Appropriateness of cholecystectomy: the public and private sectors compared

To investigate the appropriateness of cholecystectomies undertaken in the public and private health sectors.

Retrospective case note review using the findings of two consensus panels.

35 consultant surgeons working for North West Thames Regional Health Authority and in the private sector.

269 patients undergoing cholecystectomy during the study period, of whom 17 were excluded because there was insufficient information available.

Appropriateness ratings as assessed by two consensus panels, one composed of surgeons and one mixed, containing doctors from different specialties.

The mixed panel would have rated 41 per cent of cases appropriate, less than 1 per cent equivocal and 30 per cent inappropriate. The remaining 29 per cent had indications about which the panel did not reach agreement. The surgical panel would have rated 52 per cent appropriate, 3 per cent equivocal and 2 per cent inappropriate. The remaining 44 per cent had indications about which the panel did not reach agreement. Most of the patients who would have been rated inappropriate had vague symptoms only. There were no significant differences between the NHS and private patients as regards their appropriateness. NHS patients were more likely to have more than one ultrasound and to be operated on as an emergency.

An appreciable proportion of patients undergo cholecystectomy for indications which were deemed inappropriate by a mixed panel, but not a surgical panel. Variation in clinical judgement is an important factor in the decision to operate--44 per cent of cases had indications, the appropriateness of which the surgical panel were undecided about. There were no significant differences between NHS and private patients as regards the appropriateness of their indications. These findings need to be confirmed by further studies comparing the public and private sectors.