Longitudinal cholecystectomy study: patterns of care in a total community experience.

The purpose of this study was to determine outcomes and safety of laparoscopic cholecystectomy (LC) versus open cholecystectomy (OC) in a community setting at multiple open staff hospitals with multiple surgeons. This second-year study retrospectively examined all cholecystectomy records in one city at each of five hospitals over a 1-year period beginning in April 1991 through March 1992. All charts were examined for type of surgery, rate of conversion to open procedure, sex, weight, previous abdominal surgery, surgeon, hospital, preoperative workup, operative time, antibiotic prophylaxis, cholangiograms, concurrent procedures, drains, hospital stay, common duct stones and their follow-up, pathology, reoperations, complications, and mortality. One thousand eight hundred one gallbladders were removed. One thousand three hundred four (72.4%) were successfully removed at LC. One hundred eighty-three (10.2%) others were attempted laparoscopically and converted to open cholecystectomy (CC), which represented 12.3% of the attempted LCs. Three hundred fourteen (17.4%) were removed via a standard OC. The mean operative times were 72.3 minutes for LC, 100.1 minutes for CC, and 86.2 minutes for OC. Cholangiography was attempted in 916 (70.3%) LCs, 144 (78.7%) CCs, and 250 (79.6%) OCs, with similar operative times, except in LC, when done via the GB, operative time was 65.2 versus 73.4 minutes when done via the cystic duct. Diagnosis of acute cholecystitis occurred in 306 (23.5%) LCs, 119 (65.0%) CCs, and 145 (46.2%) OCs. Complications requiring reoperation occurred in 30 (2.3%) LCs, 5 (2.7%) CCs, and 5 (1.6%) OCs. Common bile duct (CBD) injuries occurred in 5 (34%) LCs, with 4 converted to CC and 1 repaired 5 days later. Trocar site hernias occurred in 11 (0.8%) LCs. Thirty-nine surgeons participated in the study with mean numbers of 33.4 LC cases, 5.5 CC cases, and 7.2 OC cases, with ranges of 1 to 165 LC cases, 1 to 17 CC cases, and 1 to 24 OC cases. Death occurred in 12 (0.9%) LC cases, 4 (2.2%) CC cases, and 25 (8.0%) OC cases. The mean hospital stay was 39.6 hours for LC, 156.5 hours for CC, and 198.3 hours for OC.

On-center vs off-center dental care for Job Corps members: cost and utilization.

While Job Corps Centers vary in size, location, and administrative structure, they are subject to uniform requirements for health services, established by federal regulation and must make individual decisions about whether to furnish dental care on-site or by some alternative arrangement in the community. Analysis of cost and utilization data indicated that expenditures for on-site dental care are greater than for off-center care. However, on-center care results in more dental visits and a lower cost/visit. These observations hold even for the smallest size centers.