Big-data analysis: A clinical pathway on endoscopic retrograde cholangiopancreatography for common bile duct stones
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摘要
BACKGROUND A clinical pathway(CP) is a standardized approach for disease management.However, big data-based evidence is rarely involved in CP for related common bile duct(CBD) stones, let alone outcome comparisons before and after CP implementation.AIM To investigate the value of CP implementation in patients with CBD stones undergoing endoscopic retrograde cholangiopancreatography(ERCP).METHODS This retrospective study was conducted at Nanjing Drum Tower Hospital in patients with CBD stones undergoing ERCP from January 2007 to December2017. The data and outcomes were compared by using univariate and multivariable regression/linear models between the patients who received conventional care(non-pathway group, n = 467) and CP care(pathway group, n= 2196).RESULTS At baseline, the main differences observed between the two groups were the percentage of patients with multiple stones(P < 0.001) and incidence of cholangitis complication(P < 0.05). The percentage of antibiotic use and complications in the CP group were significantly less than those in the nonpathway group [adjusted odds ratio(OR) = 0.72, 95% confidence interval(CI):0.55-0.93, P = 0.012, adjusted OR = 0.44, 95%CI: 0.33-0.59, P < 0.001, respectively].Patients spent lower costs on hospitalization, operation, nursing, medication, and medical consumable materials(P < 0.001 for all), and even experienced shorter length of hospital stay(LOHS)(P < 0.001) after the CP implementation. No significant differences in clinical outcomes, readmission rate, or secondary surgery rate were presented between the patients in the non-pathway and CP groups.CONCLUSION Implementing a CP for patients with CBD stones is a safe mode to reduce the LOHS, hospital costs, antibiotic use, and complication rate.
BACKGROUND A clinical pathway(CP) is a standardized approach for disease management.However, big data-based evidence is rarely involved in CP for related common bile duct(CBD) stones, let alone outcome comparisons before and after CP implementation.AIM To investigate the value of CP implementation in patients with CBD stones undergoing endoscopic retrograde cholangiopancreatography(ERCP).METHODS This retrospective study was conducted at Nanjing Drum Tower Hospital in patients with CBD stones undergoing ERCP from January 2007 to December2017. The data and outcomes were compared by using univariate and multivariable regression/linear models between the patients who received conventional care(non-pathway group, n = 467) and CP care(pathway group, n= 2196).RESULTS At baseline, the main differences observed between the two groups were the percentage of patients with multiple stones(P < 0.001) and incidence of cholangitis complication(P < 0.05). The percentage of antibiotic use and complications in the CP group were significantly less than those in the nonpathway group [adjusted odds ratio(OR) = 0.72, 95% confidence interval(CI):0.55-0.93, P = 0.012, adjusted OR = 0.44, 95%CI: 0.33-0.59, P < 0.001, respectively].Patients spent lower costs on hospitalization, operation, nursing, medication, and medical consumable materials(P < 0.001 for all), and even experienced shorter length of hospital stay(LOHS)(P < 0.001) after the CP implementation. No significant differences in clinical outcomes, readmission rate, or secondary surgery rate were presented between the patients in the non-pathway and CP groups.CONCLUSION Implementing a CP for patients with CBD stones is a safe mode to reduce the LOHS, hospital costs, antibiotic use, and complication rate.
BACKGROUND A clinical pathway(CP) is a standardized approach for disease management.However, big data-based evidence is rarely involved in CP for related common bile duct(CBD) stones, let alone outcome comparisons before and after CP implementation.AIM To investigate the value of CP implementation in patients with CBD stones undergoing endoscopic retrograde cholangiopancreatography(ERCP).METHODS This retrospective study was conducted at Nanjing Drum Tower Hospital in patients with CBD stones undergoing ERCP from January 2007 to December2017. The data and outcomes were compared by using univariate and multivariable regression/linear models between the patients who received conventional care(non-pathway group, n = 467) and CP care(pathway group, n= 2196).RESULTS At baseline, the main differences observed between the two groups were the percentage of patients with multiple stones(P < 0.001) and incidence of cholangitis complication(P < 0.05). The percentage of antibiotic use and complications in the CP group were significantly less than those in the nonpathway group [adjusted odds ratio(OR) = 0.72, 95% confidence interval(CI):0.55-0.93, P = 0.012, adjusted OR = 0.44, 95%CI: 0.33-0.59, P < 0.001, respectively].Patients spent lower costs on hospitalization, operation, nursing, medication, and medical consumable materials(P < 0.001 for all), and even experienced shorter length of hospital stay(LOHS)(P < 0.001) after the CP implementation. No significant differences in clinical outcomes, readmission rate, or secondary surgery rate were presented between the patients in the non-pathway and CP groups.CONCLUSION Implementing a CP for patients with CBD stones is a safe mode to reduce the LOHS, hospital costs, antibiotic use, and complication rate.
