Cholecystectomy (Gallbladder Removal) in California: A Close-Up of Geographic Variation

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1 (Gallbladder Removal) in California: A Close-Up of Geographic Variation C A LIFORNIA HEALTHCARE FOUNDATION Geographic Variation Series. This Close-Up is part of a comprehensive set of reports that examine the rates at which 13 elective procedures are delivered in different communities across the state. They include cardiac procedures, carotid endarterectomy, hip and knee replacement, mastectomy, hysterectomy, childbirth procedures, gallbladder surgery, and weight loss surgery. A research summary, All Over the Map: Elective Procedure Rates in California Vary Widely, provides additional background information on the topic of regional variation and a complete methodology for the study. 1 The data are from 2005 through 2009 and are based on patients place of residence. Rates can vary widely, even in contiguous communities. The data account for age, sex, income, education, insurance status, and race. Gallstones a r e pe b b l e-li k e g r o w t h s that range in size from a grain of sand to a golf ball. They are formed from cholesterol and substances in bile and are found in the gallbladder or bile duct. While some people never exhibit symptoms from gallstones, others experience pain, nausea, vomiting, or other symptoms that cause them to pursue treatment. The pain from gallstones is called biliary colic, which commonly manifests itself as a very severe, sudden cramping pain in the right upper part of the abdomen. Treatment choices for gallbladder attacks include: Watchful waiting Medical therapy with drugs that dissolve cholesterol, a major component of gallstones Lithotripsy, which uses sound waves to break up gallstones so they are small enough to pass through the bile duct to remove the gallbladder Most gallstones are detected as silent gallstones, meaning those that do not cause symptoms. Gallstones are sometimes found on imaging tests that are done for abdominal pain other than typical biliary colic. Patients with gallstones and no symptoms (or atypical symptoms) do not require immediate treatment; rather, they should be educated about the symptoms of gallstone disease and when to seek treatment if symptoms occur. People who suffer from gallstones that cause symptoms may want to consider treatment options. Patients choosing not to have surgery may try to prevent attacks by making lifestyle choices, such as staying close to a healthy weight and avoiding rapid weight loss. Some kinds of gallstones can be treated with drugs to dissolve the cholesterol. Alternatively, gallstones can sometimes be broken up using shock wave lithotripsy, which involves a powerful beam of sound. While lithotripsy is generally considered to be a safe procedure, risks include bleeding around the kidney, ulcers in the stomach or small intestine, and kidney infection. Finally, the gallbladder can be surgically removed (cholecystectomy) to prevent future attacks. In rare cases, a stone blocks the bile duct completely, and surgery must be performed immediately to prevent injury to the pancreas., or surgical removal of the gallbladder, can be performed through open surgery or a laparoscopic operation. Sometimes gallstones are also removed from the common bile duct. If the surgery is done laparoscopically, recovery can take seven to ten days. Risks from close-up Sep t e m b e r 2011

2 laparoscopic surgery are very low, but the most serious are infection, bleeding, injury to the common bile duct or small intestine, and risks associated with general anesthesia. If cholecystectomy is done via open surgery, recovery can take four to six weeks. Risks from open surgery are similar to those for laparoscopic surgery, but include injury to the liver or major blood vessels, and blood clots or pneumonia during the longer recovery. 2 Patients in several California communities (hospital service areas or HSAs) undergo cholecystectomy (gallbladder removal) at rates notably higher or lower than the state rate. 3 See Figure 1. Residents under 65 of three of eight Napa HSAs undergo cholecystectomy at more than one and a half times the state rate. See Figure 2 on the following page. Figure 1. Geographic Variation in, California, Note: This is a static representation of a portion of the data that can be seen on an interactive map at: data variation analyses Residents of Oroville HSA (Chico HRR) are at least three and a half times as likely to undergo cholecystectomy as residents of Laguna Hills HSA (Orange HRR). Residents of Marysville HSA (Sacramento HRR) are at least two and a half times as likely to undergo cholecystectomy as residents of South Lake Tahoe HSA (Sacramento HRR). Residents of Ridgecrest HSA (San Bernardino HRR) are at least twice as likely to undergo cholecystectomy as residents of Santa Monica HSA (Los Angeles HRR). Residents of Willits HSA (Napa HRR) are at least twice as likely to undergo cholecystectomy as residents of Oakland HSA (Alameda HRR). Residents of Hanford HSA (Fresno HRR) are at least one and a half times as likely to undergo cholecystectomy as residents of Santa Barbara HSA (Santa Barbara HRR). DEFINITIONS: Hospital service areas (HSAs) represent a local health care market for community-based inpatient care. HSAs can include more than one community. Hospital referral regions (HRRs) represent a health care market for tertiary medical care. (A tertiary designation is based on where patients receive major cardiovascular surgical procedures and neurosurgery.) Each HRR includes at least one HSA that has a hospital or hospitals that perform major cardiovascular procedures or neurosurgery. 2 California HealthCare Foundation

