Keywords

Health Planning; Pancreatitis, Acute Necrotizing

Dear Sir,

Acute pancreatitis is a serious condition that significantly impacts both patients and the healthcare system. The incidence of acute pancreatitis in the United States has been estimated to be 33-80 per 100,000 per year [1, 2]. From 1985-2005, hospitalizations rates for acute pancreatitis have nearly doubled, although case fatality rates have declined, likely attributed to improved therapeutic options and management [2, 3]. Despite a decrease in mortality, acute pancreatitis significantly impacts healthcare cost, with an estimated cost of acute pancreatitis in 2003 being $2.2 billion, approximately $10,000 per patient [4]. Given the significant impact on patient outcomes and healthcare costs, we, at the University of Missouri Hospital and Clinics in Columbia, examined the issue further.

In 1996 and 1997, information was obtained that showed the University of Missouri Hospital and Clinics experienced a higher mortality rate (6.6%) with acute pancreatitis in comparison to similar academic medical centers in the Midwest. Subsequently, in 1997, the newly formed Office of Clinical Effectiveness began to look at ways that care could be delivered safer, better, and more cost-effective, with acute pancreatitis high on the list. Upon further investigation, not only was acute pancreatitis mortality elevated, but was ranked 13 on a list of the diagnoses that the hospital had lost money on in 1995.

At that time, the committee decided that this condition met the five different criteria for institutional improvement focus, but were unclear if anything could be done about improving costs for patients with acute pancreatitis. The criteria used to select pancreatitis as the most favorable diagnosis to make a difference with were as follows: 1) there was a good opportunity for improvement in outcomes such as average length of stay compared with benchmarks that were being used at the time; 2) care of acute pancreatitis crossed multiple services including family practice, internal medicine, and surgery, bringing more expertise to the table; 3) significant variability in the way pancreatitis was being treated at the time (Departments of Internal Medicine, Surgery, and Family Practice were all involved in the care of acute pancreatitis); 4) data from secondary sources was available to measure any change; and 5) a high level of interest in making changes for the improvement of any care and its cost by various customers of the University.

In the initial stages, a series of questions were investigated by the group to determine if there was variation in the care delivery for these patients internally and as compared with other academic medical centers. Subsequently, the committee conducted a search of the literature for guidelines in the treatment of acute pancreatitis and consulted experts in the fields of gastroenterology, critical care, and surgery for recommendations.

Based upon this expertise, it was determined that the most effective changes in the hospital care of acute pancreatitis could be done by initiating two new steps. The first step was to establish an algorithm to be followed upon admission to the hospital for a diagnosis of acute pancreatitis. The second step was to perform daily severity assessments on patients with acute pancreatitis by any one of several accepted methods of evaluation. Physicians were given the option of using one of four assessment scales, including the modified Glasgow scale and Ranson's criteria.

The algorithm was adopted and implemented in 1998 (Figures 1 and 2). Usage of the algorithm was prompted by laboratory notification of an amylase level 3 times higher than the upper reference limit. Once prompted, the algorithm was reviewed by house staff and attending physicians as a resource and guide for hospital admissions with acute pancreatitis and placed in the patient’s chart. The focus of care became doing daily assessments and triage to the ICU if necessary. Ongoing attention to pain control, hydration, nutritional support, and treatment of alcohol related issues were parts of the new focus.

Figure 1. Acute pancreatitis algorithm at the University of Missouri - Columbia.

Figure 2. Acute pancreatitis algorithm at the University of Missouri - Columbia.

Data on mortality, cost, and length of stay were collected over the next few years. There were noted to be improvements in all of these areas using the hospital as its own control. Mortality was significantly reduced from 6.6% (4/61) in 1997 (pre-algorithm) to a mean of 2.3±2.0% (±SD) over the subsequent 11 years (Figure 3). The average length of hospital stay was also significantly reduced from 9.62 days in 1997 (prealgorithm) to a mean of 7.24±1.68 days over the subsequent 11 years (Figure 4). In the year prior to the initiation of the algorithm, the average cost of taking care of a patient with acute pancreatitis was $6,186. In the eleventh year of data collection, the average cost per patient was $6,160. Although this appears to be only a small cost reduction, if adjusted for inflation and persistently rising healthcare costs in the United States, this small reduction becomes a significant decrease in patient care costs.

Figure 3. Mortality rates for acute pancreatitis from pre-algorithm (year 0) to year 11 (2008).

Figure 4. Average length of stay (ALOS) for acute pancreatitis from pre-algorithm (year 0) to year 11 (2008).

The data continues to be collected with the trend in improvement in outcomes has been sustained since the year 2000. No other institution-wide changes were made involving the diagnosis and care of acute pancreatitis since the algorithm was introduced. Therefore, we believe that the development of the acute pancreatitis algorithm and its use is primarily responsible for the improvement observed at the University of Missouri Hospital and Clinics in the outcomes of our treatment of acute pancreatitis.

Conflict of interest

The authors have no potential conflicts of interest

References

1. Frey CF, Zhou H, Harvey DJ, White RH. The incidence and case-fatality rates of acute biliary, alcoholic, and idiopathic pancreatitis in California, 1994-2001. Pancreas 2006; 33:336-44. [PMID 17079936]
2. Lowenfels AB, Maisonneuve P, Sullivan T. The changing character of acute pancreatitis: epidemiology, etiology, and prognosis. CurrGastroenterol Rep 2009; 11:97-103. [PMID 19281696]
3. Brown A, Young B, Morton J, Behrns K, Shaheen N. Are health related outcomes in acute pancreatitis improving? An analysis of national trends in the U.S. from 1997 to 2003. JOP. J Pancreas (Online) 2008; 9:408-14. [PMID 18648131]
4. FagenholzPJ, Fernández-del Castillo C, Harris NS, Pelletier AJ, Camargo CA Jr. Direct medical costs of acute pancreatitis hospitalizations in the United States. Pancreas 2007; 35:302-7. [PMID 18090234]