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Study identifies socioeconomic and ethnic disparities for gallstone surgery

A new Stanford study has found that patients from disadvantaged socioeconomic and ethnic groups are less likely to receive a health-preserving type of gallbladder surgery.

Many physicians recommend a two-part therapy for gallstones, which are small, hard crystalline masses that can form in the gallbladder or the bile ducts. Most gallstones are harmless, but they can cause serious disease if they get stuck in the bile ducts — those thin vessels that connect the liver with the gallbladder and the small intestine.

"When the stone gets wedged into the bile duct and doesn’t pass through, many complications can occur including pancreatitis which can be life threatening," said Subhas Banerjee, MD, associate professor of medicine at Stanford and a gastroenterologist who treats gallstone disease. “This is serious stuff.”

It's also extremely painful, often causing cramping, inflammation and infection. Banerjee said the recommended treatment is for the physician to first remove the wedged-in stone from the bile duct, and then, in separate procedure a few days later, to remove the gallbladder to prevent recurrence of the disease.

In a study published this weekend in Gastroenterology, senior author Banerjee and other Stanford researchers, found that half of all patients with gallstone disease are not receiving this second part of the treatment, called a cholecystectomy (link to .pdf), in a timely manner — which leaves them at risk for future disease and complications that can be deadly.

This is a startling gap in health care, the researchers say, which can be attributed in part to racial and socioeconomic inequalities.

"We didn’t suspect it was such a large portion of the population that wasn’t getting this relatively straightforward surgery," says Robert Huang, MD, a postdoctoral scholar at Stanford and first author of the study. "We were surprised that only 50 percent of Americans (with gallstone disease) were receiving this surgery."

To conduct the study, researchers examined ambulatory, inpatient and emergency department databases of patients from the states of California, New York and Florida over a three-year period of time, then followed the outcomes of the 4,516 patients in the databases who had been hospitalized with a gallstones.

In addition to the low numbers of patients who underwent the gallbladder removal, results of the study showed that certain disadvantaged populations were at greater risk of not getting the necessary procedure.

In particular, Hispanics and Asians were less likely to undergo cholecystectomy after their first gallstone attack. Also, patients with Medicaid, or no insurance at all, were less likely to get the procedure compared to patients with private insurance, Huang said.

"It is a problem of poverty, access, and perhaps also a problem of communication and language," Huang said. "Some members of minority populations might not speak English well enough to understand directions for follow-up. For some, cultural norms might make them afraid of the health-care system or surgery."

The study also showed patients not undergoing cholecystectomy had a 10-fold higher risk of a recurrent gallstone attack, as well as a 16-fold higher risk of death from a recurrent gallstone attack compared to patients who underwent cholecystectomy.

"We hope the findings of this study will lead to more awareness by physicians and policymakers of this gap in health care and the disparities by socioeconomic levels and ethnicity," Huang said.

Previously: Study shows racial disparities in HPV vaccination, and Report shows continuing health disparities for racial and ethnic minorities
Photo by John Chew, Army Medicine

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