INTRODUCTION
Symptomatic cholelithiasis is a common surgical problem and yet there is no consensus on optimal timing for surgery for symptomatic patients who present to the emergency department (ED). Many patients require multiple gallstone-related ED visits while waiting for elective cholecystectomy. The Social Vulnerability Index (SVI) was developed by the Centers for Disease Control & Prevention to identify vulnerable populations after a natural disaster. Its use has been adapted in surgery to identify similar groups of at-risk patients. The purpose of this study is to assess the association between socially vulnerable patients and outpatient management of symptomatic cholelithiasis.

METHODS
We retrospectively identified all patients who presented to the ED with symptomatic cholelithiasis at our 51-hospital health system from 2016 to 2022. Clinical outcomes data was then merged with SVI census-track data, which comprises of 4 SVI subthemes (socioeconomic status, household composition & disability, minority status & language, and housing type & transportation) and an overall summarized risk. Patients in the 90^th percentile of SVI were identified within each subtheme. Multivariate analysis was used for statistical analysis.

RESULTS
A total of 46,682 patients presented to the ED with symptomatic cholelithiasis. The mean age was 48.5 years, body mass index was 31.7 kg/m², and 68.2% were female. Of these patients, 13,692 (29.3%) required urgent cholecystectomy and 9240 (19.8%) underwent elective cholecystectomy within 1 year of the index ED visit. The median time to elective cholecystectomy was 22 days. A subset of patients (n=2912, 6.2%) required multiple gallstone-related ED visits (range 1-11 visits) while waiting for elective surgery. Multivariate analysis identified Hispanic or Latino ethnicity (2.4 OR, 95% CI 2.25-2.75) to be associated with return ED visits. SVI subthemes of socioeconomic status (1.81 OR, 95% CI 1.55-2.10) and minority status & language (2.80 OR, 95% CI 2.40-3.27) and overall SVI (1.42 OR, 95% CI 1.24-1.63) were also associated with gallstone-related return ED visits.

CONCLUSION
Socially vulnerable patients are more likely to return to the ED with symptomatic cholelithiasis while waiting for elective cholecystectomy. Policies to help and support this vulnerable population in the outpatient setting with timely elective cholecystectomy can reduce delays in care and overutilization of scarce healthcare resources.

Richard Essner

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