引文
1 Acalovschi M.Gallstones in patients with liver cirrhosis:Incidence,etiology,clinical and therapeutical aspects.World J Gastroenterol 2014;20:7277-7285[PMID:24966598 DOI:10.3748/wjg.v20.i23.7277]
2 Zhu Q,Sun X,Ji X,Zhu L,Xu J,Wang C,Zhang C,Xue F,Liu Y.The association between gallstones and metabolic syndrome in urban Han Chinese:A longitudinal cohort study.Sci Rep 2016;6:29937[PMID:27443986 DOI:10.1038/srep29937]
3 Anand G,Patel YA,Yeh HC,Khashab MA,Lennon AM,Shin EJ,Canto MI,Okolo PI,Kalloo AN,Singh VK.Factors and Outcomes Associated with MRCP Use prior to ERCP in Patients at High Risk for Choledocholithiasis.Can J Gastroenterol Hepatol 2016;2016:5132052[PMID:27446845 DOI:10.1155/2016/5132052]
4 Tazuma S.Gallstone disease:Epidemiology,pathogenesis,and classification of biliary stones(common bile duct and intrahepatic).Best Pract Res Clin Gastroenterol 2006;20:1075-1083[PMID:17127189DOI:10.1016/j.bpg.2006.05.009]
5 Aslan F,Arabul M,Celik M,Alper E,Unsal B.The effect of biliary stenting on difficult common bile duct stones.Prz Gastroenterol 2014;9:109-115[PMID:25061492 DOI:10.5114/pg.2014.42507]
6 Kenny R,Richardson J,Mc Glone ER,Reddy M,Khan OA.Laparoscopic common bile duct exploration versus pre or post-operative ERCP for common bile duct stones in patients undergoing cholecystectomy:Is there any difference?Int J Surg 2014;12:989-993[PMID:24998206 DOI:10.1016/j.ijsu.2014.06.013]
7 Bray MS,Borgert AJ,Folkers ME,Kothari SN.Outcome and management of endoscopic retrograde cholangiopancreatography perforations:A community perspective.Am J Surg 2017;214:69-73[PMID:28173939 DOI:10.1016/j.amjsurg.2017.01.034]
8 Morris S,Gurusamy KS,Sheringham J,Davidson BR.Cost-effectiveness analysis of endoscopic ultrasound versus magnetic resonance cholangiopancreatography in patients with suspected common bile duct stones.PLo S One 2015;10:e0121699[PMID:25799113 DOI:10.1371/journal.pone.0121699]
9 Sheffield KM,Ramos KE,Djukom CD,Jimenez CJ,Mileski WJ,Kimbrough TD,Townsend CM,Riall TS.Implementation of a critical pathway for complicated gallstone disease:Translation of populationbased data into clinical practice.J Am Coll Surg 2011;212:835-843[PMID:21398156 DOI:10.1016/j.jamcollsurg.2010.12.047]
10 Elliott MJ,Gil S,Hemmelgarn BR,Manns BJ,Tonelli M,Jun M,Donald M.A scoping review of adult chronic kidney disease clinical pathways for primary care.Nephrol Dial Transplant 2017;32:838-846[PMID:27257274 DOI:10.1093/ndt/gfw208]
11 De Luca A,Toni D,Lauria L,Sacchetti ML,Giorgi Rossi P,Ferri M,Puca E,Prencipe M,Guasticchi G;IMPLementazione Percorso Clinico Assistenziale ICtus Acuto(IMPLICA)Study Group.An emergency clinical pathway for stroke patients--results of a cluster randomised trial(isrctn41456865).BMC Health Serv Res 2009;9:14[PMID:19159477 DOI:10.1186/1472-6963-9-14]
12 Schuur JD,Baugh CW,Hess EP,Hilton JA,Pines JM,Asplin BR.Critical pathways for post-emergency outpatient diagnosis and treatment:Tools to improve the value of emergency care.Acad Emerg Med 2011;18:e52-e63[PMID:21676050 DOI:10.1111/j.1553-2712.2011.01096.x]
