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Antonio P. Legorreta, MD, MPH; George N. Costantino, MD; Richard W. Kobylinski; Steven L. Zatz, MD
US Quality Algorithms and US Healthcare Blue Bell, Pa

Jeffrey H. Silber, MD, PhD
University of Pennsylvania School of Medicine Philadelphia

JAMA. 1994;271(7):501.

	Since this article does not have an abstract, we have provided the first 150 words of the full text PDF and any section headings.

In Reply.

—We appreciate the comments of Foster et al and definitely agree with them that one should be careful not to generalize results when using a "relatively small convenience sample"; however, we do not think that a private practice— based HMO having 500 000 enrollees is a small sample. The national estimated rates reported in the 1991 NHDS were based on a medical record survey sample.¹ In our study, we used a complete sample of US Healthcare's HMO enrollees in southeastern Pennsylvania.

Although it is possible that the increase in the cholecystectomy rate might have been an isolated phenomenon related only to the population that we studied—as suggested by Foster et al—there is much evidence to suggest otherwise. Orlando et al² documented a 29% increase in cholecystectomies in the state of Connecticut after the introduction of the laparoscopic approach. Drs Klar and Kongstvedt report a 52.4% increase . . . [Full Text PDF of this Article]

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