Utilization Of Endoscopic Retrograde Cholangiopancreatography Research Articles

Availability and utilization of endoscopic retrograde cholangiopancreatography at children's hospitals.

No study has explored whether availability of endoscopic retrograde cholangiopancreatography (ERCP) is adequate and equitable across US children's hospitals. We hypothesized that ERCP availability and utilization differs by geography and patient factors. Healthcare encounter data from 2009 to 2019 on children with pancreatic and biliary diseases from the Pediatric Health Information System were analyzed. ERCP availability was defined as treatment at a hospital that performed pediatric ERCP during the year of service. From 2009 to 2019, 37,946 children (88,420 encounters) had a potential pancreatic or biliary indication for ERCP; 7066 ERCPs were performed. The commonest pancreatic diagnoses leading to ERCP were chronic (47.2%) and acute pancreatitis (43.2%); biliary diagnoses were calculus (68.3%) and obstruction (14.8%). No ERCP was available for 25.0% of pancreatic encounters and 8.1% of biliary encounters. In multivariable analysis, children with public insurance, rural residence, or of Black race were less likely to have pancreatic ERCP availability; those with rural residence or Asian race were less likely to have biliary ERCP availability. Black children or those with public insurance were less likely to undergo pancreatic ERCP where available. Among encounters for calculus or obstruction, those of Black race or admitted to hospitals in the West were less likely to undergo ERCP when available. One-in-four children with pancreatic disorders and one-in-12 with biliary disorders may have limited access to ERCP. We identified racial and geographic disparities in availability and utilization of ERCP. Further studies are needed to understand these differences to ensure equitable care.

Systematic Appraisal of Guidelines for the Diagnosis and Treatment of Choledocholithiasis.

To systematically evaluate the methodological quality of the current up-to-date guidelines pertaining to choledocholithiasis, we conducted a comprehensive analysis of key recommendations and corresponding evidence, focusing on the heterogeneity among these guidelines. Systematic searches across various databases were performed to identify the latest guidelines. The identified guidelines, which met the inclusion criteria, underwent evaluation using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. The key recommendations and evidence from the included guidelines were extracted and reclassified using the Oxford Centre for Evidence-Based Medicine (OCEBM) grading system, and the obtained results were analyzed. Nine guidelines related to choledocholithiasis were included in this study, out of which 4 achieved an overall standardized score of more than 60%, indicating their suitability for recommendation. Upon closer examination of the main recommendations within these guidelines, we discovered significant discrepancies concerning the utilization of similar treatment techniques for different diseases or different treatment methods under comparable conditions, and discrepancies in the recommended treatment duration. High-quality research evidence was lacking, and some recommendations either failed to provide supporting evidence or cited inappropriate and low-level evidence. The quality of guidelines pertaining to choledocholithiasis is uneven. Recommendations for the treatment of choledocholithiasis demonstrate considerable disparities among the guidelines, particularly regarding the utilization of endoscopic retrograde cholangiopancreatography as a treatment method and the management approaches for difficult stone cases. Improvements by guideline developers for these factors contributing to the heterogeneity would be a reasonable approach to further update the guidelines for cholangiolithiasis.

Primary sclerosing cholangitis hospitalizations in the United States: characteristics and predictors of clinical outcomes

Background Primary sclerosing cholangitis (PSC) is a chronic progressive disease that primarily affects the medium and large biliary ducts. Methods This study investigated the baseline characteristics and predictors of clinical outcomes among hospitalized patients with PSC in the US. Using the National Inpatient Sample database from 2018 to 2020, we included adults with a principal diagnosis of PSC. Results Our study included 2585 adult hospitalizations. The prevalence of cirrhosis, ulcerative colitis (UC), Crohn’s disease (CD), and cholangiocarcinoma among hospitalized PSC patients was 44.5%, 32.3%, 13.15%, and 5.2%, respectively. Over a third of patients (38.1%) underwent endoscopic retrograde cholangiopancreatography (ERCP). UC, CD, cholangiocarcinoma, and autoimmune hepatitis had no impact on mortality, length of stay, or ERCP utilization. Interestingly, individuals of Asian/Pacific Islander ethnicity had higher odds of undergoing ERCP compared to White ethnicity (odds ratio 4.67, 95% confidence interval 1.25–17.4). Conversely, patients with cirrhosis and liver transplant recipients were less likely to undergo ERCP. Conclusion This is the first nationwide study to assess the clinical characteristics and outcomes of hospitalized patients with PSC. It highlights various factors associated with increased utilization of ERCP, longer length of stay, and increased inpatient mortality. Further research is warranted to explore these associations.

