The purpose of this study was to assess the rate of adoption of laparoscopic cholecystectomy and the extent to which shortening of postoperative hospitalizations after this minimally invasive procedure occurred among Caucasian and African-American patients treated at Veterans Affairs (VA) medical centers. Data for this study were drawn from two sources: an administrative claims file for all VA patients (the Patient Treatment File) and a prospectively obtained clinical record file for a large subset of VA patients (the National Veterans Affairs Surgical Quality Improvement Program (NSQIP) for October 1991 to December 1993 and January 1994 to August 1995).

Analysis of data from the Patient Treatment File showed that laparoscopic procedures were performed on 41.8% of the patients who underwent cholecystectomies in the first four years after the introduction of the procedure, with rates of 35.4% for African-American patients and 42.6% for Caucasian patients. This race pattern was evident for each age group, for patients with coexisting diseases, and in several U.S. regions (Southeast Central, Pacific, South Atlantic, and Southwest Central). Furthermore, by the fourth year after the introduction of this procedure to the VA system (1994), the racial differences were still statistically significant, with more than 50% of the total cholecystectomies among Caucasian VA patients performed as laparoscopic procedures as compared with only 42.7% among African Americans. Overall, the odds ratio for undergoing the laparoscopic procedure during the four study years, after adjustment for important potentially confounding variables for blacks versus whites, was 0.74 (95% confidence interval, 0.66 to 0.83).

The NSQIP study found that laparoscopic cholecystectomy was performed in 27.7% of the total cases, with rates of 22.1% in African American patients and 28.6% in Caucasian patients. After adjustment of sociodemographic variables, preoperative laboratory values, and clinical characteristics that may have been potentially confounding variables, African-American patients were 0.68 times as likely as Caucasian patients to undergo laparoscopic versus open cholecystectomy (95% confidence interval, 0.55 to 0.84). Other factors associated with decreased use of laparoscopic procedure included older age, male gender, lower preoperative albumin levels, higher preoperative bilirubin, alkaline phosphatase or white blood cell counts, the presence of acute cholecystitis, partially dependent functional status, impaired sensorium, and a history of acute myocardial infarction.

Again using the Patient Treatment File, after adjustment for important clinical factors, region, and year of procedure, there were no significant differences found in the likelihood of operative death between African-American and Caucasian VA patients (adj. OR=1.33; 95% confidence interval=0.93 to 1.90). Patients who underwent open versus laparoscopic cholecystectomy were three times as likely to suffer in-hospital death (adj. OR 3.03; 95% confidence interval 2.11-4.34). The postoperative length of stay differed according to the type of operation, year of surgery and race. The mean postoperative length of stay of Caucasian patients who underwent laparoscopic cholecystectomy was 3.9 days in the first year and 3.3 days in the fourth year after introduction of the procedure. Among African-American patients, mean postoperative length of stay for the laparoscopic cholecystectomy patients was 7.7 days in the first year and 4.3 days in the fourth year.

The authors note that "learning curve" effects are important for surgeons to improve clinical outcomes of patients who undergo new procedures like laparoscopic cholecystectomy, including fewer surgical complications and shortened overall lengths of postoperative stay. In this study, the majority of the learning curve effects associated with shortened postoperative recovery times were observed in the first year of adoption of the laparoscopic procedure among Caucasian patients, but took an additional three years for African-American patients. "There does not appear to be any obvious biological reasons that racial variations should exist."

Conducting racial comparisons at VA centers is advantageous because the VA medical system provides for equal access, thus racial patterns are not confounded by economic factors that limit access to new technologies. Evaluating racial patterns in use of laproscopic cholecystectomy is particularly informative with regard to potential clinician bias in treatment decisions because, in contrast to studies of cardiac or cerebrovascular disease where treatment options are medical or surgical, treatment of clinically significant gallbladder disease represents a choice between two surgical procedures: an open cholecystectomy versus a minimally invasive laparoscopic procedure. Additionally, unlike specialized procedures that are limited to relatively few VA medical centers, cholecystectomies are performed at all VA medical centers that have operating room facilities. Finally, lower rates of adoption of laparoscopic cholecystectomy procedures are likely to be associated with meaningful differences in a clinically relevant outcome – average duration of postoperative hospitalization.

Possible explanations for the observed racial differences in this VA system study include "differences in the severity of gallbladder disease, differences in the presence or severity of coexistent diseases, cultural differences in attitudes toward new procedures or newer treatments in general, social support differences that might affect postoperative discharge plans, and differences in attitudes among health care providers." The authors added that, "the extent to which subtle or overt discrimination by health care providers underlies racial differences in the use of laparoscopic cholecystectomies and rate of improvement in outcomes is not known."