Gallstone Guideline Documentation

This explicit evidence-based guideline was developed in the fall of 1996 by a team of clinicians and epidemiologists from Group Health Cooperative of Puget Sound. The following specialties were represented on the team: general surgery and primary care. When the guideline was updated, input was sought from a Network representative.

Clinical Topic: Management of gallstones and indications for cholecystectomy

Population Addressed: All adults

Sponsoring Bodies
Central Region Clinical Planning & Improvement Committee
Clinical Planning & Improvement Council

Approved for Systemwide Implementation: May 1996

Most Recent Literature Review: January 1999

Original Guideline Development Team (1996)

Eric Froines, MD, General Surgery (Lead)
Mick Braddick, MB, ChB, Clinical Epidemiologist, Guideline Development Support Team
Nancy Carosso, RN, Central Region Clinical Planning & Improvement
Michael Evans, MD, Family Practice
Matt Handley, MD, Guideline Development Support Team
Lance Lang, MD, Director of Clinical Planning & Improvement

Process of Development
Explicit evidence-based process, including systematic literature search, critical appraisal with evidence grading, evidence synthesis, and a balance sheet quantifying benefits, harms, and costs of alternative practices.

Sources of Information and the Approach Used to Assess and Interpret Evidence
Evidence was obtained through a search of MEDLINE (up to October 1998), and the Cochrane Library (through the fourth quarter of 1998) for evidence regarding

• Prognosis with asymptomatic gallstones
• Outcomes of cholecystectomy

Methods used to formulate recommendations
The guideline identifies those clinical symptoms associated with gallstones, and provides information about the natural history of gallstones as well as the outcome following surgery to enable patients and providers to engage in shared decision-making.

Perceived Gaps

• Uncertainty as to which symptoms are due to gallstones
• Use of ultrasound to detect gallstones when they are unlikely to be responsible for symptoms
• Pressure to operate once gallstones are detected, irrespective of whether they are truly symptomatic

Pilot
The guideline was piloted for acceptability and clarity to providers in gastroenterology and primary care, and the pamphlet was piloted with patients.

Balance sheet summary

• Clinical outcomes: an increased threshold for investigating GI symptoms will result in some consumers having biliary colic or complications. However, the number of cholecystectomies performed should be reduced (20% reduction estimated, based on expert opinion).
• Cost/utilization: reduced number of cholecystectomies and gallbladder ultrasound
• Patient and provider satisfaction: should be increased with shared decision making

Implementation Plan
The following approaches are recommended:

• Large and small group CME
• Guideline materials formatted for use in exam rooms and available on the internal web
• Opinion leaders
• Patient information

Measurement Plan: Cholecystectomy rate

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