 2008, the average hospital charge of $5,292 could be reduced by 50 percent if patients had only two preoperative visits to primary care physicians or the emergency department and one clinical imaging study. Researchers found that patients on average had more than four visits to a primary care physician, emergency department, or surgical clinic and nearly three imaging studies, including ultrasound, computed tomography, or a nuclear medicine scan of the liver, gallbladder, biliary tract, and small intestine, from the time they first showed symptoms of gallbladder disease to the time of the operation.

The researchers concluded that delays in obtaining surgical care of symptomatic gall-stones resulted in unnecessary visits to the emergency department for pain relief and additional diagnostic imaging. "I don't want to say that physicians are managing gallbladder disease in the wrong way, but we and other researchers are trying to find a better way, particularly in the current climate of trying to improve the quality and reduce the cost of care. As surgeons, we're hopeful that patients will be referred to us earlier and go the OR sooner rather than come back for more visits and more imaging studies. It just costs more money, and the patient has to go through more pain and waiting in the emergency department. So once the diagnosis of symptomatic gallstones has been made, we believe patients should see a surgeon who can make the determination of when they need to go to the operating room. We also think that if a patient has an imaging modality study that shows gallstones, they don't need to have another one," explained Lindsee E. McPhail, MD, a fellow in gastrointestinal surgery.

Findings from the study carry a message not only for primary care physicians who refer patients to surgeons for treatment of gallstones but also for patients. "When patients have a bout with gallstones, they often go to the emergency room to get medications. When they feel better, they don't feel the need to see a surgeon or have a follow-up. But then they end up having more pain and come back to the emergency department. So the onus is on patients and physicians as well to get this problem taken care of surgically as soon as they can," she said.

The researchers reviewed every patient who had been surgically treated for gallstones at the University of North Carolina (Chapel Hill) hospitals, tabulated the number of times patients went to the emergency department or saw their primary care physician as well as the number of imaging studies they had prior to their operation, and added up the total hospital charges before they underwent the procedure. The research team plans to extend the study to the entire state of North Carolina. "This study was limited to UNC, so we did not capture patients who were treated and had imaging studies at other hospitals. We hope to get a much better picture of the management of gallbladder disease using all the data from the state," Dr. McPhail said.

Blockage of the bile ducts by gallstones is the most common reason why patients are hospitalized for severe abdominal pain. Because gallstones almost never disappear spontaneously, they are treated most effectively by surgically removing the gallbladder [cholecystectomy]. "I think most people know that if they have symptomatic gallstones, the answer is to take out the gallbladder surgically. We are hoping that the information from this study will show that the management of gallbladder disease can be streamlined and that timely surgical care is essential if we hope to contain costs," Dr. McPhail said.

SOURCE American College of Surgeons