Trends in Adoption of Laparoscopic Cholecystectomy in Rural Versus Urban Hospitals

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Abstract
For many general surgeons, the professional isolation of rural practice serves as an obstacle to the adoption of new techniques. Whether this obstacle impeded the dissemination of laparoscopy in rural settings is not known. We performed a retrospective, descriptive comparison of the adoption rate of laparoscopic cholecystectomy in small rural versus urban hospitals in the US using the Nationwide Inpatient Sample from 1988 to 1997. Additionally, we examined differences in in-hospital mortality, length of hospital stay, and in-hospital reintervention rates. There were 4,985,465 cholecystectomies performed nationwide from 1988 to 1997. Over this time period, the proportion of procedures done laparoscopically increased from 2.5% to 76.6% for elective cholecystectomy and from 0.7% to 67.5% for urgent cholecystectomy. The proportion of elective procedures done laparoscopically increased sharply from 1989 to 1992, from 3.5% to 73.7%, and remained high in both rural and urban areas, with negligible difference in timing of adoption. Use of the laparoscopic approach for urgent cholecystectomy increased sharply from 1990 to 1992 (4.9% to 54.6%) and, since 1992, has increased similarly in both rural and urban areas. The adjusted in-hospital mortality rate for laparoscopic cholecystectomy did not differ significantly between rural and urban hospitals (0.47% and 0.57%, respectively, p=0.6). The in-hospital reintervention rate was 0.88% for both rural and urban hospitals (p=0.98). There were no significant differences in mortality or reintervention rates when cases were stratified by admission type (elective versus urgent). Most rural surgeons successfully overcame professional isolation in learning and adopting laparoscopic cholecystectomy.