Timely Care is Patient-Centered Care for Patients with Acute Cholecystitis at a Safety-Net Hospital

Abstract

Background:

Multiple strategies exist to improve the timeliness and efficiency of surgical care at safety-net hospitals (SNH), such as acute care surgery models and nighttime surgery. However, the patient-centeredness of such approaches is unknown.

Methods:

Adults (≥18 years) with acute cholecystitis were interviewed upon admission to a SNH. Interviews were semi-structured and designed to obtain both exploratory qualitative data and ratings of patient-centered outcomes, ranked by importance to the patient. Outcomes included for rating were general health, symptom status, quality of life, and return to prior functional status. Latent content analysis applying inductive coding methods were used to code and condense raw qualitative data from interview transcripts.

Results:

Thematic saturation was reached with a sample size of 15 patients. Most participants were female (87%), Hispanic (87%), and had prior diagnosis of benign biliary disease (60%). Patients identified symptom resolution as the highest-ranked outcome in their treatment. Themes expressed by patients during the exploratory segments of the interview included: desire for pain alleviation, frustration with delays to both symptom resolution and surgical intervention, lack of perceived control over their healthcare, and reticence in discussing preferences with physicians. All patients preferred to have surgical treatment as soon as possible, even if that meant having nighttime surgery.

Conclusions:

Effective and timely resolution of symptoms is of utmost importance to patients with acute cholecystitis at a SNH. Efforts to improve timeliness of surgical care are also perceived as patient-centered.

Introduction:

Safety-net hospitals (SNH) are essential to the health care system in the United States by providing care for uninsured and vulnerable patients. High quality surgical care for these patients is critical. However, recent studies reported surgical care at SNH lags is worse than at non-SNHs in five of the six quality domains, as defined by the Institute of Medicine (IOM): timeliness, equity, patient-centeredness, safety, effectiveness, and efficiency. [1, 2] Specifically, SNHs repeatedly perform poorest in timeliness or provision of health care with minimal wait or delay for both patients and providers. [2] For example, surgical care for patients with acute cholecystitis at SNH is frequently delayed, despite strong evidence that early surgery for acute cholecystitis improves outcomes. [3–6] Difficulty in diagnosis, lack of access to surgical care, and limited resources result in inappropriate discharges from the emergency room without surgical consultation or cholecystectomy. [7] Nighttime surgery and acute care surgery models aim to improve timeliness and efficiency of surgical care. [8–10]

Nighttime surgery is the practice of performing non-elective procedures by an in-house, fully staffed surgical team overnight, in addition to the traditionally performed emergency surgeries. At the study’s SNH, nighttime surgery was associated with improved timeliness and efficiency as evidenced by decreased time to surgery and decreased hospital length of stay, although there was an increase in the risk of minor complications. [10] Other studies have not found a difference in safety when utilizing nighttime surgery. [11, 12]

While there is growing data regarding the performance of surgical care at SNHs in many quality domains, there is little known about patient-centeredness. The IOM defines patient-centered care as: “Providing care that is respectful of, and responsive to, individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.” [1] Better understanding of patient needs will offer new targets for quality improvement. The primary aim of this study was to explore the outcomes most important to patients with acute cholecystitis cared for at a SNH. A secondary aim was to explore patients’ perspectives and preferences regarding improving timeliness by models such as the acute care surgery model and nighttime surgery.

Methods

An exploratory research design using semi-structured interviews was selected as little is known about the patient-centeredness of strategies to improve timeliness and efficiency of surgical care. [13] As an exploratory approach, qualitative research was believed to be best suited to exploring participants’ perspectives and topics not previously researched. [14]

McGovern Medical School at UTHealth approved this study as a quality improvement project. Purposive sampling was used to approach adult patients with acute cholecystitis upon admission to Lyndon Baines Johnson General Hospital (LBJGH) and prior to any procedural intervention 2016–2017. Informed consent was obtained for interview and patients were able to stop the interview at will. Interviews were conducted in English or Spanish, with the aid of an in-person or phone medical interpreter as needed.

