Variation in the use of laparoscopic cholecystectomy for elderly patients with acute cholecystitis

Abstract

Hypothesis: There is regional variation in the use of laparoscopic cholecystectomy (LC) for acute cholecystitis in the New England (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut) Medicare population.

Design: Population-based, cross-sectional study.

Setting: Hospital service areas (HSAs), small geographic areas reflecting local hospital markets, in New England.

Patients: We identified from the claims database 21 570 Medicare patients undergoing cholecystectomy between 1995 and 1997. Patients with acute calculous cholecystitis but no bile duct stones (n = 6156) were then identified using International Classification of Diseases, Ninth Revision diagnostic codes. To reduce variation by chance, we excluded patients residing in HSAs with fewer than 26 cases, leaving 5014 patients in 77 HSAs.

Main outcome measures: For each HSA, we assessed the rate of cholecystectomies performed laparoscopically, mortality, and hospital length of stay.

Results: Overall, 53.5% of patients with acute cholecystitis underwent LC. There was wide regional variation in the rate of patients undergoing laparoscopic surgery, from 30.3% in the Salem, Mass, HSA to 75.5% in the Hyannis, Mass, HSA. Seventeen HSAs had rates below 40%, while 9 had rates above 70%. The average length of stay (7.6 days) was approximately 1 day shorter in HSAs with high rates of patients undergoing LC than in other HSAs. There was no correlation between regional use of laparoscopic surgery and 30-day mortality (3.1% overall).

Conclusions: The likelihood of elderly patients with acute cholecystitis receiving LC depends strongly on where they live. Efforts to reduce regional variation should focus on disseminating techniques for safe LC in this high-risk population.