Itemized Bill: Novel Method to Audit the Process of Laparoscopic Cholecystectomy
Khawaja Mohammad Inam Pal, M.B.B.S., M.Sc., Mushtaq Ahmed, M.B.B.S.
Department of Surgery, The Aga Khan University Hospital, Stadium Road, P.O. Box 3500 Karachi, 74800 Pakistan
Published Online: May 2, 2003
Abstract. One of the recurring obstacles to the successful completion of a
medical audit cycle is the unavailability of accurate and complete informa-
tion. This is particularly evident in the review of clinical processes, where
the hand-written medical record is the source of information. We have at-
tempted to bypass this information deficit by using information recorded
primarily for financial transactions, using the itemized bill. The study was
conducted in two parts. Initially information recorded as an itemized bill
for the in-hospital process of laparoscopic cholecystectomies over a one-
year period was analyzed. Areas for change in practice were identified, and
recommendations were developed. These recommendations were pre-
sented to a multidisciplinary group consisting of consultants, residents,
and nursing staff involved in caring for these patients. A clinical pathway
was developed and implemented from these recommendations. One year
after introduction, a review of the clinical pathway was undertaken using
the same methodology. The in-hospital process consisted of 23 charge cat-
egories according to the itemized bill. Of these, 8 accounted for 95% of the
total charge. The surgeon’s fee and the anesthesiologist’s fee accounted for
34% of the total; medical/surgical supplies, 20%; operating theater time,
17%; pharmacy, 7%; radiology, 5%; laboratory, 7%; and ward, 4%. Areas
were identified in the latter 6 categories for change. Review of practice 1
year after implementation of the changes showed that a large number of
recommendations were in place. We describe a new method for auditing the
processes of medical care, using the itemized bill to adapt and use infor-
mation primarily recorded for financial purposes.
The success of any audit activity depends on the completion of an
audit cycle. In the case of a clinical audit cycle, success depends on
the following factors: (1) accurate and timely recording of pertinent
data related to clinical practice in a format that is accessible, en-
sures fidelity, and is reproducible; (2) adoption of standards of
practice from evidence-based medicine; (3) cyclical review to de-
termine variations from the prescribed practice and identification
of areas requiring change [1, 2].
A significant stumbling block in performing a clinical audit is the
quality of the medical record, which often lacks accuracy and com-
pleteness. By contrast, the data recorded for cost recovery tends to
be accurate and complete. We describe a new way to audit the pro-
cess of medical care, using a tool developed primarily for its finan-
cial efficiency, the itemized bill.
The Aga Khan University Hospital (AKUH) is a private teaching
hospital in a developing country; the issues of competitive charges
and improving the quality of care are of particular and immediate
relevance to the institution. Laparoscopic cholecystectomy, ac-
counting for 15% of general surgical workload, is the most common
general surgical procedure. We undertook an audit of the in-
hospital care process for this surgical procedure using the charge
structure set forth in the itemized bill.
Materials and Methods
The study was conducted in two phases, an initial 12-month audit
period and a 6-month follow-up that was undertaken a year later.
Phase I
Initially a 12-month period, 1 January 1997 to 31 December 1997,
was selected for review. The hospital medical records database was
used to identify patients who had undergone laparoscopic chole-
cystectomy during this period. This information is entered prospec-
tively from a face sheet attached to the patient’s case file, com-
pleted by the primary team with the help of a qualified medical
coder using the ICD9 classification [3].
Because we sought to obtain a homogeneous study population,
only patients admitted electively through the outpatient clinic were
selected for the audit study. Patients with acute presentations and
those having more than one procedure were excluded. Finally, only
patients admitted to the general ward were selected to ensure uni-
formity of charge.
The patient billing department of the hospital was asked to pro-
vide an itemized bill for each patient. The in-hospital medical care
process was defined using the information obtained from the item-
ized bill. The data collected was analyzed using commercially avail-
able computer software: Microsoft Excel spreadsheet and Micro-
soft Access database.
Recommendations addressing changes in the process of care
were developed from this review and presented to the general sur-
gery group, which is made up of consultants, residents, and nursing
staff. Consensus for change was reached, and the recommenda-
tions were used to develop and introduce a clinical pathway [4] for
laparoscopic cholecystectomy.
Correspondence to: Khawaja Mohammad Inam Pal, M.B.B.S., M.Sc.,
e-mail: inam.pal@aku.edu
WOR LD
Journal of
SURGERY
© 2003 by the Socie´te´
Internationale de Chirurgie
World J. Surg. 27, 666–670, 2003
DOI: 10.1007/s00268-003-6795-0