HPB P40 Assessing The Cholecystectomy Pathway: Are Standards Being Truly Met?
Authors: Farah Nima , Hammer Clare , Gatenby Piers , Pencavel Timothy 
Published: December 2022

Abstract

Background
Research suggests better outcomes for patients having cholecystectomy &lt;8 days of presenting with symptoms1. Locally collected data from the GI surgery department at Royal Surrey County Hospital (RSCH) reported that 94% of eligible cases with acute biliary pathology underwent cholecystectomy &lt;8 days of presentation. However, Hospital episode statistics (HES) data suggest it's lower.
RSCH participates in a national project evaluating the care of patients presenting acutely with biliary pathology (the CholoeQuic-ER study), and the latest outcomes from that study indicate that we are in the top 5 trusts nationally for acute management of gallstone disease, with a median time from admission to surgery of 3 days, resulting in significant improvements in bed occupancy and patient experience The primary aim was to ascertain what proportion of patients; 1) were eligible for an acute cholecystectomy or deemed unfit. 2) were eligible for cholecystectomy but were not referred during the inpatient admission, 3) were coded as having acute biliary pathology but had an alternative primary diagnosis. The secondary aim was to ascertain whether they met the standard of undertaking cholecystectomy &lt;8 days of presentation with gallstone disease and why there was a discrepancy between the departmental data and HES data.

Methods
The hospital coding department provided a list of patients discharged from RSCH in September 2019 with a coding suggesting acute biliary pathology. ICD-10 codes covering cholelithiasis, cholecystitis, other diseases of the gallbladder and acute pancreatitis were used (the same methodology as the CholeQuic-ER study).

Results
There were 118 patients who were discharged in September 2019 with ICD-10 codes diagnostic of acute biliary pathology. Of the 118 patients, 48 (40.7%) were correctly coded with biliary pathology and 70 (59.3%) were not. Twenty-eight (58.3%) of those patients who were correctly coded had a surgical/ procedural intervention. Twenty (41.7%) of the correctly coded patients did not have surgical/procedural intervention, 9 (45%) discharged with outpatient surgical/AEC review pertaining to the biliary pathology. Nine (45%) discharged with alternative primary diagnosis, 2 (10%) discharged with a primary biliary pathology and no surgical intervention/follow-up. Of the original 118 patients, 70 (59.3%) patients did not have biliary pathology; 31 (44.2%) had no data specifically for September 2019, for the further 39 (55.7%) patients, there was incorrect coding e.g. Pneumonia Using the ICD codes employed by the CholeQuic-ER study, 66.9% of cases identified were inappropriately classified as primary biliary pathology and were not eligible for cholecystectomy.
The final outcomes were 28/48 (58.3%) had underwent appropriate procedure for their primary biliary pathology at index admission. 20/48 (41.7%) did not have definitive treatment at their index admission.

Conclusions
The results demonstrate a high number of patients with acute biliary pathology who did not undergo definitive treatment at their index admission or within 8 days of presentation.
Use of the methodology employed by the CholeQuic-ER study using HES data was inaccurate in correctly identifying patients with acute biliary pathology. Accurate coding of patients requires liaison between coding and clinical teams to help narrow discrepancies between HES data and RSCH data not only in the field of general surgery but in other departments.
We plan to work with the coding department to improve the outcome coding to help reflect the excellent outcomes we are achieving for these patients.
References:
Bamber JR, Stephens TJ, Cromwell DA, Duncan E, Martin GP, Quiney NF, Abercrombie JF, Beckingham, on behalf of the Cholecystectomy Quality Improvement Collaborative. Effectiveness of a quality improvement collaborative in reducing time to surgery for patients requiring emergency cholecystectomy. British Journal of Surgery. 2019; 3:802–811.