title: The risk paradox: use of elective cholecystectomy in older patients is independent of their risk of developing complications.
abstract: BACKGROUND
  We recently developed and validated a prognostic model that accurately predicts the 2-year risk of emergent gallstone-related hospitalization in older patients presenting with symptomatic gallstones.
  
  
  METHODS
  We used 100% Texas Medicare data (2000 to 2011) to identify patients aged 66 years and older with an initial episode of symptomatic gallstones not requiring emergency hospitalization. At presentation, we calculated each patient's risk of 2-year gallstone-related emergent hospitalization using the previously validated model. Patients were placed into the following risk groups based on model estimates: <30%, 30% to <60%, and ≥ 60%. Within each risk group, we calculated the percent of elective cholecystectomies (≤ 2.5 months from initial episode) performed.
  
  
  RESULTS
  In all, 161,568 patients had an episode of symptomatic gallstones. Mean age was 76.5 ± 7.3 years and 59.9% were female. The 2-year risk of gallstone-related hospitalizations increased from 15.9% to 41.5% to 65.2% across risk groups. For the overall cohort, 22.3% in the low-risk group, 20.9% in the moderate-risk group, and 23.2% in the high-risk group underwent elective cholecystectomy in the 2.5 months after the initial symptomatic episode. In patients with no comorbidities, elective cholecystectomy rates decreased from 34.2% in the low-risk group to 26.7% in the high-risk group. Of patients who did not undergo cholecystectomy, only 9.5% were seen by a surgeon in the 2.5 months after the initial episode.
  
  
  CONCLUSIONS
  The risk of recurrent acute biliary symptoms requiring hospitalization has no influence, or even a paradoxical negative influence, on the decision to perform elective cholecystectomy after an initial symptomatic episode. Translation of the risk prediction model into clinical practice can better align treatment with risk and improve outcomes in older patients with symptomatic gallstones.
authors: Department of Surgery, The University of Texas Medical Branch, Galveston, TX. Electronic address: tsriall@utmb.edu.
authors: Taylor S
authors: TS
authors: Riall
authors: Department of Surgery, The University of Texas Medical Branch, Galveston, TX.
authors: Deepak
authors: D
authors: Adhikari
authors: Department of Surgery, The University of Texas Medical Branch, Galveston, TX; Department of Surgery, The University of California, San Francisco-East Bay, Oakland, CA.
authors: Abhishek D
authors: AD
authors: Parmar
authors: Department of Surgery, The University of Texas Medical Branch, Galveston, TX.
authors: Suzanne K
authors: SK
authors: Linder
authors: Department of Surgery, The University of Texas Medical Branch, Galveston, TX; Department of Surgery, The University of South Florida, Tampa, FL.
authors: Francesca M
authors: FM
authors: Dimou
authors: Department of Surgery, The University of Texas Medical Branch, Galveston, TX.
authors: Winston
authors: W
authors: Crowell
authors: Department of Surgery, The University of Texas Medical Branch, Galveston, TX; Department of Surgery, The University of California, San Francisco-East Bay, Oakland, CA.
authors: Nina P
authors: NP
authors: Tamirisa
authors: Department of Surgery, The University of Texas Medical Branch, Galveston, TX.
authors: Courtney M
authors: CM
authors: Townsend
authors: Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX.
authors: James S
authors: JS
authors: Goodwin
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002763:Cholecystectomy / Q000379:methods*; D017558:Elective Surgical Procedures; D005260:Female; D005500:Follow-Up Studies; D042882:Gallstones / Q000601:surgery*; D006801:Humans; D015994:Incidence; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000453:epidemiology* / Q000209:etiology; D011379:Prognosis; D015203:Reproducibility of Results; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D015996:Survival Rate; D013781:Texas / Q000453:epidemiology; D013997:Time Factors; D014481:United States / Q000453:epidemiology