S1070 Outcomes and Trends of Endoscopic Retrograde Cholangio-Pancreatography in Bariatric Surgery Patients - A National Inpatient Sample (NIS) Study

Introduction: Bariatric surgery (BS) is a widely used modality of treatment in patients with morbid obesity. The lifetime risk of these patients needing Endoscopic Retrograde Cholangio-Pancreatography (ERCP) has increased. ERCP in this population is time-consuming and technically challenging due to altered anatomy. Despite several techniques, there are complications associated with each type of ERCP. Our aim was to assess trends and outcomes of ERCP in BS patients. Methods: We utilized the Nationwide Inpatient Sample (NIS) database from 2007 to 2018. We identified adult hospitalized patients who underwent ERCP using CPT procedure codes. These were divided based on the presence of bariatric surgery (BS) status and nonbariatric surgery (NBS). All procedures were captured using previously validated CPT codes, comorbidities were captured using previously validated ICD 9 and 10 codes. Univariate and multivariate logistic regression for categorical variables and linear regression for continuous variables was carried out to identify independent associations at p < 0.05. Statistical Analysis was performed using R studio. Results: Total 2,178,983 patients had ERCP between 2007 and 2018, from which 36,713 (1.7%) were performed in BS patients. Among the patients who received ERCP, 68% were females, 72% were Caucasians (Table). Rates of ERCP in BS patients increased from 1,593 (4.3%) in 2007 to 5075 (14%) in 2018 (p < 0.01). Total charges associated with BS was $76,902 vs $55,252 (p< 0.001). ERCP for Cholecdocholithiaisis (2.1% vs 1.4%) was more common in BS patients. On univariate analysis, bleeding, intra-abdominal infections, bile duct perforation, and inpatient mortality were statistically significant amongst BS patients as compared to NBS patients. On multivariate analysis, BS patients had higher risk of death (aOR: 1.38, 1.18-1.63) and bleeding complications (aOR: 1.73, 1.44-2.07) as compared to NBS patients. While acute pancreatitis was significantly higher in NBS patients as compared to BS patients. Acute cholangitis was comparable in BS and NBS patients (Table 2). Conclusion: The utilization of ERCP has been increasing over the last decade. The BS group had younger females and had higher utilization of health care resources. BS group despite being younger had a higher mortality rate and had more bleeding complications as compared to NBS. ERCP should be performed with caution in patients with BS to avoid mortality and worse inpatient outcomes. Table 1. - Demographics, indications of bariatric and nonbariatric surgery patients Non Bariatric Surgery Group (n = 2,142,270) Bariatric Surgery Group (n= 36,713) p-value AGE 62 (46, 76) 57 (44, 67) < 0.001 AGE GROUP < 0.001 18-27 116,840 (5.5%) 425 (1.2%) 28-37 343,200 (16%) 2,262 (6.2%) 38-47 391,922 (18%) 5,754 (16%) 48-57 387,558 (18%) 8,811 (24%) 58-67 313,532 (15%) 8,042 (22%) 68-77 216,827 (10%) 6,094 (17%) 78-87 197,928 (9.2%) 4,015 (11%) 88 and above 174,463 (8.1%) 1,311 (3.6%) GENDER < 0.001 Male 879,110 (41%) 11,618 (32%) Female 1,262,064 (59%) 25,080 (68%) Unknown 1,097 (< 0.1%) 15 (< 0.1%) RACE < 0.001 White 1,326,854 (68%) 24,424 (72%) African American 178,702 (9.1%) 3,558 (10%) Hispanic 305,630 (16%) 4,081 (12%) Asian/Pacific Islander 72,335 (3.7%) 852 (2.5%) Native American 13,664 (0.7%) 153 (0.4%) Other 66,140 (3.4%) 1,016 (3.0%) Unknown 178,946 (8.4%) 2,628 (7.2%) LENGTH OF STAY (Days) 4.0 (3.0, 7.0) 6.0 (3.0, 12.0) < 0.001 YEAR < 0.001 2007 157,405 (7.3%) 1,593 (4.3%) 2008 172,320 (8.0%) 1,829 (5.0%) 2009 170,895 (8.0%) 2,135 (5.8%) 2010 176,302 (8.2%) 2,661 (7.2%) 2011 179,012 (8.4%) 2,440 (6.6%) 2012 168,425 (7.9%) 2,500 (6.8%) 2013 167,540 (7.8%) 2,540 (6.9%) 2014 168,515 (7.9%) 3,145 (8.6%) 2015 174,610 (8.2%) 3,440 (9.4%) 2016 200,030 (9.3%) 4,595 (13%) 2017 201,935 (9.4%) 4,760 (13%) 2018 205,280 (9.6%) 5,075 (14%) OBESITY 309,544 (14%) 11,259 (31%) < 0.001 TOTAL CHARGES ($) $55,252 (34,801, 87,258) $76,902 (46,432, 139,565) < 0.001 INDICATIONS FOR ERCP Acute Pancreatitis 14,015 (0.7%) 255 (0.7%) 0.7 Acute Cholangitis 124,546 (5.8%) 1,498 (4.1%) < 0.001 Choledocholithiasis 30,785 (1.4%) 765 (2.1%) < 0.001 Pancreatic Cancer 25,946 (1.2%) 460 (1.3%) 0.7 Hilar Cholangiocarcinoma 20,022 (0.9%) 278 (0.8%) 0.12 Table 2: - Multivariate Logistic Regression of ERCP Complications and Inpatient Mortality Adjusted Odds Ratio 95% CI p-value Inpatient Mortality 1.75 1.49-2.07 < 0.01 Acute Pancreatitis 0.36 0.15-0.86 0.02 Acute Cholangitis 1 0.92-1.11 0.84 Bleeding 2.05 1.71-2.45 < 0.01 Cholecystitis 1.18 0.79-1.77 0.42 Intraabdominal Infections 4.12 3.33-5.11 < 0.01 Bile Duct Perforation 3.77 3.07-4.63 < 0.01

