Despite wide adoption of CPs throughout different departments currently, their evaluation and optimization remain doubtful[20]. The purpose of this study was to compare the indicators of CP implementation in five domains (clinical outcome, efficiency indicators, financial indicators, and antibiotic use indicators) for patients with CBD stones undergoing ERCP. Our results confirmed that pathway implementation in CBD stones was associated with reduced total LOHS, costs, antibiotic use, antibiotic use duration, and complication rate. More importantly, the decrease has not been achieved at the expense of increased readmission rate or mortality.

With the development of endoscopic technique, ERCP is considered a preferred therapeutic method in management of CBD stones. However, it can be still challenging in some cases, such as high total hospital expenses and high risk of post-ERCP complications[21,22]. CP, one of the main modes to standardize treatment and care, is increasingly adopted by hospitals to strive to better outcomes and lower costs. However, the definition of CP has not yet been fully elucidated in clinical practice, and the impact of pathway complementation is varied by different factors and conditions[23,24]. Findings of our study are consistent with those obtained by Kristin et al who demonstrated a considerable reduction in terms of costs and LOHS in patients with complicated gallstone disease after the CP implementation[9]. More recent studies showed similar improvements in other specialties of diseases, such as acute pancreatitis[25], breast cancer[15], and chronic obstructive pulmonary disease[26]. However, pre-operative length of stay showed no distinct disparity in our study, and the implementation of pathway might have greater impact on postoperative hospital stay. Similar to our results in terms of antibiotic use, Dona et al[27] reported that there was a reduction of antibiotic prescriptions in patients with community-acquired pneumonia after introducing a CP. Our study provided further evidence that the CP implementation can also significantly reduce the duration of antibiotic use and three-line antibiotic prescriptions. Thus, it is possible to conclude that a marked reduction of costs appears to be associated with several factors, such as effective pre-operative examination and rational use of medications and materials. Moreover, CP seems to be one of key approaches to maximize cost-effectiveness, while without sacrificing good treatment outcomes[28]. The most common causes of dropout from CP were postoperative complications that needed additional treatment. The findings of the present study demonstrated that rates of complications were lower in patients operated upon admission who implemented the CP compared to patients receiving routine care. There have been multiple previous publications in various domains which have demonstrated the lower incidence of complications following critical pathways[29-31]. However, critical factors may have affected outcomes, such as patients’ characteristics, living habits, disease features, and individual laboratory measurements. Thus, these factors did not affect the findings that CP use achieved a significantly shorter LOHS, lower costs, and reduced complications after adjustments.

Large-scale populations with gallstones and data process and application platform utilization are the main strengths in the present study. Furthermore, the findings were demonstrated by adjusting the potential confounders. However, this study was limited by its single-center retrospective design, indicating that further multiple-center trials with larger variable are in need to confirm the results.

In conclusion, findings of our study have demonstrated that patients with CBD stones who accepted the CP appear to be significantly lower in the LOHS, the costs, the rate of antibiotic use, and the incidence of complications. Our study provides further evidence of CP use in Chinese patients and also standardizes gallstone management and treatment.