13 Bradywood A,Farrokhi F,Williams B,Kowalczyk M,Blackmore CC.Reduction of Inpatient Hospital Length of Stay in Lumbar Fusion Patients With Implementation of an Evidence-Based Clinical Care Pathway.Spine(Phila Pa 1976)2017;42:169-176[PMID:27213939 DOI:10.1097/BRS.0000000000001703]
14 El Baz N,Middel B,van Dijk JP,Oosterhof A,Boonstra PW,Reijneveld SA.Are the outcomes of clinical pathways evidence-based?A critical appraisal of clinical pathway evaluation research.J Eval Clin Pract2007;13:920-929[PMID:18070263 DOI:10.1111/j.1365-2753.2006.00774.x]
15 van Dam PA,Verheyden G,Sugihara A,Trinh XB,Van Der Mussele H,Wuyts H,Verkinderen L,Hauspy J,Vermeulen P,Dirix L.A dynamic clinical pathway for the treatment of patients with early breast cancer is a tool for better cancer care:Implementation and prospective analysis between 2002-2010.World J Surg Oncol 2013;11:70[PMID:23497270 DOI:10.1186/1477-7819-11-70]
16 de Vries M,van Weert JC,Jansen J,Lemmens VE,Maas HA.Step by step development of clinical care pathways for older cancer patients:Necessary or desirable?Eur J Cancer 2007;43:2170-2178[PMID:17870519 DOI:10.1016/j.ejca.2007.08.004]
17 Shin KC,Lee HS,Park JM,Joo HC,Ko YG,Park I,Kim MJ.Outcomes before and after the Implementation of a Critical Pathway for Patients with Acute Aortic Disease.Yonsei Med J 2016;57:626-634[PMID:26996561 DOI:10.3349/ymj.2016.57.3.626]
18 Thursky K,Lingaratnam S,Jayarajan J,Haeusler GM,Teh B,Tew M,Venn G,Hiong A,Brown C,Leung V,Worth LJ,Dalziel K,Slavin MA.Implementation of a whole of hospital sepsis clinical pathway in a cancer hospital:Impact on sepsis management,outcomes and costs.BMJ Open Qual 2018;7:e000355[PMID:30019016 DOI:10.1136/bmjoq-2018-000355]
19 van der Kolk M,van den Boogaard M,Ter Brugge-Speelman C,Hol J,Noyez L,van Laarhoven K,van der Hoeven H,Pickkers P.Development and implementation of a clinical pathway for cardiac surgery in the intensive care unit:Effects on protocol adherence.J Eval Clin Pract 2017;23:1289-1298[PMID:28719134 DOI:10.1111/jep.12778]
20 Dong W,Huang Z.A Method to Evaluate Critical Factors for Successful Implementation of Clinical Pathways.Appl Clin Inform 2015;6:650-668[PMID:26763576 DOI:10.4338/ACI-2015-05-RA-0054]
21 Dasari BV,Tan CJ,Gurusamy KS,Martin DJ,Kirk G,Mc Kie L,Diamond T,Taylor MA.Surgical versus endoscopic treatment of bile duct stones.Cochrane Database Syst Rev 2013;CD003327[PMID:23999986 DOI:10.1002/14651858.CD003327.pub3]
22 Platt TE,Smith K,Sinha S,Nixon M,Srinivas G,Johnson N,Andrews S.Laparoscopic common bile duct exploration;a preferential pathway for elderly patients.Ann Med Surg(Lond)2018;30:13-17[PMID:29946453 DOI:10.1016/j.amsu.2018.03.044]
23 Lion KC,Wright DR,Spencer S,Zhou C,Del Beccaro M,Mangione-Smith R.Standardized Clinical Pathways for Hospitalized Children and Outcomes.Pediatrics 2016;137:pii:e20151202[PMID:27002007 DOI:10.1542/peds.2015-1202]
24 Singh SB,Shelton AU,Greenberg B,Starner TD.Implementation of cystic fibrosis clinical pathways improved physician adherence to care guidelines.Pediatr Pulmonol 2017;52:175-181[PMID:27797455DOI:10.1002/ppul.23635]
25 Vujasinovic M,Makuc J,Tepes B,Marolt A,Kikec Z,Robac N.Impact of a clinical pathway on treatment outcome in patients with acute pancreatitis.World J Gastroenterol 2015;21:9150-9155[PMID:26290642 DOI:10.3748/wjg.v21.i30.9150]
