A Prospective Outcomes Study and Cost Analysis of Post-Procedure Radiologistʼs Interpretation of ERCP X-Ray Films

Abstract

Purpose: The aims of this study are to prospectively determine if post-ERCP x-ray film reading by radiologists alters clinical decision-making and to determine whether the current standard of care is a cost-efficient practice. Methods: A preliminary, prospective analysis of 145 patients undergoing ERCP over the course of 4 months was performed. A separate endoscopist (E), not involved in the patient's care, reviewed the radiologist's (R) report of the ERCP x-ray films to determine if there was either concordance or discordance with the procedural findings. The patients' clinical courses were prospectively followed to determine if clinical decision-making was affected by the R's interpretation of the x-ray films. Secondarily, a cost analysis was performed. Results: Of the 145 patients, there was an overall discordance between the E and R in 80 of the cases (55%). One patient underwent a laproscopic common bile duct exploration based on R's interpretation that was discordant to the E's, however, the abnormality reported by the R was not confirmed surgically. In two further cases, additionally imaging studies (liver MRI and abdominal CT scan) were ordered based upon R's readings which were discordant from the E's; again, the E's findings were validated by the further imaging. In the other 77 cases, no additional procedures, imaging, or laboratory tests were ordered. In total, 130 cholangiograms with 61 discordances (47%), and 72 pancreatograms with 27 discordances (38%) were evaluated. Radiologists were reimbursed $5,395 for interpretation of ERCP x-ray films, and over the course of a year, their reimbursement would be greater than $17,000. Extra testing based on discordant reports resulted in an additional $2,510 of reimbursement for 3 patients. Conclusions: The R's interpretation of ERCP films was inadequate, with a 47% discordance rate among cholangiograms and a 38% discordance rate among pancreatograms. The routine practice of post-procedure ERCP x-ray film interpretation by R altered clinical practice in only 3 of the 80 discordant cases; subsequent care did not confirm R's findings and imparted increased risk to the patients. This practice proved to be a misallocation of resources and should not be continued. Additional patient enrollment, multi-center involvement, and continued cost analysis are needed to verify these preliminary findings.