Trends in Follow-Up of Patients Presenting to the Emergency Department with Symptomatic Cholelithiasis

Abstract

Background Fewer than 25% of Medicare beneficiaries presenting with symptomatic cholelithiasis undergo elective cholecystectomy. To better understand underuse of cholecystectomy, we examined physician follow-up patterns after emergency department (ED) visits for symptomatic gallstones. Study Design We used 100% Texas Medicare claims (2001-2010) to identify patients ≥66 years who presented to the ED with symptomatic cholelithiasis and were discharged home without cholecystectomy. Timing of outpatient physician visits after ED discharge and rates of emergent cholecystectomy based on physician follow-up patterns were compared. Results 11,126 patients presented to the ED with symptomatic cholelithiasis and were discharged without cholecystectomy. After discharge, 5,327 patients (47.9%) had an outpatient surgeon visit; 29.0% saw another physician and never saw a surgeon, and 23.1% never saw a physician. 68.2% of patients who saw a surgeon underwent elective cholecystectomy. 8.3% of patients who saw a surgeon, 14.6% of patients who saw other physicians and no surgeon, and 77.6% of patients who never saw any physician required emergent hospitalization (p<0.0001). For people who did not see a physician, mean time to emergent hospitalization was 7.5 days (median=2 days); 95.9% presented within 2 weeks after their initial presentation. Conclusions Fewer than half of patients were evaluated by a surgeon after an initial ED visit for symptomatic gallstones. Patients who did not have physician follow-up were most likely to require emergent cholecystectomy, suggesting inappropriate ED discharge and highlighting the need for timely follow-up. Early outpatient surgical consultation is critical in determining appropriateness for cholecystectomy and avoiding emergent cholecystectomy in older patients with symptomatic gallstones.

Risk Factors for Urgent or Emergent Cholecystectomy Mid-workup for Symptomatic Cholelithiasis

“…13 When compared to no follow up or non-surgical physician follow up after ED presentation, evaluation by a surgical team is associated with a significantly lower risk of subsequent emergent hospitalizations. 12 Beyond expedited surgical follow up, some findings support the stance that patients who present with symptomatic cholelithiasis in the ED should be admitted and undergo cholecystectomy within 24 hours of their initial evaluation, even if symptoms resolve and there is no evidence of cholecystitis. A small randomized control trial has demonstrated that patients who meet these criteria and are admitted for surgery within 24 hours have shorter operative times, shorter hospital lengths of stay, and reduced risk of conversion to an open technique compared to those who are discharged with outpatient follow up.…”

“…13 When compared to no follow up or non-surgical physician follow up after ED presentation, evaluation by a surgical team is associated with a significantly lower risk of subsequent emergent hospitalizations. 12…”

“…While efficiency and effectiveness of referral coordination varies by institution, recent data suggests that just under half of patients discharged from the ED with a diagnosis of symptomatic cholelithiasis will follow up with a surgeon. 12,13 These patients are also at high risk of subsequent re-presentations to the ED and prolonged time to OR. 13 When compared to no follow up or non-surgical physician follow up after ED presentation, evaluation by a surgical team is associated with a significantly lower risk of subsequent emergent hospitalizations.…”

How Safe is Performing Cholecystectomy in the Oldest Old? A 15‐year Retrospective Study from a Single Institution

“…Several studies in the literature support the fact that acute cholecystitis is an underestimated condition in the elderly and that too often the surgeon is not even consulted when the patient first presents in the emergency department [15]. Avoiding surgical treatment may lead to inappropriate discharges which promote multiple emergency readmissions, increased percentage of open procedures and also an additional payment of $7000, compared to early surgical management [41].…”

Identifying vulnerable populations with symptomatic cholelithiasis at risk for increased health care utilization

“…If urgent intervention is not performed, patients are typically discharged with a referral to a surgeon or primary care physician (PCP). However, some will experience repeat ED visits (ED revisits) for biliary-related symptoms and progression of disease while waiting for this follow-up appointment 8,9 …”