EGS P13 Hot gall bladder service in NHS – clinical and financial implications in a retrospective analysis
Authors: Arifuzaman Mohammed , Shah Jigar , Bhattacharya Sayan 
Published: December 2022

Abstract

Background
Gallstone disease is one of the most common general surgical presentations, leading to index admissions at hospitals across NHS. The patients are usually managed conservatively with analgesia and antibiotics, as and when required, and are booked for elective cholecystectomy scheduled for a later date, which may at times drag on for months. In the meantime, the patients may present to the hospital again with the same symptoms and get managed similarly or may present with more severe symptoms like jaundice, gallbladder perforation or pancreatitis, which may lead to morbidity or mortality. This may be considered as patient harm. NICE recommends that every eligible patient with cholecystitis should be offered cholecystectomy in their index admission or within 7 days, for gallstone related pancreatitis, this is index admission and 14 days respectively. Financial and technical reasons can be attributed to the long waiting list and subsequent delayed management of such patients. We wanted to study the rate of admissions, readmissions and complications of the gallbladder disease management at our hospital and the overall clinical and financial implications of starting a hot gall bladder service.

Methods
A retrospective analysis was conducted at out hospital for the patients admitted with acute cholecystitis from a period of July 2019 to March 2020. Inclusion criteria were fit patients aged from 16 to 80 years and exclusion criteria was patients unfit for surgery. The patients who had first presentation admission and readmission were calculated. These patients were listed for elective cholecystectomy to be performed at a later date. The patients were also divided based upon the initial presentation. The total number of patient days per year and per week were calculated based upon the patients presented in the study time. Total length of stay of each patient along with the mean duration of stay during admission and readmission were calculated and bed cost per day was calculated. The financial burden for readmission patients were calculated for the period of study as well as the annual burden. The recommendation was to run hot gall bladder service at our hospital and hence the annual theatre cost for running two half day sessions per week for over 42 weeks per annum along with the surgeon cost were calculated for a grand annual total.

Results
A total of 108 patients who fit the inclusion criteria were studied during July 2019 to March 2020. 61 (56.5%) were first admission and 47 (43.5%) were readmission, out of which 32 (68%) had same presentation and 15 (32%) had disease progression (13 – cholecystitis and 2 – pancreatitis). The total length of stay for first admission patients were 229 days with a mean of 3 days and that for readmission patients was 169 days with a mean of 2 days. The bed cost per day was GBP 310 and hence the readmitted patients had a financial burden of £52,390 in 9 months or £70,000 annually. Of the readmitted patients with same presentation 22 (68.8%) developed cholecystitis and of the readmitted patients with disease progression 13 (86.5%) had developed cholecystitis and 2 (13.5%) had developed pancreatitis. The overall development of preventable complications was 35 (74.5%) cholecystitis and 2 (25.5%) pancreatitis, leading to 362 bed days including readmissions and 19 bed days including readmissions respectively. The annual theatre cost for running two half day sessions of acute cholecystectomy service per week for 42 weeks was calculated as approximately £80,000 and surgeons cost was about £24,000 with a total annual cost of £1,04,000.

Conclusions
The result of the study clearly demonstrates that by performing index admission cholecystectomy we could have prevented 47 patients from being re-admitted in 9 months or 63 patients in one year. It could have saved 169 bed days in 9 months or 225 bed days in 12 months. This could have prevented disease progression in 15 patients, prevented cholecystitis in 35 patients and pancreatitis in 2 patients. The total amount saved was about £52,390 in 9 months or approximately £70,000 in one year. On the other hand, the amount needed to run two half day sessions per week of acute cholecystectomy service is about £1,04,000 which greatly reduces the readmission rates, reduces hospital stay (bed costs) and can promote best practice tariff. This also has medico-legal implications as patients with gallstone disease are prone to pancreatitis and may be develop life threatening complications which may lead to the trusts facing severe criticism and costly settlements. Based on the findings of the study, our hospital has decided to start hot gallbladder service which will be twice a week half day session from May 2022.