Hospital Variation in Cholecystectomies in The Netherlands: A Nationwide Observational Study

Abstract

Background: Practice variation generally raises concerns about the quality of care. This study determined the longitudinal degree of hospital variation in proportion of patients with gallstone disease undergoing cholecystectomy, while adjusted for case-mix, and the effect on clinical outcomes. Methods: A nationwide, longitudinal, database study was performed in all hospitals in the Netherlands in 2013-2015. Patients with gallstone disease were collected from the diagnosis-related group database. Hospital variation in casemix-adjusted cholecystectomy rates was calculated per year. Clinical outcomes after cholecystectomy were compared between hospitals in the lowest/highest 20th percentile of the distribution of adjusted cholecystectomy rates in all 3 subsequent years. Results: In total, 96,673 patients with gallstones were included. The cholecystectomy rate was 73.6%. In 2013-2015, the case-mix-adjusted performance of cholecystectomies was in hospitals with high rates 1.5-1.6 times higher than in hospitals with low rates. Hospitals with a high adjusted cholecystectomy rate had a higher laparoscopy rate, shorter time to surgery, and less emergency department visits after a cholecystectomy compared to hospitals with a low-adjusted cholecystectomy rate. Conclusion: Hospital variation in cholecystectomies in the Netherlands is modest, cholecystectomy rates varies by <2-fold, and variation is stable over time. Cholecystectomies in hospitals with high adjusted cholecystectomy rates are associated with improved outcomes.

Budget Impact of Restrictive Strategy Versus Usual Care for Cholecystectomy (SECURE-Trial)

“…Based on a study into practice variation over time until 2015, about 19% of hospitals perform cholecystectomies in less than 60% of their patients, a performance level indicative for a restrictive strategy put into practice. 15 This most plausible 19% market share of the restrictive strategy was used in the BIA with a 'usual care to restrictive strategy'-ratio of 4.27 or 0.81/0.19.…”

Patients with Clinically Suspected Gallstone Disease: A More Selective Ultrasound May Improve Treatment Related Outcomes

“…Laparoscopic cholecystectomy is the most commonly performed gastrointestinal surgical procedure, resulting in 80,000 surgeries in the United Kingdom and 24,000 in the Netherlands annually [ 5 , 6 ]. In the Netherlands, the surgery rate of patients with symptomatic gallstone disease is approximately 70% [ 7 ]. Symptomatic cholecystolithiasis is an ill-defined condition ranging from epigastric pain to steady, nonparoxysmal pain in the presence of gallstones on transabdominal ultrasound (US) [ 8 ].…”

A Clinical Decision Tool for Selection of Patients With Symptomatic Cholelithiasis for Cholecystectomy Based on Reduction of Pain and a Pain-Free State Following Surgery

“…Cholecystectomy, the most commonly performed gastrointestinal surgical procedure worldwide, is indicated for complicated gallstone disease, while consensus among surgeons and gastroenterologists for the selection for cholecystectomy in uncomplicated gallstone disease is absent . Consequently, cholecystectomy rates vary widely between practices, regions, and countries …”

“…4,5 Consequently, cholecystectomy rates vary widely between practices, regions, and countries. 1,6 Typically, symptomatic cholelithiasis (uncomplicated gallstone disease) presents with biliary colic, that is, acute severe pain attacks located in the right upper quadrant or epigastrium and lasting 15 to 30 minutes or longer. 7,8 The selection for laparoscopic cholecystectomy is generally based on application of these Rome III criteria.…”