26 Nishimura K,Yasui M,Nishimura T,Oga T.Clinical pathway for acute exacerbations of chronic obstructive pulmonary disease:Method development and five years of experience.Int J Chron Obstruct Pulmon Dis 2011;6:365-372[PMID:21760723 DOI:10.2147/COPD.S20423]
27 DonàD,Zingarella S,Gastaldi A,Lundin R,Perilongo G,Frigo AC,Hamdy RF,Zaoutis T,Da Dalt L,Giaquinto C.Effects of clinical pathway implementation on antibiotic prescriptions for pediatric community-acquired pneumonia.PLo S One 2018;13:e0193581[PMID:29489898 DOI:10.1371/journal.pone.0193581]
28 Kim HE,Kim YH,Song KB,Chung YS,Hwang S,Lee YJ,Park KM,Kim SC.Impact of critical pathway implementation on hospital stay and costs in patients undergoing pancreaticoduodenectomy.Korean J Hepatobiliary Pancreat Surg 2014;18:14-20[PMID:26155241 DOI:10.14701/kjhbps.2014.18.1.14]
29 Husni ME,Losina E,Fossel AH,Solomon DH,Mahomed NN,Katz JN.Decreasing medical complications for total knee arthroplasty:Effect of critical pathways on outcomes.BMC Musculoskelet Disord 2010;11:160[PMID:20630086 DOI:10.1186/1471-2474-11-160]
30 Burgers PT,Van Lieshout EM,Verhelst J,Dawson I,de Rijcke PA.Implementing a clinical pathway for hip fractures;effects on hospital length of stay and complication rates in five hundred and twenty six patients.Int Orthop 2014;38:1045-1050[PMID:24337751 DOI:10.1007/s00264-013-2218-5]
31 Walters DM,Mc Garey P,La Par DJ,Strong A,Good E,Adams RB,Bauer TW.A 6-day clinical pathway after a pancreaticoduodenectomy is feasible,safe and efficient.HPB(Oxford)2013;15:668-673[PMID:23458383 DOI:10.1111/hpb.12016]
2 Zhu Q,Sun X,Ji X,Zhu L,Xu J,Wang C,Zhang C,Xue F,Liu Y.The association between gallstones and metabolic syndrome in urban Han Chinese:A longitudinal cohort study.Sci Rep 2016;6:29937[PMID:27443986 DOI:10.1038/srep29937]
3 Anand G,Patel YA,Yeh HC,Khashab MA,Lennon AM,Shin EJ,Canto MI,Okolo PI,Kalloo AN,Singh VK.Factors and Outcomes Associated with MRCP Use prior to ERCP in Patients at High Risk for Choledocholithiasis.Can J Gastroenterol Hepatol 2016;2016:5132052[PMID:27446845 DOI:10.1155/2016/5132052]
4 Tazuma S.Gallstone disease:Epidemiology,pathogenesis,and classification of biliary stones(common bile duct and intrahepatic).Best Pract Res Clin Gastroenterol 2006;20:1075-1083[PMID:17127189DOI:10.1016/j.bpg.2006.05.009]
5 Aslan F,Arabul M,Celik M,Alper E,Unsal B.The effect of biliary stenting on difficult common bile duct stones.Prz Gastroenterol 2014;9:109-115[PMID:25061492 DOI:10.5114/pg.2014.42507]
6 Kenny R,Richardson J,Mc Glone ER,Reddy M,Khan OA.Laparoscopic common bile duct exploration versus pre or post-operative ERCP for common bile duct stones in patients undergoing cholecystectomy:Is there any difference?Int J Surg 2014;12:989-993[PMID:24998206 DOI:10.1016/j.ijsu.2014.06.013]
7 Bray MS,Borgert AJ,Folkers ME,Kothari SN.Outcome and management of endoscopic retrograde cholangiopancreatography perforations:A community perspective.Am J Surg 2017;214:69-73[PMID:28173939 DOI:10.1016/j.amjsurg.2017.01.034]