S1080 Utilization of Endoscopic Retrograde Cholangiopancreatography (ERCP) in a Nationwide Cohort of Patients Admitted With Acute Biliary Pancreatitis With Cholangitis

Introduction: Acute pancreatitis (AP) is the most common gastrointestinal cause of hospital admissions in the United States, with biliary pancreatitis being the most common cause of acute pancreatitis. Acute Cholangitis is a bacterial infection of the biliary system and is most commonly caused by a complete or partial obstruction of the biliary tree by gall stones. One of the most important prognostic factors for acute cholangitis is the timing of biliary drainage. ACG guidelines for acute pancreatitis recommend that patients with AP and concurrent acute cholangitis should undergo ERCP within 24 h of admission. We aimed to estimate the impact of ERCP on hospitalization outcomes in this patient population. Methods: We collected data from the Healthcare Cost and Utilization Project- (HCUP) Nationwide Readmission Database- 2018. Patients admitted with acute biliary pancreatitis with concurrent cholangitis were identified and discharge weights were applied. Median and IQR were used to describe Continuous variables, and proportions were used with categorical variables. Comparison between groups was performed by Mann Whitney test for continuous variables and the Chi-Square test for Categorical variables. Results: We identified 3,981 index hospitalizations with acute biliary pancreatitis with cholangitis, 71.4% of whom received ERCP. Patient received ERCP had significantly lower mortality (3.3% vs. 7.1%, P< 0.001) compared to those who didn’t but performing ERCP was associated with increased length of stays (6; IQR: 4-9 vs. 5; IQR: 3-8 P< 0.001) and higher total costs of hospitalization ($68,904; IQR: $44,876 -$109,459 vs. $50,667; IQR: $28,694- $101,917, P< 0.001). Only 65.2% of ERCPs were performed within 24 hours of admission. Those who received ERCP within 24 hours had decreased LOS (5; IQR: 3-8 vs. 7; IQR: 5-11, P < 0.001), lower hospitalization costs ($63,263; IQR: $41,180-$102,942 vs. $76,958; IQR: $48,808-$128,660, P< 0.001) and lower 90-day readmission rates (15.1% vs. 19.9%, P= 0.006) compared to those who received ERCP after 24 hours of admission. (Table) Conclusion: Performing ERCP was associated with lower inpatient mortality in patients admitted with acute biliary pancreatitis with cholangitis and performing the ERCP within 24 hours of admission was associated with decreased length of stays, hospitalization costs, and 90-day readmission rates. Our study supports ACG guidelines and urges clinicians to adhere to the recommendations to improve outcomes. Table 1. - Demographic and clinical characteristics of patients with biliary pancreatitis with cholangitis ERCP performed NoN= 1,137 YesN= 2,844 P-value Median Age (IQR) 71 (59- 81) 72 (61-81) 0.452 Sex (%) Male 544 (47.8) 1,453 (51.1) 0.064 Female 593 (52.2) 1391 (48.9) Hypertension (%) 471 (41.4) 1,357 (47.7) < 0.001 Diabetes mellitus (%) 356 (31.3) 927 (32.6) 0.433 Dyslipidemia (%) 466 (41) 1,311 (46.1) 0.004 Obesity (%) 270 (23.7) 640 (22.5) 0.399 COPD (%) 134 (11.8) 288 (10.1) 0.124 Acute kidney failure (%) 342 (30.1) 865 (30.4) 0.835 CKD (%) 188 (16.5) 546 (19.2) 0.051 Heart failure (%) 225 (19.8) 424 (14.9) < 0.001 Cirrhosis (%) 33 (2.9) 115 (4) 0.086 ICU admission (%) 20 (1.8) 36 (1.3) 0.232 Bed size of the hospital (%) Small 195 (17.2) 319 (11.2) < 0.001 Medium 357 (31.4) 764 (26.9) Large 585 (51.5) 1,761 (61.9) Insurance (%) Medicare 711 (62.5) 1901 (66.8) 0.002 Medicaid 91 (8) 243 (8.5) Private insurance 267 (23.5) 558 (19.6) Self-pay 30 (2.6) 85 (3) Other 8 (0.7) 4 (0.1) No charge 30 (2.6) 54 (1.9) 90-day readmission (%) 155 (18.7) 359 (16.9) 0.261

