Racial Disparity in Mortality of Hospitalized Patients with Acute Cholangitis: Differences in Disease vs Differences in Treatment?

Abstract

Introduction: Acute cholangitis is a serious and life threatening condition. There are significant differences in the outcome of treated patients, with worse outcome among African Americans. We sought to evaluate whether disparities in treatment received explained the observed worse outcome. Methods: We analyzed the 2001 to 2010 Nationwide Inpatient Sample database (NIS). Adult patients (aged>18years) with acute cholangitis were identified using International Classification of Disease 9th Revision, Clinical Modification (ICD9-CM) codes 576.1. Demographics, case-mix, disease, and hospital characteristics were retrieved. The rates and outcomes for patients who received Endoscopic Retrograde Cholangiopancreatography (ERCP) or percutaneous biliary drainage (PTBD) or who were managed medically without any procedure (No procedure) were compared across racial groups. We conducted bivariate analysis with chi-square and student t test. Multivariable logistic regression adjusting for patient demographics such as age, sex, income, hospital diagnosis, comorbidities, and hospital characteristics (bed size, hospital location, rural/urban, teaching vs non-teaching) was used to investigate the odds of mortality associated with different treatment across racial groups. Results: A total of 68,776 discharges with a diagnosis of acute cholangitis met inclusion criteria. Majority of patients were white (73.5%, n = 50,612), male (50.6%, n = 34,890), aged >60 years (65.8%, n = 45,281) insured (94.0%, n = 64,738), treated at teaching hospitals (51.7%, n = 34,448), in urban settings (91.0%, n = 62,432). Patients were predominantly managed medically, without any biliary drainage interventions (51.3%, n = 35,323). A total of 30,483(44.1%) received ERCP versus PTBD in 3,987 (5.8%). ERCP and PTBD were recorded concurrently in 1,178 (1.7%). Overall, African-Americans had the highest mortality rate 9.6% vs 5.1% (P < 0.001) compared with non-Hispanic whites. Compared with non-Hispanic whites, African-Americans were more likely not to receive any biliary drainage procedure (OR:1.32; 95%CI:1.22-1.44). When restricted to patients who underwent ERCP the increased mortality among African-Americans persisted (OR: 1.32; 95%CI: 1.02-1.71). Conclusion: African-Americans were less likely to receive the standard therapy when admitted for acute cholangitis but still had worse outcome when standard treatment was given. This suggests both treatment differences and disease differences.Table 1: Adjusted Odds of overall mortality by Race*