8 Morris S,Gurusamy KS,Sheringham J,Davidson BR.Cost-effectiveness analysis of endoscopic ultrasound versus magnetic resonance cholangiopancreatography in patients with suspected common bile duct stones.PLo S One 2015;10:e0121699[PMID:25799113 DOI:10.1371/journal.pone.0121699]
9 Sheffield KM,Ramos KE,Djukom CD,Jimenez CJ,Mileski WJ,Kimbrough TD,Townsend CM,Riall TS.Implementation of a critical pathway for complicated gallstone disease:Translation of populationbased data into clinical practice.J Am Coll Surg 2011;212:835-843[PMID:21398156 DOI:10.1016/j.jamcollsurg.2010.12.047]
10 Elliott MJ,Gil S,Hemmelgarn BR,Manns BJ,Tonelli M,Jun M,Donald M.A scoping review of adult chronic kidney disease clinical pathways for primary care.Nephrol Dial Transplant 2017;32:838-846[PMID:27257274 DOI:10.1093/ndt/gfw208]
11 De Luca A,Toni D,Lauria L,Sacchetti ML,Giorgi Rossi P,Ferri M,Puca E,Prencipe M,Guasticchi G;IMPLementazione Percorso Clinico Assistenziale ICtus Acuto(IMPLICA)Study Group.An emergency clinical pathway for stroke patients--results of a cluster randomised trial(isrctn41456865).BMC Health Serv Res 2009;9:14[PMID:19159477 DOI:10.1186/1472-6963-9-14]
12 Schuur JD,Baugh CW,Hess EP,Hilton JA,Pines JM,Asplin BR.Critical pathways for post-emergency outpatient diagnosis and treatment:Tools to improve the value of emergency care.Acad Emerg Med 2011;18:e52-e63[PMID:21676050 DOI:10.1111/j.1553-2712.2011.01096.x]
13 Bradywood A,Farrokhi F,Williams B,Kowalczyk M,Blackmore CC.Reduction of Inpatient Hospital Length of Stay in Lumbar Fusion Patients With Implementation of an Evidence-Based Clinical Care Pathway.Spine(Phila Pa 1976)2017;42:169-176[PMID:27213939 DOI:10.1097/BRS.0000000000001703]
14 El Baz N,Middel B,van Dijk JP,Oosterhof A,Boonstra PW,Reijneveld SA.Are the outcomes of clinical pathways evidence-based?A critical appraisal of clinical pathway evaluation research.J Eval Clin Pract2007;13:920-929[PMID:18070263 DOI:10.1111/j.1365-2753.2006.00774.x]
15 van Dam PA,Verheyden G,Sugihara A,Trinh XB,Van Der Mussele H,Wuyts H,Verkinderen L,Hauspy J,Vermeulen P,Dirix L.A dynamic clinical pathway for the treatment of patients with early breast cancer is a tool for better cancer care:Implementation and prospective analysis between 2002-2010.World J Surg Oncol 2013;11:70[PMID:23497270 DOI:10.1186/1477-7819-11-70]
16 de Vries M,van Weert JC,Jansen J,Lemmens VE,Maas HA.Step by step development of clinical care pathways for older cancer patients:Necessary or desirable?Eur J Cancer 2007;43:2170-2178[PMID:17870519 DOI:10.1016/j.ejca.2007.08.004]
17 Shin KC,Lee HS,Park JM,Joo HC,Ko YG,Park I,Kim MJ.Outcomes before and after the Implementation of a Critical Pathway for Patients with Acute Aortic Disease.Yonsei Med J 2016;57:626-634[PMID:26996561 DOI:10.3349/ymj.2016.57.3.626]
18 Thursky K,Lingaratnam S,Jayarajan J,Haeusler GM,Teh B,Tew M,Venn G,Hiong A,Brown C,Leung V,Worth LJ,Dalziel K,Slavin MA.Implementation of a whole of hospital sepsis clinical pathway in a cancer hospital:Impact on sepsis management,outcomes and costs.BMJ Open Qual 2018;7:e000355[PMID:30019016 DOI:10.1136/bmjoq-2018-000355]