Racial disparities in endoscopic retrograde cholangiopancreatography (ERCP) utilization in the United States: are we getting better?

We identified trends of inpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in the United States (US), focusing on outcomes related to specific patient demographics. The National Inpatient Sample was utilized to identify all adult inpatient ERCP in the US between 2007-2018. Trends of utilization and adverse outcomes were highlighted. P-values ≤ 0.05 were considered statistically significant. We noted a rising trend for total inpatient ERCP in the US from 126,921 in 2007 to 165,555 in 2018 (p = 0.0004), with a significant increase in utilization for Blacks, Hispanics, and Asians. Despite an increasing comorbidity burden [Charlson Comorbidity Index (CCI) score ≥ 2], the overall inpatient mortality declined from 1.56% [2007] to 1.46% [2018] without a statistically significant trend (p = 0.14). Moreover, there was a rising trend of inpatient mortality for Black and Hispanic populations, while a decline was noted for Asians. After a comparative analysis, we noted higher rates of inpatient mortality for Blacks (2.4% vs 1.82%, p = 0.0112) and Hispanics (1.17% vs 0.83%, p = 0.0052) at urban teaching hospitals between July toand September compared to the October to June study period; however, we did not find a statistically significant difference for the Asian cohort (1.9% vs 2.10%, p = 0.56). The mean length of stay (LOS) decreased from 7days in 2007 to 6days in 2018 (p < 0.0001), while the mean total hospital charge (THC) increased from $48,883 in 2007 to $85,909 in 2018 (p < 0.0001) for inpatient ERCPs. Compared to the 2015-2018 study period, we noted higher rates of post-ERCP pancreatitis (27.76% vs 17.25%, p < 0.0001) from 2007-2014. Therapeutic ERCP utilization and inpatient mortality were on the rise for a subset of the American minority population, including Black and Hispanics.

Trend and Predictors of the Utilization of Endoscopic Retrograde Cholangiopancreatography in Acute Pancreatitis Hospitalizations.

