Nov 22 2013
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The Imperative to Improve Gallbladder Disease Treatment and Outcomes for Men

SreyRam Kuy, MD, MHS, is an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program, and a vascular surgery fellow at the Medical College of Wisconsin.

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Gallbladder disease, and specifically gallstones, can present as pain in the upper abdomen, usually after eating fatty foods.  More severely, gallstones can progress to an inflammation and infection called cholecystitis or cholangitis, both of which require prompt surgical treatment.  Gallbladder disease is an important medical problem as it accounts for $650 billion in health care costs annually in the United States[i], making it the second most costly digestive disease in the country.[ii] With more than 700,000 cholecystectomies (surgeries to remove the gallbladder) performed annually in the United States, gallbladder disease is the number one reason for abdominal surgery in the nation.[i]  Cholecystectomies can be done with traditional surgery (open cholecystectomy) or performed minimally invasively (laparoscopic cholecystectomy).

The National Health and Nutrition Examination Survey estimates 6.3 million men and 14.2 million women in the United States have gallbladder disease.[iii]  It occurs two times more frequently in women than in men.[i][iv] However, during the reproductive years, women have a four-fold higher prevalence of gallstones than men.[iii] As a result of its disproportionate burden on women, gallbladder disease is a critically important topic in women’s health.

There is currently a lack of consensus on whether a patient’s gender affects how soon they get surgery for cholecystitis, what type of surgery they get (open versus laparoscopic cholecystectomy), and how they do after surgery.  My prior work and that of my colleagues has clearly shown that older age negatively impacts how patients do following cholecystectomy.[v] Therefore, to determine whether gender, independent of other factors, affects outcome, we examined a national group of patients hospitalized with cholecystitis over an eight-year period, age-matched to account for the effect of age, and identified gender-based differences in patients hospitalized with cholecystitis. We measured outcomes of women compared with men who underwent cholecystectomy during that admission for cholecystitis, and identified factors associated with outcome.

Among patients admitted with cholecystitis, we found that women accounted for 65 percent of all admissions for cholecystitis.  Women were more likely to experience a shorter time than men from when they were admitted to the time of surgery (1.6 days compared with 1.9 days) and were more likely than men to undergo minimally invasive surgery (laparoscopic cholecystectomy) (86% vs. 76%).  

Following cholecystectomy, women had lower rates of death during that hospitalization than men (0.6% vs. 1.1%), fewer complications (16.9% vs. 24.1%), shorter lengths of hospitalization (4.2 days vs. 5.4 days), and lower cost of hospitalization ($10,556 vs. $13,201).  On multivariate analysis of age-matched patients (adjusting for differences in patient and hospital characteristics), women had lower odds of mortality (OR 0.75), complications (OR 0.86), length of hospital stay (OR 0.95), and cost of hospitalization (OR 0.93) than men. In addition, experiencing a longer time from admission to surgery and undergoing an open cholecystectomy (instead of a minimally invasive laparoscopic cholecystectomy) were independent predictors of worse outcomes in both women and men.

In conclusion, in both cholecystitis and cholecystectomy, women have better clinical and economic outcomes then age-matched men, with time to surgery and type of surgery being key factors affecting how well patients do.  Even though gender is not a modifiable factor, type of surgery and time to surgery are both potentially modifiable factors.  

Gallbladder disease is one of the most costly digestive diseases in the United States.  Therefore, it is vital that measures be taken to improve the care of this population and reduce medical expenditures. The implications of this study for both patients and providers are that prompt diagnosis and early treatment are vital in improving the care of all patients, women and men, with gallstone disease.  

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[i] Shaffer EA, Gallstone disease: Epidemiology of gallbladder stone disease. Best Pract Res Clin Gastroenterol. 2006;20(6): 981-996.

[ii] Richter JE. The enormous burden of digestive diseases on our healthcare system. Curr Gastroenterol Rep. 2003 Apr; 5(2): 93-94.

[iii]Everhart JE, Khare M, Hill M, Maurer KR: Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 1999, 117:632–639.

[iv] Shaffer EA, Epidemiology and risk factors for gallstone disease: has the paradigm changed in the 21st century? Curr Gastroenterol Rep. 2005 May; 7(2): 132-40.

[v] Kuy S, Sosa J, Roman S, Desai R, Rosenthal R. Age matters: a study of clinical and economic outcomes following cholecystectomy in elderly Americans. Am J Surg. 2011;201(6):789-796.

Tags: Clinical Scholars, Health Care Quality, Research & Analysis, Voices from the Field