title: Regional differences in appropriateness of cholecystectomy in a prepaid health insurance system.
abstract: BACKGROUND
  Previous studies have reported variation in the population-based use rate of diagnostic and therapeutic procedures. Cholecystectomy is one of the most common surgical procedures, and we conducted this study to assess whether in Israel the use of this procedure varied by region and whether differences in use can be related to differences in appropriateness of use. In Israel, there is a pre-paid health insurance system and all surgeons are salaried.
  
  
  METHODS
  Age-adjusted rates of cholecystectomy in four hospitals, each serving a defined population in Israel, were calculated. Two hundred and sixty-six potential clinical indications for performing cholecystectomy were rated as to their appropriateness by a panel of 9 expert physicians. A trained team abstracted the medical records of all patients who underwent the operation in the four Israeli hospitals in 1986 (n = 702) and recorded the clinical indication for the surgery.
  
  
  RESULTS
  The population-based age-adjusted rates of cholecystectomy varied over threefold among the four hospitals. 29% of the cholecystectomies were performed for less than appropriate reasons, and this figure varied by hospital from 36% to 17% (p = 0.002). However, appropriateness did not vary systematically with the population-based use rate.
  
  
  CONCLUSIONS
  Cholecystectomy was performed frequently for inappropriate or equivocal reasons, even in a country in which resources are limited, and physicians are salaried. Efforts to improve surgical decision making should be undertaken.
authors.affiliation: Epidemiology and Evaluation of Health Services Unit, Soroka Medical Center of Kupat Holim, Beer Sheva, Israel.
authors.forename: D
authors.initials: D
authors.lastname: Pilpel
authors.forename: G M
authors.initials: GM
authors.lastname: Fraser
authors.forename: J
authors.initials: J
authors.lastname: Kosecoff
authors.forename: S
authors.initials: S
authors.lastname: Weitzman
authors.forename: R H
authors.initials: RH
authors.lastname: Brook
mesh_terms: D000328:Adult; D000368:Aged; D002763:Cholecystectomy / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data*; D003710:Demography; D005260:Female; D006801:Humans; D007557:Israel; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D017061:Prepaid Health Plans / Q000191:economics*; D012040:Regional Health Planning / Q000706:statistics & numerical data*