Racial variation in the use of laparoscopic cholecystectomy in the Department of Veterans Affairs Medical System

Background: While studies have found racial differences in the rates of use of established invasive cardiac and cerebrovascular procedures, no study h as evaluated racial variation in the rates of adoption of new surgical proc edures. For patients undergoing laparoscopic cholecystectomy, the procedure represents a new and safe option that shortens the duration of postoperati ve hospitalization by almost one week. In this study, we evaluated whether, in the equal access Veterans Affairs (VA) medical system, the rate of adop tion of this procedure and improvements in the duration of postoperative ho spitalization differed between African-American and Caucasian patients. Study Design: Data were obtained from two sources-administrative claims fri es and prospectively compiled clinical data from medical records and patien t interviews. In both data sets, frequency of use, length of stay, and outc omes for African-American and Caucasian patients undergoing minimally invas ive and open gallbladder surgery were analyzed for the first four years of use of the procedure in the VA system (1992 to 1995). Results: Analyses based on claims files indicated that, after adjustment fo r potentially confounding variables, African-American patients who underwen t cholecystectomy in VA medical centers were 25% less likely to undergo a m inimally invasive cholecystectomy during the first 4 years of use of the ne w procedure (adjusted odds ratio, 0.74; 95% confidence interval, 0.66-0.83) . Shortening of the average postoperative length of stay from 9 days or mor e in the prelaparoscopic era to less than 4.5 days for patients undergoing the laparoscopic procedure occurred in the first year for Caucasian patient s, but did not occur until the fourth year for African-American patients (p < 0.001). The overall difference in postoperative length of stay between A frican-American and Caucasian patients more than doubled from 1.7 days befo re introduction of laparoscopic cholecystectomy to 3.8 days in the fourth y ear. In comparison, analyses based on nurse-compiled clinical data indicate d that, after adjustment for relevant clinical factors, racial variations i n the rate of laparoscopic surgery were even larger (adjusted odds ratio fo r laparoscopic versus open cholecystectomy for African-American versus Cauc asian veterans, 0.68; 95% confidence interval, 0.55-0.84). Conclusions: Compared to Caucasian patients, African-American patients who underwent cholecystectomy in VA medical centers had an approximately 25% to 32% lower likelihood of undergoing minimally invasive cholecystectomy proc edures. The differences in rates of adoption of laparoscopic surgery did no t appear to be from mote comorbid illnesses among African-American patients . African-American and Caucasian veterans may differ in their preference fo r new surgical procedures like laparoscopic cholecystectomy. Conversely, VA physicians may have been less likely to recommend laparoscopic cholecystec tomies to African-American patients. (J Am Cell Surg 1999;188:604-622. (C) 1999 by the American College of Surgeons).