BackgroundAcute pancreatitis is a sudden inflammation of the pancreas, and biliary pancreatitis remains the most common cause of acute pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) is both a diagnostic and therapeutic invasive procedure to evaluate and treat pancreaticobiliary system diseases. ERCP is very commonly used in acute pancreatitis with coexisting acute cholangitis or biliary obstruction. There was a need for a nationwide study to evaluate ERCP utilization trends and health-care costs among acute pancreatitis patients.AimWe sought to determine the prevalence trend, hospitalization cost and stay, and predictors of utilization of ERCP amongst patients with acute pancreatitis.MethodsWe performed a population-based retrospective analysis of national data in adult acute pancreatitis hospitalizations. We evaluated the characteristics of the ERCP cohort, prevalence trend, and hospital utilization cost and stay using univariate analysis. Multivariable survey logistic regression analysis was performed to evaluate predictors of utilization for ERCP among acute pancreatitis hospitalization.ResultsAmong 2,632,309 hospitalizations for acute pancreatitis, 49108 (1.87%) had ERCP. The prevalence trend of ERCP declined from 3.88% in 2003 to 0.97% in 2014.(pTrend<0.0001). Patients with ERCP were older (>55-years old) (53.01% vs 39.36%;p<0.0001), female (58.45% vs 48.04%; p<0.0001), Hispanic (16.30% vs 12.86%; p<0.0001), utilizing Medicare (40.29% vs 31.88%; p<0.0001), elective admission (8.15% vs 4.98%; p<0.0001), and with gallbladder etiology (65.98% vs 26.06%; p<0.0001). Acute pancreatitis hospitalization with ERCP had a higher cost of utilization (Costdiff:+$25077;p<0.0001) and mean stay (LOSdiff:+3.5 days; p<0.0001). In regression analysis, old adults [Odds ratio(OR):1.087; Confidence interval (CI):1.008-1.173), Hispanic (OR:1.086; CI:1.019-1.156), asian (OR:1.146; CI:1.007-1.304), female (OR:1.074; CI:1.028-1.122), elective admission (OR:1.649; CI:1.524-1.785), gallbladder etiology (OR:4.437; CI:4.224-4.662), concurrent chronic pancreatitis (OR:1.643; CI:1.536-1.757), systemic inflammatory response syndrome (SIRS) (OR:1.264; CI:1.112-1.436), pleural effusion (OR:1.874; CI:1.231-2.854), and portal vein thrombosis (OR:1.646; CI:1.221-2.219).ConclusionIn nationwide data, we have found a decreased utilization trend and higher hospital utilization cost and stay associated with ERCP. The predictors of utilization will be helpful to examine the cost-utility of ERCP, especially with the advent of acute pancreatitis treatment systems to mitigate the health care burden.

S0113 The Timing of Endoscopic Retrograde Cholangiopancreatography in Acute Biliary Pancreatitis Without Cholangitis: A Nationwide Inpatient Cohort Study

INTRODUCTION: Endoscopic Retrograde Cholangiopancreatography (ERCP) is recommended within 24 hours for patients with Acute biliary pancreatitis (ABP) with signs of cholangitis. In the absence of cholangitis, the impact of the timing of ERCP remains unclear. We aimed to analyze the timing of ERCP in ABP patients without cholangitis. METHODS: This is a retrospective, longitudinal study of patients from 2005 to 2014, who presented to the US hospitals with diagnosis of ABP and received ERCP within first 24 hours (urgent ERCP) or within 24 to 72 hours (early ERCP). Study cohort was extracted from the Nationwide Inpatient Sample database. Hospital ERCP volumes were generated using unique hospital identifiers. Multivariate regression modeling was used to analyze the predictors of urgent vs. early ERCP use, and to determine various outcome variables between the two cohort. RESULTS: Overall, 105,433 admissions were evaluated. There was a significant P-trend (P < 0.001) increase in urgent ERCP performed over the 10-year study period (Figure 1). Predictors of urgent ERCP in ABP patients utilizing multivariate regression model are shown in Figure 2. Older patients, males, patients with comorbidities, African American and Hispanic patient population were significantly less likely to receive ERCP urgently. Intermediate ERCP volume hospitals were more likely to perform urgent ERCP in ABP patients. Additionally, teaching hospitals and hospitals in the Midwest and West were more likely to perform urgent ERCP. Use of abdominal imaging modalities prior to ERCP resulted in 50% decrease in the utilization of urgent ERCP. There were no differences in mortality rates or the complications rates between the two cohorts (Table 1). The composite variable encompassing all the complications was not significant between the two groups. There were significant differences in length of stay and healthcare cost analysis. CONCLUSION: We performed a retrospective study of patients with ABP (but without cholangitis) that showed an increasing trend of urgent ERCP over the study period without clinically significant benefit in mortality, length of stay and healthcare cost analysis. Further, urgent ERCP utilization is not uniform across various demographic and hospital cohorts. Hence, early ERCP may be over-utilized, and it may be reasonable to perform early ERCP (within 24–72 hours) instead of urgent ERCP in ABP patients in the absence of cholangitis.Figure 1.: Trends of urgent ERCP utilization in Acute Biliary Pancreatitis patients without signs of cholangitis across a 10-year period from 2005 to 2014.Figure 2.: Multivariate regression model predicting demographic and hospital factors affecting urgent ERCP utilization in Acute Biliary Pancreatitis without signs of cholangitis.Table 1.: Mutivariate Hazard Ratios and Regression Coefficients of various outcome factors based on patients receiving urgent ERCP in Acute Biliary Pancreatitis patients without signs of cholangitis compared to patients receiving early ERCP

