S110 Racial Differences in the Performance of Endoscopic Retrograde Cholangiopancreatography (ERCP) in Acute Cholangitis: A Nationwide Time Trend Analysis, 2008-2018

Abstract

Introduction: Black race was shown to have high mortality from acute cholangitis (AC) previously (1998-2009) and to undergo less endoscopic retrograde cholangiopancreatography (ERCP) (2009-2012). We conducted a longitudinal racial breakdown of ERCP performed in AC in the USA over 11 years (2008-2018). Methods: This is a retrospective longitudinal trend analysis using National Inpatient Sample. Adult patients (≥18 years old) with AC were identified. Multivariate linear or logistic regression was performed when appropriate. To control for the severity of AC, we also included severe sepsis, septic shock, systemic inflammatory response syndrome with acute organ dysfunction, acute renal failure, acute respiratory failure, thrombocytopenia, altered mental status, and abnormal coagulation in the regression model. Stata (v.14.2) was used to perform analyses considering a 2-sided P-value< 0.05 as statistically significant. Results: A total of 312,849 patients with AC were included in the analysis. Before 2015, the longitudinal trend for the overall total and early ERCPs performed in Whites and Hispanics was increasing (P< 0.01) (Table). The trend was stable in Asians but in Blacks, even though the trend for early ERCP was increasing (P< 0.01) but the overall ERCPs performed for AC remained the same (P=0.07). After 2015, the trends for both early and total ERCPs remained stable for all races (P >0.05). However, upon examining the proportion of early ERCPs among total ERCPs performed, Blacks represented the racial category with the lowest numbers (Figure). Even though the trend of proportions for all racial categories was increasing (P< 0.01) however, the rate of increase was lowest for Blacks (per year increase for Whites was 1.37%, Blacks 1.18%, Hispanics 1.47%, and 1.37 for Asians). Racial mortality comparison showed that compared to Whites, Blacks had the highest odds of mortality (for Blacks, adjusted odds ratio (aOR) 1.86, P< 0.01, Hispanics aOR 1.29, P< 0.01, Asians aOR 1.30, P=0.01). Conclusion: The modification in International Classification of Diseases (ICD) coding in 2015 resulted in an apparent sharp change in the proportion of ERCPs performed due to coding change. Even though the trend for the performance of early ERCP for AC is on the rise in all races, there still exists a racial disparity in the use of early ERCP. The black population was at risk of receiving lower rates of early ERCP (calculated as a fraction of total ERCP), which may impart higher mortality.Figure 1.: Trend for the proportion of early ERCP comparing to total ERCP (ERCP: endoscopic retrograde cholangiopancreatography, AC: acute cholangitis, %: percentage, ICD: International Classification of Diseases) Table 1. - Trends for early and total ERCP performance in acute cholangitis Year 2008 2010 2012 2014 P value a,b 2016 2018 P value a,b White Total ERCP, % 47.58 48.75 50.21 50.55 < 0.01 33.42 32.55 0.37 Early ERCP, % 24.43 25.60 28.38 29.01 < 0.01 18.89 18.90 0.99 Black Total ERCP, % 41.20 39.75 43.59 43.45 0.07 30.97 30.21 0.72 Early ERCP, % 17.34 18.09 22.58 21.93 < 0.01 13.96 14.72 0.66 Hispanic Total ERCP, % 53.87 53.85 56.36 58.14 < 0.01 35.61 35.51 0.96 Early ERCP, % 28.70 27.64 31.94 34.36 < 0.01 17.64 20.28 0.13 Asians Total ERCP, % 54.34 52.86 55.28 53.04 0.84 35.08 37.58 0.39 Early ERCP, % 31.69 27.32 33.45 33.18 0.31 17.16 22.33 0.27 ERCP: endoscopic retrograde cholangiopancreatography.aLinear P trend values.bTime-interrupted trends (before and after 2015) were obtained due to International Classification of Diseases (ICD) coding change from ICD-9 to ICD-10 in 2015.