Falling cholecystectomy thresholds since the introduction of laparoscopic cholecystectomy
J. J. Escarce, W. Chen and J. S. Schwartz
Department of Medicine, School of Medicine, University of Pennsylvania, Philadelphia 19104-2676, USA.
OBJECTIVES--To determine whether cholecystectomy rates among the elderly
increased following the introduction of laparoscopic cholecystectomy in
1989, and to assess whether changes in rates were accompanied by lower
clinical thresholds for performing cholecystectomy. DESIGN--Time-series
quasi-experimental design based on quarterly observations from 1986 to
1993. Data were obtained from Medicare hospital discharge files for
Pennsylvania. PATIENTS--Medicare patients aged 65 years or older who
resided in Pennsylvania, did not have end-stage renal disease, and
underwent cholecystectomy in Pennsylvania from 1986 to 1993. MAIN OUTCOME
MEASURES--Cholecystectomy rates per 1000 elderly Medicare beneficiaries,
stage of gallstone disease (uncomplicated vs complicated) at
cholecystectomy, type of admission (elective vs urgent/emergent), patient
age and comorbidities, and 30-day postoperative mortality.
RESULTS--Cholecystectomy rates increased 22% from 1989 to 1993. The
proportions of cholecystectomy patients with uncomplicated gallstone
disease and with elective admissions declined from 1986 to 1989 but then
increased rapidly after laparoscopic cholecystectomy was introduced. In
contrast, the age distribution and comorbidities of cholecystectomy
patients did not change during the study period. Postoperative mortality
rates were stable from 1986 to 1989 but decreased thereafter.
CONCLUSIONS--Growth in cholecystectomy rates following the introduction of
laparoscopic cholecystectomy was accompanied by evidence of lower clinical
thresholds for performing surgery. The normative, or prescriptive,
implications of lower cholecystectomy thresholds require further analyses
that consider lower direct medical costs and indirect costs and reduced
postoperative morbidity after laparoscopic cholecystectomy.
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