Purposive sampling, also known as expert sampling, is a type of non-probability sampling. The goal of purposive sampling is to select for particular characteristics of interest, i.e., acute cholecystitis, to better address research questions. [15] The target sample was 15–20 participants before reaching data saturation, or informational redundancy, the point at which no new themes emerge from data analysis. [16] In qualitative research, research aims are the basis for selecting study design, sample size, and data collection methods and analysis. As this study addressed a specific research question employing semi-structured interviews that followed an interview guide, analyzed using thematic and constant comparison methods, the common sample size for such a study could reasonably be expected to be 15–20 participants.

Interviews were semi-structured and designed to obtain both exploratory qualitative data and ratings of patient-centered outcomes, ranked by importance to the patient. An interview guide was developed (Table 1). Patients were first asked open-ended questions about what brought them to the hospital, duration of symptoms, and how their life has been affected by their illness. They were asked about their treatment expectations, fears, and the outcomes most important to them. Patients were then asked to rank a pre-defined list of outcomes by importance. The list included patient-centered outcomes previously identified by the Patient-Centered Outcomes Research Institute: general health, symptom status, quality of life, and return to prior functional status. [17, 18] Finally, patients were asked if they would be willing to have surgery at nighttime.

Table 1:

Interview guide utilized during semi-structured interviews

Interview Guide
What brought you to the hospital this admission?
Did you suspect or know that you had gallstones prior to this visit? If yes, how long have you known that you have had gallstones? If no, have you had similar symptoms in the past? For how long have you had similar symptoms?
How has your condition (having gallstones) affected you and your life?
What course do you expect your condition to take?
Can you tell me what results are most important to you that you expect in seeking treatment for your gallstones?
Has your physician discussed with you the different treatments available for gallstones?
Do you understand these different treatments and the advantages and disadvantages of each?
Have you discussed your treatment preference with your physician?
Is there anything you believe you can do as a patient to help you reach the results you want from your treatment?
What other treatments, help or care would you like to receive?
Would you prefer to wait or start treatment now? Would you prefer to wait to have surgery or have surgery as soon as possible? Would you be willing to have surgery in the middle of the night?
What do you most fear about your condition?
What do you most fear about the treatment?
Do you need any help with caring for yourself, understanding your condition or getting the medical care you need?
Is there anything else you would like to add?

Data Analysis:

Interviews were audio-taped, transcribed verbatim, and analyzed using thematic and constant comparison analysis. Transcribed interviews were evaluated and categorized by hand-coding. Three members of the research team (GH, KM, IL) trained in qualitative analysis initially independently coded 7 interviews each to develop a coding frame, a list of code name and their meanings. Analysts met to compare, discuss and reach consensus on the coding frame that was applied to code all transcripts independently. At least two individual coders independently coded each transcript. Thematic analysis using inductive coding was used to code, categorize and summarize patterns in the data within and across individual transcripts to discern recurring themes (Table 2). Constant comparison – a continuous process whereby data emerging from the coding of each additional transcript are compared within and across previously coded transcripts – was employed to refine categories, develop themes, accurately account for all the data, and ensure credibility of findings and data saturation. [19]

Table 2:

Stages of qualitative analysis

Stages in Qualitative Analysis
Familiarization	The first stage entailed familiarization with the data, reading and re-reading respondents’ narratives, noting salient ideas and patterns for an overview of all the data.
Researcher triangulation	Researchers developed a coding frame and independently reviewed the narratives to establish consensus among researchers. The coding framework remained open to refinement as the analysis proceeded.
Constant comparison	Through constant comparison of codes both within and across individual narratives emergent and recurring patterns were merged into categories and themes.
Peer debriefing	Researchers compared and discussed interpretations to reach agreement, further refine emerging themes, ensure accuracy between integration of data and interpretations, and ensure that themes were appropriate. To enhance credibility, findings were discussed by research team ensuring assertions were supported by the data.
Use of quotes	Participants’ verbatim quotes are used to substantiate analytic findings, providing evidence of how the data built the interpretation.
Comparison with literature	Results of analyses were compared with existing literature to confirm and expand study findings.

Analyst triangulation was used to establish rigor of results. Triangulation is the use of multiple data sources, theories, or researchers to study research questions in which results from each are compared and cross-validated to increase credibility and validity of findings. Analyst triangulation used multiple researchers to analyze findings to decrease effects of individual analyst bias, thus ensuring confirmability and neutrality of results.