3 Note regarding Figures 2 and 3: The narrow vertical line at the top of each bar displays the range of the confidence intervals. Figure 2., Napa HSAs Compared to State Rate, by Patient s Age Group, COMPARED TO STATE RATE Under and older All Clearlake Deer Park Fort Bragg Garberville Lakeport Napa Ukiah Willits Residents of Ridgecrest HSA (San Bernardino HRR) undergo cholecystectomy at more than one and a half times the state rate. See Figure 3. Figure 3., San Bernardino HSAs Compared to State Rate, by Patient s Age Group, COMPARED TO STATE RATE Under and older All Apple Valley Banning Barstow Big Bear Lake Chino Fontana Hemet Loma Linda Redlands Ridgecrest Riverside San Bernardino Sun City Upland Victorville (Gallbladder Removal) in California: A Close-Up of Geographic Variation 3

4 Note: Each dot in this graph represents the rate for a procedure in a single California HSA. Dots at the top and bottom of the graphs represent the extremes in rates. The narrower the graph, the greater the variation in rates across HSAs. Figure 4., by HSA, Highest Rates Rate per 100,000 Oroville (Chico HRR) 649 Ridgecrest (San Bernardino HRR) 534 Willits (Napa HRR) 530 Marysville (Sacramento HRR) 528 Paradise (Chico HRR) 493 State Rate Oroville California HealthCare Foundation

5 Table 1. Rates of in California Hospital Service Areas (HSAs), HOW TO USE THIS TABLE: In the Marysville HSA, residents undergo cholecystectomy at least 164% of the state rate (and at most 186%). That means they are at least one and a half times as likely as the average Californian to undergo the procedure. Notes: An HSA includes both the city for which it is named as well as surrounding areas. Confidence intervals describe a range and are listed in parentheses. For example, 57% 70% indicates that, with 95% confidence, the range of possible values spans from 57% to 70% of the state rate. Blank cells indicate insufficient data. Legend At least twice the state rate At least one and a half times the state rate California 100% Alameda 79% (72% 87%) Anaheim 98% (96% 101%) Antioch 99% (95% 104%) Apple Valley 101% (95% 107%) Arcadia 90% (86% 94%) Arcata 151% (137% 166%) Arroyo Grande 97% (89% 105%) Auburn 84% (78% 90%) Avalon 53% (35% 81%) Bakersfield 126% (123% 129%) Banning 118% (110% 126%) Barstow 85% (78% 94%) Bellflower 102% (97% 108%) Berkeley 79% (73% 85%) Big Bear Lake 89% (80% 100%) Brawley 115% (106% 125%) Burbank 86% (83% 89%) Burlingame 92% (86% 98%) Camarillo 117% (110% 125%) Canoga Park 101% (97% 105%) Carmichael 96% (93% 100%) Castro Valley 91% (86% 97%) Chester 86% (69% 108%) Chico 125% (119% 132%) Chino 80% (76% 85%) Chula Vista 96% (93% 100%) Clearlake 158% (143% 175%) Coalinga 121% (107% 137%) Colusa 119% (104% 135%) Concord 103% (98% 108%) Corcoran 146% (129% 164%) Corona 81% (77% 84%) Coronado 74% (62% 89%) Covina 93% (88% 98%) Culver City 73% (66% 81%) Daly City 92% (87% 97%) Davis 101% (94% 109%) Deer Park 78% (69% 87%) Delano 116% (109% 124%) Dinuba 122% (111% 134%) Downey 86% (83% 89%) Duarte 101% (90% 112%) El Centro 110% (104% 117%) Encinitas 70% (65% 75%) Encino 99% (83% 118%) Escondido 82% (79% 86%) Eureka 140% (130% 151%) Fairfield 81% (76% 87%) Fall River Mills 123% (103% 145%) Fallbrook 88% (80% 97%) Folsom 113% (104% 122%) Fontana 93% (89% 98%) Fort Bragg 119% (105% 136%) Fortuna 141% (127% 156%) Fountain Valley 96% (92% 100%) Fremont 85% (82% 89%) Fresno 121% (118% 124%) Fullerton 98% (95% 102%) Garberville 132% (104% 167%) Garden Grove 90% (85% 95%) Gardena 72% (66% 80%) Gilroy 85% (79% 92%) Glendale 85% (82% 87%) Glendora 86% (81% 91%) Granada Hills 92% (85% 100%) (Gallbladder Removal) in California: A Close-Up of Geographic Variation 5