S0994 Trend and Predictors of Endoscopic Retrograde Cholangiopancreatography in Liver Transplant Patients

INTRODUCTION: Despite advancement in surgical techniques, biliary complications following liver transplant (LT) remain a major cause of morbidity and mortality for which endoscopic retrograde cholangiopancreatography (ERCP) remains the preferred treatment. We aim to determine the hospitalization trend, predictors, mortality, and morbidity risks in patients who receive ERCP after LT from a nationally representative sample. METHODS: he study cohort was derived from the Nationwide Inpatient Sample (NIS) for the years 2002-2014. Adult hospitalizations with LT status were identified using International Classification of Diseases 9th Edition Clinical Modification (ICD-9-CM) diagnosis codes and ERCP were identified by ICD-9-CM procedure codes. We then utilized the Cochran Armitage trend test and multivariate survey logistic regression to analyze temporal trends, predictors, and outcomes. RESULTS: Out of total 358,445 hospitalizations among LT patients, ERCP was performed in 8452 (2.36%) hospitalizations. The utilization of ERCP increased from 473 (0.05%) in 2002 to 775 (0.09%) in 2014. Among the patients who received ERCP, mean age was 54 (1.3), 64.5% were males, 67.5% whites, 16.6% Hispanics, and 8.5% African American. Among the patients who received ERCP, 7.7% were discharged to a facility and 1.1% died during the hospitalization. In multivariate analysis, age (10-year increase) (OR 1.32, 95% CI 1.09–1.61; P < 0.001), Hispanic race (OR 1.27, 95% CI 1.04–1.54; P 0.01), uninsured (OR 1.32; 95% CI 1.15–1.52; P < 0.001) and west region (OR 1.83; 95% CI 1.42–2.35; P < 0.001) were significantly associated with higher odds of ERCP utilization. However rural and non teaching hospitals were associated with lower odds of ERCP utilization. CONCLUSION: In our study we were able to delineate the epidemiology of ERCP among liver transplant patients. We noted that there has been an increase in ERCP procedures over the years among LT patients along with the discrepancies among demographics,regions and hospital types.

Use of ERCP in the United States over the past decade.

Abstract Background and study aims With newer imaging modalities, indications for use of endoscopic retrograde cholangiopancreatography (ERCP) have changed in the last decade. Despite advances in ERCP, paucity in recent literature regarding utilization and outcomes of ERCP exists. Thus, the aim of this study was to assess the inpatient use of ERCP, outcomes, and most common indications. Patients and methods Retrospective-cohort study using the Nationwide Inpatient Sample 2007–2016. All patients with ICD9–10CM procedural codes for ERCP were included. The primary outcome was the use of ERCP. Secondary outcomes included determining procedural specifics (stenting, sphincterotomy and dilation), complications (post-ERCP pancreatitis [PEP], bile duct perforation), hospital length of stay, total hospital costs and charges. Multivariate regression analysis was used to adjust for confounders. Results A total of 1,606,850 patients underwent inpatient ERCP. The mean age was 59 years (60 % female). The total number of ERCPs increased over the last decade. Patients undergoing ERCP in 2016 had greater odds of undergoing bile duct stent placement, pancreatic duct (PD) stenting, biliary dilation, pancreatic sphincterotomy, PEP and biliary perforation. Inpatient mortality decreased. Hospital charges increased, while length of stay (LOS) decreased. Conclusions The number of ERCPs increased in the past decade. Odds of therapeutic interventions and complications increased. The most common principal diagnoses were choledocholithiasis and gallstone-related AP. Hence, physicians must be aware to promptly diagnose and treat complications. These findings may reflect the increased case complexity and fact that ERCP continues to evolve into an increasingly interventional tool, contrasting from its former role as a predominantly diagnostic and gallstone extraction tool.