Results

Data saturation was reached with a sample size of 15 patients. The majority of participants were female (87%), Hispanic (87%), and had prior diagnosis of benign biliary disease (60%). All patients were admitted to the surgical service and all patients went on to have a cholecystectomy after interview. Themes commonly expressed by patients during the exploratory segments of the interview included: desire for pain alleviation, frustration with delays to both symptom resolution and surgical intervention, lack of perceived control over their healthcare, and desire for an effective non-surgical treatment option.

Themes

Desire for pain alleviation

Patients consistently stated that symptom resolution, which for all patients focused on pain alleviation, was their main priority in seeking care. While some patients had experienced symptoms for only a few weeks or months, most had lived with intermittent pain for years. Some patients reported pain was debilitating and had radically altered their life to the extent that they could no longer work: “It [pain] doesn’t allow me to do anything. It is unbearable.” (Patient #13) Severe pain is what led them to seek treatment at the hospital: “I don’t like pain. This is the worst. I would prefer to give birth than this pain.” (Patient #15)

Frustration with delays to symptom resolution and surgical intervention

While the majority of participants had experienced recurrent pain for years and had previously sought treatment, their symptoms were not determined to be severe enough to merit surgery or were expected to resolve over time: “[I have this pain] about 4 or 5 years…Well, they [physicians] told me they thought it would pass on its own without having surgery.” (Patient #1) Many reported that they had repeatedly sought care over time, without symptom resolution: “I have come [to the hospital] seven times before for this pain.” (Patient #3) Postponement of surgery led patients to express frustration with delays to symptom resolution and surgical intervention: “It’s just like you have to be close to it [gallbladder] exploding or it killing you before they’ll take it out.” (Patient #8) Frustration was heightened since physicians consistently told patients that surgery was the only viable treatment to resolve symptoms and alleviate pain.

Lack of perceived control over treatment

While some patients reported that they could exert control over their health and improve recovery from surgery by changing their diet or by following physician post-operative recommendations, they reported a lack of agency regarding treatment decision-making. All patients stated that physicians had not discussed non-surgical options for treating gallstone disease. Additionally, patients were not asked about their preferences for care: “I didn’t tell them [the doctors] what I wanted. They told me what they wanted and what was GOING to happen.” (Patient #1) As such, they did not feel that they had control over their healthcare decision-making: “I don’t think that it’s [treatment] in my hands.” (Patient #4) Many expressed unfamiliarity with having control over decision-making regarding their medical treatment.

Desire for an effective non-surgical treatment option

While some patients accepted physician recommendations that surgery was the best treatment, a few expressed that their preference was for an effective non-surgical treatment. These patients reported either having taken, and hence, a preference for, a more natural approach to treating gallstone disease, or were concerned about complications resulting from surgery: “If they give me any other treatment and [the pain] goes away, I would prefer to not have surgery.” (Patient #15)

Patients identified symptom resolution, in all cases pain was the primary symptom, as the highest-ranked outcome in their treatment (Figure 1). Many patients ranked some aspect as equally important as another. All patients preferred to have treatment as soon as possible, even if that meant having nighttime surgery. Most patients indicated that their desire to have surgery as soon as possible was based on the belief that surgery would be the only definitive relief of their pain, as implied by their physician.

Figure 1:

Rankings of outcomes by importance to the patient

Discussion

This qualitative study at a safety-net hospital identified multiple patient-centered outcomes of importance to patients with acute cholecystitis and ranked pre-identified outcomes. Themes expressed by patients during the exploratory segments of the interview included: desire for pain alleviation, frustration with delays to symptom resolution and surgical intervention, and lack of perceived control over their healthcare. All patients preferred to have surgical treatment as soon as possible, even if that meant having nighttime surgery.

