title: Trends in Follow-Up of Patients Presenting to the Emergency Department with Symptomatic Cholelithiasis.
abstract: BACKGROUND
  Fewer than 25% of Medicare beneficiaries presenting with symptomatic cholelithiasis undergo elective cholecystectomy. To better understand underuse of cholecystectomy, we examined physician follow-up patterns after emergency department (ED) visits for symptomatic gallstones.
  
  
  METHODS
  We used 100% Texas Medicare claims (2001 to 2010) to identify patients 66 years of age and older who presented to the ED with symptomatic cholelithiasis and were discharged home without cholecystectomy. Timing of outpatient physician visits after ED discharge and rates of emergent cholecystectomy based on physician follow-up patterns were compared.
  
  
  RESULTS
  In total, 11,126 patients presented to the ED with symptomatic cholelithiasis and were discharged without cholecystectomy. After discharge, 5,327 patients (47.9%) had an outpatient surgeon visit, 29.0% saw another physician and never saw a surgeon, and 23.1% never saw a physician; 68.2% of patients who saw a surgeon underwent elective cholecystectomy; and 8.3% of patients who saw a surgeon, 14.6% of patients who saw other physicians and no surgeon, and 77.6% of patients who never saw any physician, required emergent hospitalization (p < 0.0001). For people who did not see a physician, mean time to emergent hospitalization was 7.5 days (median 2 days); 95.9% presented within 2 weeks after their initial presentation.
  
  
  CONCLUSIONS
  Fewer than half of patients were evaluated by a surgeon after an initial ED visit for symptomatic gallstones. Patients who did not have physician follow-up were most likely to require emergent cholecystectomy, suggesting inappropriate ED discharge and highlighting the need for timely follow-up. Early outpatient surgical consultation is critical in determining appropriateness for cholecystectomy and avoiding emergent cholecystectomy in older patients with symptomatic gallstones.
authors.affiliation: Department of Surgery, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of South Florida, Tampa, FL.
authors.forename: Francesca M
authors.initials: FM
authors.lastname: Dimou
authors.affiliation: Department of Surgery, University of Texas Medical Branch, Galveston, TX.
authors.forename: Deepak
authors.initials: D
authors.lastname: Adhikari
authors.affiliation: Department of Surgery, University of Texas Medical Branch, Galveston, TX.
authors.forename: Hemalkumar B
authors.initials: HB
authors.lastname: Mehta
authors.affiliation: Department of Surgery, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Arizona, Tucson, AZ. Electronic address: tsriall@surgery.arizona.edu.
authors.forename: Taylor S
authors.initials: TS
authors.lastname: Riall
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002763:Cholecystectomy / Q000706:statistics & numerical data*; D017558:Elective Surgical Procedures; D004636:Emergency Service, Hospital; D005260:Female; D005500:Follow-Up Studies; D042882:Gallstones / Q000150:complications / Q000175:diagnosis* / Q000628:therapy*; D006760:Hospitalization; D006801:Humans; D008297:Male; D006278:Medicare; D013781:Texas; D014481:United States
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