Disparities in treatment of biliary disease at an urban safety-net hospital

Thomas P McIntyre, MD, Felix Ho, BS, Muthukumar Muthusamy, MD. Kings County Hospital Center

Introduction:

It has been well described that patient payer status and racial differences may account for disparities in treatment for benign biliary disease, resulting in lower rates of laparoscopic cholecystectomy and increased non-operative management. We conducted a retrospective chart review of patients who received cholecystectomy for benign biliary disease at an urban safety-net hospital. Our objective was to characterize the management of benign biliary disease in a population that may be at a high risk for suffering from disparities in care.

Methods:

We examined records of 130 patients who received cholecystectomy at our institution between February 2009 and February 2012 for benign biliary disease. We recorded demographic data (age, sex, race, payer status, zip code), diagnosis at surgery, time from initial presentation with biliary disease to surgery (definitive treatment), length of stay post surgery and in total, number of ED visits, and total number of inpatient admissions.

Results:

At our urban public hospital 61.5% of patients had Medicaid, 16.9% had private insurance, 13.8% were uninsured and 6.9% had Medicare. 81.5% of our patients were black, 14.6% were Hispanic, 0.7% were white, and 3.1% were not identified as a particular race. Indications for cholecystectomy were symptomatic cholelithiasis (46.2%), acute cholecystitis (20.0%), choledocolithiasis (15.4%), gallstone pancreatitis (12.3%), and combined acute cholecystitis with pancreatitis (6.2%).

All patients underwent laparoscopic cholecystectomy, with a 2.3% open conversion rate. 54.6% of patients had an outpatient procedure. The average number of ED visits for all diagnoses was 1.57 and 38% of all patients made repeat visits. Average time from initial presentation to surgery for all diagnoses was 188.8 days. Patients spent an average of 4.85 days as inpatients for all admissions for treatment of benign biliary disease.

Conclusion:

National trends and practice guidelines recommend urgent or elective cholecystectomy for most benign biliary disease. The majority of our patients are African American and poor, based upon our high rates of uninsured and Medicaid patients, and therefore at risk for disparities in care. In this population we found that there is a delay in patients receiving cholecystectomy as definitive treatment for benign biliary disease as reflected by a long time lapse between diagnosis and surgery, a significant number of repeat ER visits and a high cumulative number of days spent in the hospital. Further research is warranted to directly address the magnitude of this disparity and develop interventions to reduce it.

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