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Objective: To compare the operative outcomes of early and delayed cholecystectomy for acute cholecystitis., Background: Randomized trials comparing early to delayed cholecystectomy for acute cholecystitis have limited contemporary external validity. Furthermore, no study to date has been large enough to assess the impact of timing of cholecystectomy on the frequency of serious rare complications including bile duct injury and death., Methods: This is a population-based retrospective cohort study of patients emergently admitted to hospital with acute cholecystitis and managed with cholecystectomy over the period of April 1, 2004, to March 31, 2011. We used administrative records for the province of Ontario, Canada. Patients were divided into 2 exposure groups: those who underwent cholecystectomy within 7 days of emergency department presentation on index admission (early cholecystectomy) and those whose cholecystectomy was delayed. The primary outcome was major bile duct injury requiring operative repair within 6 months of cholecystectomy. Secondary outcomes included major bile duct injury or death, 30-day postcholecystectomy mortality, completion of cholecystectomy with an open approach, conversion among laparoscopic cases, and total hospital length of stay. Propensity score methods were used to address confounding by indication., Results: From 22,202 patients, a well-balanced matched cohort of 14,220 patients was defined. Early cholecystectomy was associated with a lower risk of major bile duct injury [0.28% vs 0.53%, relative risk (RR)=0.53, 95% confidence interval [CI]: 0.31-0.90], of major bile duct injury or death (1.36% vs 1.88%, RR=0.72, 95% CI: 0.56-0.94), and, albeit non-significant, of 30-day mortality (0.46% vs 0.64%, RR=0.73, 95% CI: 0.47-1.15). Total hospital length of stay was shorter with early cholecystectomy (mean difference 1.9 days, 95% CI: 1.7-2.1). No significant differences were observed in terms, open cholecystectomy (15% vs 14%, RR=1.07, 95% CI: 0.99-1.16) or in conversion among laparoscopic cases (11% vs 10%, RR=1.02, 95% CI: 0.93-1.13)., Conclusions: These results support the benefit of early overdelayed cholecystectomy for patients with acute cholecystitis.

Objective: To explore whether a discrepancy between the availability of trauma services (potential access) and trauma center utilization rates (realized access) exists, with the aim of informing strategies to improve access., Background: Lack of access to trauma center care has frequently been attributed to the geographic distribution of trauma centers. Alternatively, impeded access to trauma center care might be due to suboptimal triage practices in the setting of appropriate resources., Methods: Population-based retrospective cohort study of severely injured adult patients (2002-2010). Potential access to trauma center care was evaluated using network-based spatial analysis of census data and was defined as residing within 1 hour of a trauma center. Realized access to trauma center care was evaluated using population-based data sources and was defined as direct transport from the scene of injury to a trauma center. Concordance between potential and realized access (high, moderate, or low) was evaluated at the county level., Results: Of the population in the study region, 7,340,711 persons (60%) had potential access to trauma center care; persons in 11 counties (22%) had high potential access. Of 26,861 severely injured patients, 10,237 (38%) had realized access to trauma center care; patients in only 4 counties (8%) had high realized access. The concordance between potential and realized access was moderate (weighted κ = 0.49); 63% of counties (n = 7) with high potential access performed worse than expected and had moderate or low realized access., Conclusions: There is limited concordance between potential and realized access. Regions with high potential access had low realized access, and vice versa. This evaluation suggests that strategies to improve access must be based on understanding the distribution of centers and the triage practices used to access trauma care.