Recent 5-Year Trend of Endoscopic Retrograde Cholangiography in Korea Using National Health Insurance Review and Assessment Service Open Data.

Background/AimsThe utilization of endoscopic retrograde cholangiopancreatography (ERCP) is variable and largely dependent on a patient’s age, sex, and region. Herein we analyzed the publicly available Health Insurance Review and Assessment (HIRA) database with the aim of understanding the current status and trend of ERCP use in Korea.MethodsBetween 2013 and 2017, information regarding ERCP was acquired from the HIRA database using the procedural codes of the Korean Standard Classification of Disease. We analyzed the annual number of patients according to age in 10-year increments, sex, type of medical institution, and administrative division.ResultsThe total number of patients and number of patients undergoing ERCP per 100,000 people increased from 40,516 and 78.6 in 2013 to 47,027 and 91.3 in 2017, respectively those aged 70 years accounted for the highest number, and the increase was the most prominent in those aged 80 years or older. Men underwent more ERCPs than women, except in younger patients (<40 years). Most ERCPs were performed at tertiary and general hospitals; however, the ratios between the two types of institutions were different according to the procedure. There were different patterns of patients associated with each procedure according to the administrative division. Therapeutic ERCP was performed more frequently than diagnostic ERCP.ConclusionsMost procedures in Korea were therapeutic, and the increase in patients was most prominent in those aged 80 years or older. The utilization of ERCP increased markedly and varied depending on age, sex, type of medical institution, and region.

86 Acalculous Cholecystitis: Changing Trends From 2004 to 2014

INTRODUCTION: Acute acalculous cholecystitis (AAC) which accounts for 10% cases of cholecystitis is associated with high morbidity and mortality rates. The management options for AAC range from surgical removal of the gall bladder to emergent drainage either by percutaneous means or endoscopically. Data about the in-hospital outcomes of AAC is sparse. METHODS: The NIS is the largest all-payer inpatient database in the United States and contains data from approximately 8 million hospital stays each year. We analyzed the National Inpatient Sample Database (NIS) for all patients in which acute acalculous cholecystitis (ICD-9 codes: 575.0, 575.1) was the principal discharge diagnosis from 2004 to 2014. We further looked at procedure codes Endoscopic retrograde cholangiopancreatography (ERCP), Endoscopic ultrasound (EUS), Percutaneous transhepatic cholangiography (PTC), open and laparoscopic cholecystectomy. The outcome variables were in hospital mortality, length of stay and total hospital charge. Univariate and multivariate analysis was performed adjusted for multiple confounder. RESULTS: In 2014 there were 35865 hospital admissions with the principal diagnosis AAC which increased significantly from 23485 in 2004 (P &lt; 0.001). The mean length of stay for acute cholecystitis decreased by 21.6% between 2004 and 2014 (i.e., from 5.1 days to 4.0 days; (P &lt; 0.05). During the same time period, however, mean hospital charges have increased by 190.5% from US$24 514 per patient in 2004 to US$46847 per patient in 2014 (P &lt; 0.001). There were no cases of EUS guided drainage in 2004 while in 2014 there were 485 cases. A significantly higher proportion of patients received PTC, ERCP and laparoscopic cholecystectomy in 2014 compared to 2004 (P = 0.001). The in-hospital mortality declined from 1.4% in 2004 to 0.9% in 2014. Factors associated with in-hospital mortality were Diabetes mellitus (OR = 1.76, P = 0.004), presence of Chronic kidney disease (OR = 2.36, P = 0.003), hematologic malignancy (OR = 4.5, P &lt; 0.001) and metastatic cancer (OR = 14.56, P &lt; 0.0001). CONCLUSION: The number of cases of acalculous cholecystitis has shown a gradual increase from 2004 to 2014. However there has been a gradual reduction in mortality and length of stay in these patients. While it is associated with increased utilization of ERCP and EUS, causality cannot definitively be established.

Regional and racial variations in the utilization of endoscopic retrograde cholangiopancreatography among pancreatic cancer patients in the United States.

