Pancreatectomies are among the most morbid operations performed in Michigan, with significant variation in outcomes status post pancreatectomy. Reliability-adjusted complication rates range from 29–42%, while readmission rates range from 11–24%, reoperation rates from 3–11%, and hospital stays can vary from 9–14 days across 28 hospitals in the state of Michigan. While previous work demonstrated superior outcomes in pancreatic resections performed at high-volume centers,¹ patient preference and growing expertise in complex surgery drive an increasing number of cases to be performed at community hospitals.

The Michigan Surgical Quality Collaborative (MSQC) aims to improve care at all participating institutions to meet the needs of Michigan residents through the adoption of a collaborative care pathway. While it is uncertain whether travel distance plays a major role in hospital selection for high-risk surgical cases, it nevertheless remains a factor in choosing a location for surgery. In turn, this makes frequent referrals to large cancer centers for care an untenable proposition for many members of our statewide surgeon community.² Improving and standardizing care for operations like a pancreatectomy will have a positive spill-over impact on many systems of care within community hospitals. To optimize systems of care at all hospitals and among all surgeons in Michigan who perform pancreatectomies, our proposed strategy involves the development and implementation of a statewide pancreatectomy care pathway informed by quality evidence and high-performing surgeons.

Clinical care pathways are standardized tools for routine operations that improve patient outcomes after surgery. Led by high-performing sites and the best evidence, teams of surgeons from across the state come together to draft a statewide care pathway. Existing pathways include colectomy, lap cholecystectomy, hernia repair, and hysterectomies. Once complete, surgeons return to their institution to discuss the pathway in detail with partners and colleagues. All sites have the option to edit the pathway to fit their institution’s unique needs, but within a single site, there should be a single common pathway for care.

In an effort to design a pancreatectomy pathway that would be broadly implemented at all MSQC hospitals, we solicited current pathways or guidelines in use at peer institutions. Recommendations organized by phase (pre-, peri- and postoperative) were assembled into a document for presentation. Participating hospitals sent surgeon representatives to review and edit the document until a consensus pathway was finalized. The pathway was sent for approval to the executive committee of the MSQC. After approval, each surgeon representative presented the pathway to their respective institution. Institution-specific additions or changes (e.g. surgical technique) that do not fundamentally alter the MSQC-approved pathway may be made at that time.

Our pancreatectomy pathway is categorized by phase: preoperative, immediate preoperative, intraoperative, postoperative, and post-discharge (Figure 1). In the preoperative phase, special consideration is given to patient education, imaging considerations, prehabilitation, and tumor board discussion. Multimodal analgesia to reduce opioid use, infection prevention measures, and venous thromboembolism (VTE) prophylaxis are the intraoperative focus. Components of the postoperative phase include initiating proton pump inhibitor therapy, early foley removal, early alimentation, and discontinuation of IV antibiotics. Operative report standards were set to include pancreatic duct size, texture, vascular reconstruction, presence of a stent, and the type of neoadjuvant treatment utilized. Ultimately, patients meet discharge criteria if they are tolerating a diet without nausea and pain is well-controlled with oral medications. Post-discharge, patients are contacted within two business days and have a clinic visit within 2–6 weeks.

Despite an overall positive perception of clinical care pathways, barriers to their implementation exist at the cultural, educational, and patient levels.⁸ In a single institution qualitative study, a commonly cited barrier to implementation was the dichotomy between the new pathway and current provider practice patterns. Provider experience and familiarity with particular clinical practices represent a cultural barrier to implementation. Additionally, poor awareness of the pathway and frequent provider turnover limits adherence to pathways at the educational level. Finally, each patient’s unique clinical presentation and individual hospital course can impact one’s ability to adhere to clinical care pathways.

In spite of the barriers that challenge the uptake of clinical care pathways, implementation of a statewide pancreatectomy care pathway will improve standardization of care for such procedures. As complex procedures like pancreatectomies continue to branch out into surrounding community hospitals, surgeons across the state are eager to collaborate to improve the quality of care by working together to make a standard pathway. Our care pathway, unique in its reach across the state of Michigan, exemplifies an evidenced-based and practical treatment plan supported by evidence and high-performing expertise in perioperative pancreatectomy care.

In the future, within our collaborative, we plan to analyze complication rates and better understand how morbidity and mortality are impacted across MSQC institutions after this standardized pancreatectomy care pathway is implemented. Guided by these data, surgeon leaders will engage in an iterative process following a continuous quality improvement framework to optimize complex surgical care for patients across the state of Michigan.