The patient-centeredness of having nighttime surgery, which may decrease time to both symptom resolution and hospital discharge but may increase the risk of complications, is unknown. [11, 20] Patients in this study were agreeable to nighttime surgery. Symptom resolution was ranked most highly of the pre-identified patient-centered outcomes offered to patients such that all requested surgery as soon as possible. While patients in the present study were not asked specifically about decreased time to hospital discharge, a prior qualitative study from our group demonstrated that a short reduction in hospital length of stay was important to patients. [21] In a study of facilitators and barriers to implementation of an enhanced recovery after surgery (ERAS) protocol, patients stated that if they could have left the same day of surgery or reduced length of stay by half a day, they would welcome speedier discharge. [21]

Most patients reported prior episodes of biliary colic or acute cholecystitis, which suggests the need for improvement in both timeliness and equity. One reason that cholecystectomy was not performed earlier may be limited access to surgical care. Prior studies have demonstrated reduced access to cholecystectomy and other surgical care based on insurance status and race. [22, 23] Another potential reason is acute cholecystitis may have been underdiagnosed in the emergency department. In a prospective study of 200 patients with suspected biliary disease who underwent same-admission cholecystectomy, all patients had an abnormal gallbladder (acute or chronic cholecystitis or gangrene) based on operative and/or pathologic findings, regardless of preoperative clinical, laboratory, or imaging findings. [24] This study supports early cholecystectomy even when acute cholecystitis is not clinically obvious. A third reason may be lack of follow-up after emergency visits for biliary symptoms, both due to patient and provider factors. In one study, only 13% of patients discharged from the emergency department with symptomatic gallstones underwent elective cholecystectomy within two years. Furthermore, 37% had additional emergency department visits and 13% required emergent or urgent cholecystectomy. [25] Lastly, lack of consensus on the definition of biliary colic and lack of strong evidence for elective cholecystectomy in patients with biliary colic may result in variation in provider recommendations. [26]

Another theme of interest was the desire for an effective, non-operative treatment for their symptoms. Treatment of acute cholecystitis with cholecystectomy results in successful symptom resolution in 70–90% of cases. [27, 28] There has been little progress in the development of an effective, nonsurgical treatment for benign biliary disease including acute cholecystitis. Antibiotics have been used both as definitive and temporizing management of acute cholecystitis, but this has fallen out of favor, with cholecystectomy leading to faster symptom resolution and fewer long-term complications. [5, 29, 30] Percutaneous cholecystostomy drainage and endoscopic transpapillary gallbladder drainage are also used for acute cholecystitis treatment and are more frequently offered to patients with an elevated risk of surgical complications. Investigations into novel non-operative treatment of acute cholecystitis should be targeted as a patient-centered initiative.

Patients reported a lack of perceived control over their healthcare, which distinguished having some control over their health and recovery from surgery through diet, rest and following physician recommendations with making decisions regarding their treatment. All patients reported that physicians had not asked about their treatment preferences and none broached this subject with physicians themselves. Similarly, patients indicated that they had not been well-informed about treatment options. These findings have been previously described, in which physicians in the United States communicate less well with racial and ethnic minorities [31–33]. Patients also believed that their doctors knew what was best for their healthcare. Although patients who shared their surgeon’s preference for surgical treatment had aligned decision-making, there was not true shared decision-making. Interventions to improve the shared-decision making process for patients of low socio-economic status such as decisional and educational support may improve healthcare disparities. [34]

Limitations:

This study was conducted at an academic center where residents evaluate patients prior to faculty. It was not discerned whether faculty had met with a patient prior to the interview and this may have resulted in some aspects of the physician-patient interaction being incomplete. Second, since interviews occurred prior to surgery, the authors could not assess the impact of nighttime surgery on actual patients’ experiences. Third, patients were asked about being able to return to work rather than their ability to return to prior function, which may have impacted patients’ choices who reported unemployment. Finally, we did not ask patients to weigh a theoretical added risk against a desire to have prompt surgical intervention. Given that nighttime surgery has been associated with a small increase in minor complications, such as bile spillage and surgical site infection at our hospital, this should be explored in future work. [10]

Conclusions:

Efforts to improve timeliness to definitive treatment of acute cholecystitis are also patient-centered at a safety-net hospital. Patients expressed frustration in time to symptom relief and surgical treatment, lack of perceived control over their current health, and desire for an effective non-surgical treatment option. These should be targeted in future quality improvement initiatives.

Abbreviations

IOM

Institute of Medicine

SNH

Safety-Net Hospital

LBJGH

Lyndon Baines Johnson General Hospital