Early cholecystectomy for acute cholecystitis: a population-based retrospective cohort study of variation in practice

Abstract

Background: Despite evidence in favour of early cholecystectomy for most patients with acute cholecystitis, variation in practice has been reported across hospitals worldwide. We sought to characterize the extent and potential sources of variation in the performance of early cholecystectomy for acute cholecystitis within a large regional health care system.

Methods: We used a population-based retrospective cohort design. The cohort was limited to adults with a first episode of acute cholecystitis, admitted through the emergency department. Patients were identified using administrative databases comprising all emergency department visits and hospital admissions in Ontario from 2004 to 2010. Patient and hospital characteristics associated with early cholecystectomy (within 7 d of emergency department presentation) were identified using multilevel logistic regression.

Results: We identified 24 437 patients admitted to 106 hospitals with a first episode of acute cholecystitis. Most (58%, n = 14 286) underwent early cholecystectomy. Rates of early cholecystectomy varied widely across hospitals (median 51%, interquartile range [IQR] 25%-72%), even among healthy patients aged 18-49 years with uncomplicated cholecystitis (median 74%, IQR 41%-88%). Multivariable multilevel analysis showed that hospitals in the lowest quartile for volume of acute cholecystitis admissions had the lowest adjusted odds of early cholecystectomy (odds ratio 0.53, 95% confidence interval 0.35-0.78) and that hospital effects accounted for half (27%) of the explained variation (53%) in early cholecystectomy.

Interpretation: Across the hospitals of a regional health care system, similar patients with acute cholecystitis did not receive comparable care. Hospital-specific initiatives should be considered to facilitate early cholecystectomy for patients with acute cholecystitis.

Figure 1:

Selection of patients and hospitals.

Figure 2:

Rate of early cholecystectomy across hospitals among (A) all included patients (n = 24 437 at 106 hospitals) and (B) young healthy patients (< 50 yr, in the lowest comorbidity quartile and with uncomplicated disease [without concurrent biliary tract obstruction or pancreatitis]; n = 2894 at 102 hospitals).