Gastrointestinal
Hospital readmission after emergency room visit for cholelithiasis

Presented at the 10th Annual Academic Surgical Congress, February 5, 2015, Las Vegas, Nevada.
https://doi.org/10.1016/j.jss.2015.04.032Get rights and content

Abstract

Background

For patients presenting with symptomatic cholelithiasis, cholecystectomy is the definitive treatment modality. Our goal was to evaluate the surgical follow-up and outcomes in patients seen in the emergency department (ED) for an episode of symptomatic cholelithiasis and discharged home for elective follow-up.

Methods

We performed a retrospective review of consecutive patients seen in the ED for cholelithiasis and discharged without hospital admission between August 2009 and May 2014. All patients were followed for 2 y from the date of the initial ED visit. We evaluated outpatient surgeon visits, elective and emergent cholecystectomy rates, and additional ED visits. Cumulative incidence and Kaplan–Meier curves were used to examine the time from the initial ED visit to outpatient surgeon evaluation and the time from the initial ED visit to ED readmission.

Results

Seventy-one patients were discharged from the ED with a diagnosis of symptomatic gallstones. Patients who had an elective cholecystectomy in the 2 y after the initial visit were 12.6%. In this group, the mean time from the initial ED visit to outpatient surgeon follow-up was 7.7 d, and all elective cholecystectomies occurred within 1 mo of the initial visit. Of the 62 patients who did not have an elective cholecystectomy, only 14.5% of patients in this group had outpatient surgeon follow-up at mean time of 137 d from the initial ED visit for symptomatic gallstones. In addition, 37.1% of patients in this group had additional ED visits for gallstone-related symptoms, with 17.7% of patients having two or more additional ED visits, and 12.9% required emergent and/or urgent cholecystectomy. Additional ED visits (43.5%) occurred within 1 mo and 60.9% within 3 mo of their initial ED visit. In patients with additional ED visits for symptomatic cholelithiasis, 60.9% had more than one abdominal ultrasound or computed tomography scan during the course of multiple visits.

Conclusions

Failure to achieve a timely surgical follow-up leads to multiple ED readmissions and emergent gallstone-related hospitalizations, including emergency cholecystectomy. System-level interventions to ensure outpatient surgical follow-up within 1–2 wk of the initial ED visit has the potential to improve outcomes for patients with symptomatic biliary colic.

Introduction

The Society of American Gastrointestinal and Endoscopic Surgeons recommends cholecystectomy for symptomatic cholelithiasis [1], yet the optimal timing of cholecystectomy relative to the onset of symptoms remains controversial. A recent Cochrane review of randomized controlled trials identified only one trial that addressed timing of cholecystectomy with symptomatic gallstones [2]. The trial included only 75 patients and randomized patients with biliary colic to cholecystectomy within 24 h versus delayed cholecystectomy. Although the risk for bias was high, 35% of patients in the delayed group required at least one gallstone-related hospital admission while waiting for elective operation [3].

Patients with gallstones often present to the emergency department (ED) with an episode of biliary colic without laboratory or ultrasonographic evidence of cholecystitis, common duct stones, or gallstone pancreatitis. In many cases, patients are discharged from the ED with surgical follow-up; however, such follow-up is often not timely or does not occur. System-level issues with scheduling follow-up appointments, patient insurance status, and patient failure to comply are factors that may contribute to lack of appropriate outpatient surgical follow-up.

Previous nonrandomized studies also demonstrate that increased wait times for cholecystectomy result in increased risk of recurrent biliary colic and development of gallstone-related complications [4], [5], [6], [7]. Recurrent ED visits and readmissions in patients waiting for elective cholecystectomy have been reported as high as 14% and 11.5% in previous single-institutional studies [3], [5]. In a recent study of Medicare beneficiaries, 11% of beneficiaries who did not undergo elective cholecystectomy after an initial symptomatic episode requiring physician or ED visit required emergent gallstone-related hospitalization [8]. Several studies have demonstrated that admission for complicated gallstone disease is associated with longer operative time, increased length of stay, increased morbidity and mortality, and increased cost [3], [9].

Our goal was to evaluate the surgical follow-up and outcomes for patients seen by a surgeon in the ED for an episode of symptomatic cholelithiasis and discharged home for elective follow-up in single tertiary referral center. The frequency and timing of outpatient follow-up, as well as, patient outcomes such as incidence of multiple ED visits, elective surgery, and emergent surgery were assessed.

Section snippets

Data source

Patients evaluated by a surgeon and discharged from the ED for cholelithiasis and discharged without hospital admission between August 2009 and May 2014 were identified prospectively via surgical consultation and as a part of an ongoing quality improvement project for patients with gallstone disease at the University of Texas Medical Branch (UTMB) [10]. Of note, the quality improvement project focused on improving ED surgical consultation rates for patients with acute gallbladder disease,

Results

Between August of 2009 and May of 2014, a total of 71 patients were discharged from the ED with a diagnosis of symptomatic gallstones. During that same period, 960 patients were admitted for acute gallbladder disease. The mean age of all patients was 41.0 ± 14.9 y, 85.9% were women, and 49.3% were white. Fifty-six percent (56.3%) of patients were uninsured, 11.2% had Medicare, 11.2% had Medicaid, and 21.1% had commercial or private insurance; 43.7% of patients lived in Galveston and 77.5% lived

Discussion

Our study demonstrates that fewer than 15% of patients seen in our ED for symptomatic gallstones undergo timely surgical follow-up and elective cholecystectomy after the initial episode. Lack of appropriate follow-up leads to multiple ED visits, high rates of emergent cholecystectomy, and redundant radiographic studies, increasing the cost of care and quality of life of these patients. Our data contribute to the literature supporting early surgical follow-up and elective cholecystectomy in

Conclusions

Failure to achieve a timely surgical follow-up may result in multiple ED readmissions and emergent gallstone-related hospitalizations, including emergent cholecystectomy. Patients who are initially diagnosed with symptomatic cholelithiasis should be evaluated in a short period of time to reduce such complications. With future studies, a protocol or database may be most beneficial to ensure patients achieve appropriate and timely medical care.

Acknowledgment

Funding: UTMB Clinical and Translational Science Award #UL1TR000071, NIH T-32 grant #T32DK007639, AHRQ grant # 1R24HS022134.

Authors' contributions: T.P.W. and F.M.D. contributed equally to the writing and revising the submitted article. D.A. assisted with the statistical analysis. T.D.K. participated in conducting the study and revisions of the article to be submitted. T.S.R. is the corresponding author overseeing the study and article.

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