6 Grass Valley 107% (99% 115%) Greenbrae 94% (89% 99%) Greenville 76% (48% 122%) Gridley 150% (132% 171%) Hanford 145% (139% 152%) Harbor City 95% (91% 99%) Hawthorne 81% (75% 86%) Hayward 97% (92% 102%) Healdsburg 111% (100% 123%) Hemet 88% (84% 92%) Hollister 100% (93% 108%) Huntington Beach 96% (91% 101%) Indio 93% (89% 98%) Inglewood 69% (65% 72%) Irvine 94% (88% 101%) Jackson 113% (103% 123%) Joshua Tree 93% (86% 100%) King City 118% (103% 135%) La Jolla 83% (78% 89%) La Mesa 100% (97% 103%) Laguna Hills 54% (51% 57%) Lake Isabella 147% (129% 168%) Lakeport 156% (143% 169%) Lakewood 77% (70% 86%) Lancaster 103% (100% 107%) Lindsay 98% (87% 109%) Livermore 77% (71% 83%) Lodi 103% (98% 108%) Loma Linda 86% (81% 91%) Lompoc 107% (99% 116%) Long Beach 87% (84% 89%) Los Alamitos 92% (87% 98%) Los Angeles 78% (76% 80%) Los Banos 115% (105% 125%) Lynwood 95% (91% 98%) Madera 116% (109% 124%) Manteca 129% (122% 136%) Martinez 100% (92% 108%) Marysville 175% (164% 186%) Merced 118% (113% 123%) Mission Hills 89% (85% 94%) Mission Viejo 69% (66% 73%) Modesto 136% (133% 140%) Montebello 83% (79% 87%) Monterey 93% (88% 99%) Monterey Park 70% (63% 76%) Morgan Hill 87% (79% 95%) Mount Shasta 138% (122% 155%) Mountain View 96% (92% 101%) Napa 114% (108% 121%) National City 103% (96% 111%) Newport Beach 86% (82% 89%) Northridge 107% (102% 112%) Norwalk 100% (94% 105%) Novato 103% (94% 111%) Oakdale 141% (128% 154%) Oakland 75% (72% 78%) Oceanside 74% (71% 76%) Ojai 74% (64% 85%) Orange 91% (87% 96%) Oroville 215% (201% 229%) Oxnard 92% (87% 96%) Palm Springs 98% (93% 104%) Panorama City 95% (91% 99%) Paradise 163% (152% 176%) Paramount 92% (85% 99%) Pasadena 94% (89% 98%) Petaluma 106% (99% 114%) Pinole 80% (75% 87%) Pittsburg 109% (102% 115%) Placerville 98% (92% 104%) Pleasanton 104% (98% 111%) Pomona 104% (100% 108%) Porterville 101% (95% 108%) Poway 86% (81% 91%) Rancho Mirage 99% (95% 104%) Red Bluff 152% (140% 166%) Redding 130% (124% 136%) 6 California HealthCare Foundation

