To the Editor. —In their article, Legorreta et al1 suggest that the introduction of laparoscopic cholecystectomy may have caused an increase in the overall consumption of health care resources. They base their conclusion on an apparent increase of almost 60% from 1988 through 1992 in use rates for cholecystectomy from a 500 000-enrollee health maintenance organization (HMO) in southeastern Pennsylvania. While the studied data may be an accurate reflection of one HMO’s claims experience, these findings are not supported by an examination of cholecystectomy utilization in three different national data sets.In order to determine whether such an increase in cholecystectomy rates can be generalized to the nation, we analyzed all-payer data from the National Hospital Discharge Survey (NHDS),2 Medicare data from the Health Care Financing Administration (HCFA), and hospital discharge data compiled by the HCIA in conjunction with the Commission on Professional and Hospital Activities. Our analysis
This survey determined the effect of the introduction of laparoscopic cholecystectomy on the rates of cholecystectomy (total and laparoscopic) in Scotland. From 1977 to 1990, the Scottish cholecystectomy rate fell by an average of almost 1% per annum. With the advent of laparoscopic cholecystectomy, the total cholecystectomy rate (open and laparoscopic) rose considerably–by 18.7% from 1989-93 (p < 0.05). The largest increase (25%) was observed in the 45-64 years age group but it was also particularly evident (19%) in elderly patients (65-74 years). Subjects were more likely to undergo laparoscopic cholecystectomy than open cholecystectomy if they were young and female. The increased cholecystectomy rate observed merits careful scrutiny and health economic evaluation.
A study was undertaken of Medicare claims coded for cholecystectomy and those coded for laparoscopic cholecystectomy for the four year period 1990-1993 in New York State. During this time period there was a 28.12% increase in total cholecystectomies performed and an increase in the proportion of laparoscopic cholecystectomies from 15.86% to 50.0%. The increase in total cholecystectomies appears to be driven by a dramatic increase in laparoscopic procedures. Possible reasons for this increase include the performance of laparoscopy on patients previously assessed as too risky to undergo the conventional procedure, laparoscopy on mildly symptomatic patients who had previously put off a perceived higher risk open procedure and a possible broadening of indications for gallbladder surgery. The dramatic increase in the numbers of cholecystectomies performed in the early 1990s may be due in part to procedures performed on a large pool of procrastinating mildly symptomatic patients. If this is the case, then these increased rates should decline to baseline levels as soon as this pool of patients is exhausted. However, if surgeons are performing laparoscopy on asymptomatic patients with gallstones, then these rates may well be sustained. Such a broadening of indications for gallbladder surgery is of concern to many and has prompted the issuance of guidelines concerning the treatment of gallstones. Any broadening of indications for gallbladder surgery also has significant implications for health care costs and the use of health care resources.
Objective. —To examine if overall cost savings may fail to result from laparoscopic (“closed”) cholecystectomy if it also results in an increased total rate of cholecystectomies or generates additional costs unassociated with the open procedure.
Outcome Measures. —Inpatient and outpatient expenditures, incidence rates, and length of inpatient stay data for 6909 health maintenance organization enrollees with gallbladder complaints were analyzed from 1988 through 1992 using claims data from a large, private practice—based health maintenance organization.
Results. —The incidence of cholecystectomy and total health maintenance organization expenditures on gallbladder disease have increased since the introduction of laparoscopic closed cholecystectomy. The rate of cholecystectomy procedures per 1000 enrollees increased from 1.35 in 1988 to 2.15 in 1992 (P<.001). Total annual medical expenditures on gallbladder disease per 1000 enrollees (in 1992 dollars) rose 11.4% during the study period (P<.001), despite a concurrent 25.1% decline in the unit cost (physician and hospital cost) for cholecystectomy procedures (P<.001). During the same study period, no significant change was noted in the rate of appendectomy per 1000 enrollees (0.76 in 1988 to 0.73 in 1992), which is a measure of nonelective surgical care, or in the inguinal hernia repair rate (2.01 in 1988 to 2.19 in 1992), which has a physician and patient discretionary component similar to that of cholecystectomy.
Conclusions. —The introduction of laparoscopic gallbladder surgery resulted in rising rates of cholecystectomy for a population of patients in a private, independent practice—based health maintenance organization. Such a rise was not seen for hernia repair surgery or appendectomy. It seems that the use of laparoscopic cholecystectomy, a new technology touted as reducing health care costs, may result in an increased consumption of health care resources due to changes in the indications for gallbladder surgery.(JAMA. 1993;270:1429-1432)