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

Hypothesis: There is regional variation in the use of laparoscopic cholecys tectomy (LC) for acute cholecystitis in the New England (Maine, New Hampshi re, Vermont, Massachusetts, Rhode Island, and Connecticut) Medicare populat ion. Design: Population-based, cross-sectional study. Setting: Hospital service areas (HSAs), small geographic areas reflecting l ocal hospital markets, in New England. Patients: We identified from the cla ims database 21 570 Medicare patients undergoing cholecystectomy between 19 95 and 1997. Patients with acute calculous cholecystitis but no bile duct stones (n = 61 56) vi ere 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 cholecystectom ies 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 lapar oscopic 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 10 %. 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 w as no correlation between regional use of laparoscopic surgery and 30-day m ortality (3.1%; overall). Conclusions: The likelihood of elderly patients with acute cholecystitis re ceiving 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.