N. P. Tamirisa1, T. S. Riall1, F. M. Dimou1 1University Of Texas Medical Branch,Galveston, TX, USA
Introduction: Recent data demonstrate that elective cholecystectomy is performed in fewer than 25% of older patients with symptomatic gallstones; moreover, receipt of cholecystectomy is independent of patients’ risk of developing acute biliary complications. Our goal was to explore physicians’ clinical decision making in older patients.
Methods: Semi-structured interviews with 10 clinical vignettes were conducted with 9 primary care physicians (PCP), 7 gastroenterologists, and 6 surgeons. In the vignettes patients were >65 years; the severity of their gallbladder disease and associated comorbidities varied. Using a previously validated PREOP-Gallstones risk prediction model, predicted rates of gallstone-related hospitalization were calculated for each vignette. For each vignette, physicians were asked: 1) To estimate the patient’s 2-year risk of developing gallstone-related complications, and 2) If they would recommend or refer the patient for cholecystectomy. Model-predicted rates were compared to physician-predicted rates.
Results:The results from 5 vignettes are summarized in Table 1. Across specialties, physician-predicted risk of 2-year acute gallstone-related hospitalization was inconsistent with model-predicted risk. Physician-predicted risk generally increased with increased gallstone disease severity but both the direction and magnitude of the inconsistency varied with the clinical scenario and physician specialty. On average, surgeons were more likely to recommend cholecystectomy. In many cases surgeons behaved paradoxically, recommending cholecystectomy less often for patients at higher risk; they recommended cholecystectomy in 83% of patients with biliary colic (predicted a 21% 2-year risk of complications) and only 67% of patients with gallstone pancreatitis and comorbidities (predicted a 61% risk). Among PCPs and gastroenterologists, referral for cholecystectomy generally increased with perceived risk, but even when they predicted a high risk they did not uniformly refer for surgical evaluation. In most cases where surgeon recommended cholecystectomy rates were high, PCPs and gastroenterologists did not recommend referral.
Conclusion:Across specialties, physicians were inaccurate at predicting risk as compared to a recently validated risk-prediction model. Patients perceived to be at the highest risk are not routinely referred for surgical evaluation. Moreover, there appears to be a disconnect, with non-surgeons frequently not referring patients in whom surgeons would recommend cholecystectomy. Physician education and incorporation of risk prediction models into clinical practice can better align treatment with risk and improve outcomes in older patients with symptomatic gallstones.