7 Redlands 100% (95% 105%) Redwood City 94% (89% 99%) Ridgecrest 177% (161% 193%) Riverside 82% (80% 84%) Roseville 121% (116% 126%) Sacramento 106% (103% 108%) Salinas 107% (102% 112%) San Andreas 96% (87% 105%) San Bernardino 98% (95% 101%) San Clemente 84% (78% 92%) San Diego 81% (79% 83%) San Dimas 95% (86% 105%) San Francisco 80% (78% 83%) San Gabriel 74% (70% 78%) San Jose 105% (103% 108%) San Leandro 87% (82% 93%) San Luis Obispo 76% (71% 82%) San Mateo 95% (90% 101%) San Pablo 77% (72% 81%) San Pedro 89% (83% 95%) San Ramon 79% (71% 87%) Santa Ana 91% (88% 94%) Santa Barbara 77% (73% 81%) Santa Cruz 83% (79% 88%) Santa Maria 126% (120% 132%) Santa Monica 68% (64% 71%) Santa Paula 88% (81% 95%) Santa Rosa 102% (98% 106%) Sebastopol 83% (73% 93%) Selma 111% (103% 120%) Simi Valley 97% (92% 103%) Solvang 75% (65% 86%) Sonoma 92% (83% 102%) Sonora 133% (125% 142%) South El Monte 81% (74% 89%) South Laguna 66% (62% 71%) South San Francisco 105% (98% 113%) Stanford 98% (92% 105%) Stockton 120% (117% 124%) Sun City 86% (80% 91%) Tarzana 97% (90% 106%) Templeton 89% (83% 95%) Thousand Oaks 105% (99% 111%) Torrance 86% (83% 89%) Tracy 104% (97% 112%) Tulare 136% (128% 144%) Turlock 145% (138% 152%) Ukiah 150% (138% 162%) Upland 95% (92% 98%) Vacaville 89% (83% 95%) Valencia 79% (76% 83%) Vallejo 92% (87% 97%) Van Nuys 87% (84% 91%) Ventura 91% (86% 97%) Victorville 84% (80% 87%) Visalia 129% (124% 135%) Walnut Creek 102% (97% 106%) Watsonville 103% (96% 112%) Weaverville 146% (118% 182%) West Covina 93% (90% 97%) Whittier 95% (91% 98%) Wildomar/Murrieta 78% (74% 81%) Willits 175% (157% 196%) Woodland 122% (114% 129%) Yuba City 144% (136% 153%) (Gallbladder Removal) in California: A Close-Up of Geographic Variation 7

8 P r o c e d u r e s Ch o s e n f o r t h e St u d y Procedures studied were based on patient discharge data for cholecystectomy. This analysis controlled for age, sex, race, education, income, and insurance status. A u t h o r s Vanessa Hurley, MPH, policy analyst, and Shannon Brownlee, MS, acting director, New America Foundation Health Policy Program A b o u t t h e Fo u n d a t i o n The California HealthCare Foundation works as a catalyst to fulfill the promise of better health care for all Californians. We support ideas and innovations that improve quality, increase efficiency, and lower the costs of care. For more information, visit us online at E n d n o t e s 1. The research for this report was developed by Laurence Baker, PhD, of Stanford University, in collaboration with Maryann O Sullivan, JD, and the staff and leadership of the Campaign for Effective Patient Care. Analysis and interpretation of the estimates were performed by Frances Tompkins, former project assistant, and O Sullivan, former executive director, of the Campaign for Effective Patient Care, in consultation with Shannon Brownlee, MS, acting director of the New America Foundation Health Policy Program. Lance Lang, MD, chaired an advisory committee of clinicians in various specialties, which was also consulted in the production of this report to review the analysis and to ensure the accuracy of medical content. For a complete list of advisory committee members, see the research summary All Over the Map: Elective Procedure Rates in California Vary Widely, Data were obtained from the Office of Statewide Health Planning and Development. 2. This section was written using the following sources: Shannon Brownlee et al., Improving Patient Decision- Making in Health Care: A 2011 Dartmouth Atlas Report Highlighting Minnesota (Lebanon, NH: Dartmouth Atlas Project, 2011). Gallstones: Should I Have Gallbladder Surgery?, Kaiser Permanente, accessed February 8, 2011, members.kaiserpermanente.org. Lithotripsy, MedLinePlus, 3. State averages should not be taken as the correct or right rate for elective procedures; they are used only as the comparator for analysis, not as a benchmark. There is no recommended baseline for elective procedures. 8 California HealthCare Foundation