The Clinical and Cost Impact of Endoscopic Ultrasound On ERCP in a Tertiary Referral Center

Abstract

Aim: Endoscopic ultrasound (EUS) is a safe alternative to ERCP for diagnostic imaging of the common bile duct (CBD) for choledocholithiasis. Whether there has been a shift in the pattern of ERCP since the introduction of EUS in clinical practice is unknown. The purpose of this study is to assess the clinical and cost impact of a new EUS program on diagnostic ERCP at a tertiary referral center. Methods: This study represents a retrospective review of data collected during the first complete year of implementing EUS as new program at the University of Alberta Hospital (UAH), Edmonton (Capital Health region). Patients (pts) were initially referred for ERCP for suspicion of choledocholithiasis based on clinical, biochemical and radiologic parameters but were considered to have a low likelihood for therapeutic intervention and thus referred for EUS. ERCP was done if EUS suggested CBD stones and clinical follow up for 6 months if EUS was normal. Cost data reflect Alberta Health and Wellness reimbursements for cost of procedures, hospitalization and physician fees. Results: During the first year, 329 pts underwent EUS. Of these, 90 pts (63 female, mean age 58 years with range 17-90 years) had EUS for suspicion of CBD stones based on pain, elevated liver enzymes and/or unexplained CBD dilation on abdominal ultrasound. EUS suggested a CBD stones in 20/90 pts and this was confirmed on ERCP in 17/20 pts. EUS was normal in 69 pts of which none underwent subsequent ERCP during a 6 month follow-up. One pt was found to have pancreatic cancer on EUS. Overall sensitivity for EUS was 100% and specificity 96% for CBD stones. A total of 440 ERCPs were done during this year reflecting a 14% reduction in diagnostic ERCP at the UAH. There were no complications of EUS. The cost of 89 EUS (CDN$476 each) procedures was CDN$42,364 compared to CDN$103,538 for 69 ERCPs (CDN$1213 per procedure + CDN$1917/day for 3 days for cost of hospitalization related to 5% risk of pancreatitis). The total cost savings was CDN$61,174/yr for UAH. Extrapolating this to Capital Health region with ∼1,500 ERCP s /yr, the cost savings can amount to CDN$183,522/yr. Conclusion: EUS is an accurate, safe and cost-effective investigation for CBD imaging for suspected choledocholithiasis. Diagnostic ERCP should not be performed in centers that are equipped with EUS with physicians trained in accurate interpretation.