Invited Commentary

Excerpt

Prior to the introduction of laparoscopic cholecystectomy patients in the United States who had a cholecystectomy stayed in the hospital for 7–14 days. In 2002 over 900,000 cholecystectomy procedures were performed in the United States, most of them laparoscopic, and more than half of those patients were never admitted to the hospital after the operation. The average stay for the remainder of these patients was less than 1 day. Of patients undergoing open cholecystectomy in 2002, the length of stay was only 4 days. Why were open cholecystectomy patients staying 3–11 days longer in 1985 than in 2002? While some might argue that the patients of the new millennium are more resilient, or narcotics more effective, or surgeons more talented, the real reason is that surgeons of the post-laparoscopic era treat all patients (whether their procedure was open or laparoscopic) differently than in the past. As has been elegantly demonstrated in double-blind studies of laparoscopic procedures using large abdominal dressings—when neither the patient nor the managing physician knows about the size of the patient’s incision(s)—the resources utilized, the length of stay, and the charges equalize. In other words, simple use of laparoscopy doesn’t make that much of a difference when tracking process and healthcare utilization, it is the way surgeons manage patients who have had a laparoscopic or an open procedure that makes the difference in resource utilization. The tale that laparoscopy has to tell is that the surgeon’s beliefs and expectations drive the use of healthcare resources. As the study by Hirose et al. in this issue of the World Journal of Surgery demonstrates, it is these sorts of physician expectations and nonclinical factors that drove much of the healthcare utilization related to cholecystectomy in Japan from 1996 to 2000. …