—We appreciate the comments of Foster et al and definitely agree with them that one should be careful not to generalize results when using a "relatively small convenience sample"; however, we do not think that a private practice— based HMO having 500 000 enrollees is a small sample. The national estimated rates reported in the 1991 NHDS were based on a medical record survey sample.1 In our study, we used a complete sample of US Healthcare's HMO enrollees in southeastern Pennsylvania.Although it is possible that the increase in the cholecystectomy rate might have been an isolated phenomenon related only to the population that we studied—as suggested by Foster et al—there is much evidence to suggest otherwise. Orlando et al2 documented a 29% increase in cholecystectomies in the state of Connecticut after the introduction of the laparoscopic approach. Drs Klar and Kongstvedt report a 52.4% increase
Legorreta AP, Costantino GN, Kobylinski RW, Zatz SL, Silber JH. Increased Cholecystectomy Rate After Introduction of Laparoscopic Cholecystectomy-Reply. JAMA. 1994;271(7):501. doi:10.1001/jama.1994.03510310030019
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