19 van der Kolk M,van den Boogaard M,Ter Brugge-Speelman C,Hol J,Noyez L,van Laarhoven K,van der Hoeven H,Pickkers P.Development and implementation of a clinical pathway for cardiac surgery in the intensive care unit:Effects on protocol adherence.J Eval Clin Pract 2017;23:1289-1298[PMID:28719134 DOI:10.1111/jep.12778]
20 Dong W,Huang Z.A Method to Evaluate Critical Factors for Successful Implementation of Clinical Pathways.Appl Clin Inform 2015;6:650-668[PMID:26763576 DOI:10.4338/ACI-2015-05-RA-0054]
21 Dasari BV,Tan CJ,Gurusamy KS,Martin DJ,Kirk G,Mc Kie L,Diamond T,Taylor MA.Surgical versus endoscopic treatment of bile duct stones.Cochrane Database Syst Rev 2013;CD003327[PMID:23999986 DOI:10.1002/14651858.CD003327.pub3]
22 Platt TE,Smith K,Sinha S,Nixon M,Srinivas G,Johnson N,Andrews S.Laparoscopic common bile duct exploration;a preferential pathway for elderly patients.Ann Med Surg(Lond)2018;30:13-17[PMID:29946453 DOI:10.1016/j.amsu.2018.03.044]
23 Lion KC,Wright DR,Spencer S,Zhou C,Del Beccaro M,Mangione-Smith R.Standardized Clinical Pathways for Hospitalized Children and Outcomes.Pediatrics 2016;137:pii:e20151202[PMID:27002007 DOI:10.1542/peds.2015-1202]
24 Singh SB,Shelton AU,Greenberg B,Starner TD.Implementation of cystic fibrosis clinical pathways improved physician adherence to care guidelines.Pediatr Pulmonol 2017;52:175-181[PMID:27797455DOI:10.1002/ppul.23635]
25 Vujasinovic M,Makuc J,Tepes B,Marolt A,Kikec Z,Robac N.Impact of a clinical pathway on treatment outcome in patients with acute pancreatitis.World J Gastroenterol 2015;21:9150-9155[PMID:26290642 DOI:10.3748/wjg.v21.i30.9150]
26 Nishimura K,Yasui M,Nishimura T,Oga T.Clinical pathway for acute exacerbations of chronic obstructive pulmonary disease:Method development and five years of experience.Int J Chron Obstruct Pulmon Dis 2011;6:365-372[PMID:21760723 DOI:10.2147/COPD.S20423]
27 DonàD,Zingarella S,Gastaldi A,Lundin R,Perilongo G,Frigo AC,Hamdy RF,Zaoutis T,Da Dalt L,Giaquinto C.Effects of clinical pathway implementation on antibiotic prescriptions for pediatric community-acquired pneumonia.PLo S One 2018;13:e0193581[PMID:29489898 DOI:10.1371/journal.pone.0193581]
28 Kim HE,Kim YH,Song KB,Chung YS,Hwang S,Lee YJ,Park KM,Kim SC.Impact of critical pathway implementation on hospital stay and costs in patients undergoing pancreaticoduodenectomy.Korean J Hepatobiliary Pancreat Surg 2014;18:14-20[PMID:26155241 DOI:10.14701/kjhbps.2014.18.1.14]
29 Husni ME,Losina E,Fossel AH,Solomon DH,Mahomed NN,Katz JN.Decreasing medical complications for total knee arthroplasty:Effect of critical pathways on outcomes.BMC Musculoskelet Disord 2010;11:160[PMID:20630086 DOI:10.1186/1471-2474-11-160]
30 Burgers PT,Van Lieshout EM,Verhelst J,Dawson I,de Rijcke PA.Implementing a clinical pathway for hip fractures;effects on hospital length of stay and complication rates in five hundred and twenty six patients.Int Orthop 2014;38:1045-1050[PMID:24337751 DOI:10.1007/s00264-013-2218-5]
31 Walters DM,Mc Garey P,La Par DJ,Strong A,Good E,Adams RB,Bauer TW.A 6-day clinical pathway after a pancreaticoduodenectomy is feasible,safe and efficient.HPB(Oxford)2013;15:668-673[PMID:23458383 DOI:10.1111/hpb.12016]