BackgroundPancreatic cancer is projected to become the second leading cause of cancer‐related deaths by 2030. Endoscopic retrograde cholangiopancreatography (ERCP) is recommended as first‐line therapy for biliary decompression in pancreatic cancer. The aim of our study was to characterize geographic and racial/ethnic disparities in ERCP utilization among patients with pancreatic cancer.MethodsRetrospective cohort study using the US Surveillance, Epidemiology, and End Results (SEER)‐Medicare database to identify patients diagnosed with pancreatic cancer from 2003‐2013. The primary outcome was receipt of ERCP, with or without stent placement, vs any non‐ERCP biliary intervention.ResultsOf the 36 619 patients with pancreatic cancer, 37.5% (n = 13 719) underwent an ERCP, percutaneous drainage, or surgical biliary bypass. The most common biliary intervention (82.6%) was ERCP. After adjusting for tumor location and stage, Blacks were significantly less likely to receive ERCP than Whites (aOR 0.84, 95% CI 0.72, 0.97) and more likely to receive percutaneous transhepatic biliary drainage (PTBD) (aOR 1.38, 95% CI 1.14, 1.66). Patients in the Southeast and the West were more likely to receive ERCP than those in the Northeast (Southeast aOR 1.21, 95% CI 1.04, 1.40; West aOR 1.16, 95% CI 1.01, 1.32).ConclusionRacial/ethnic and geographic disparities in access to biliary interventions including ERCP exist for patients with pancreatic cancer in the United States. Our results highlight the need for further research and policies to improve access to appropriate biliary intervention for all patients.

National trends of endoscopic retrograde cholangiopancreatography utilization and outcomes in decompensated cirrhosis.

Endoscopic retrograde cholangiopancreatography (ERCP) can be challenging in patients with decompensated cirrhosis (DC) due to increased risk of adverse events related to liver dysfunction. Limited data exist regarding its national utilization in patients with DC. We aim to determine the trends in utilization and outcomes of ERCP among patients with DC in US hospitalizations. We identified hospitalizations undergoing ERCP (diagnostic and therapeutic) between 2000 and 2013 from the National Inpatient Sample (NIS) database and used validated ICD9-CM codes to identify DC hospitalizations. We utilized Cochrane-Armitage test to identify changes in trends and multivariable survey regression modeling for adjusted odds ratios (aOR) for adverse outcomes and mortality predictors. There were 43782 cases of ERCPs performed in DC patients during the study period. Absolute number of ERCPs performed in this population from 2000 to 2013 showed an upward trend; however, the proportion of DC patients undergoing ERCP remained stable. We noted significant decrease in utilization of diagnostic ERCP and an increase of therapeutic ERCPs (P < 0.01). There was a significant decrease in the mean length of stay for DC patients undergoing ERCP from 8.2 days in 2000 to 7.2 days in 2013 (P < 0.01) with an increase in the mean cost of hospitalization from $17053 to $19825 (P < 0.001). Mortality rates showed a downward trend from 2000 to 2013 from 13.6 to 9.6% (P < 0.01). Increasing age, Hispanic race, diagnosis of hypertension and diabetes mellitus, and private insurance were related to adverse discharges(P < 0.01). Increasing age, presence of hepatic encephalopathy, and sepsis were associated with higher mortality (P < 0.01). There is an increasing trend in therapeutic ERCP utilization in DC hospitalizations nationally. There is an overall decrease in mortality in DC hospitalizations undergoing ERCP. This improvement in mortality suggests improvement in both procedural technique and peri-procedural care as well as overall decreasing mortality in cirrhosis.

Tu1555 Healthcare Utilization of Endoscopic Retrograde Cholangiopancreatography (ERCP) in United States

Tu1555 Healthcare Utilization of Endoscopic Retrograde Cholangiopancreatography (ERCP) in United States

Mo1059 Nationwide Utilization of Same Day EUS & ERCP: A Comparison Across Practice Types

Prior data have suggested that practice variation exists in the utilization of same day upper and lower endoscopy compared to separate day procedures, which we hypothesize is due to differences in reimbursement. The aim of this study is to examine trends and utilization across various practice types of same day endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) compared with EUS performed on a separate day within 1-14 days of ERCP.

Sa1191 National Trends of Endoscopic Retrograde Cholangiopancreatography Utilization and Outcomes In Decompensated Cirrhosis

Sa1191 National Trends of Endoscopic Retrograde Cholangiopancreatography Utilization and Outcomes In Decompensated Cirrhosis

Median Household, Racial, and Insurance Disparities in Endoscopic Retrograde Cholangiopancreatography (ERCP)

Introduction: To identify variants which may affect ERCP utilization in the United States over a decade. Potential variants that may contribute are Age, sex, race (White, Black, Hispanic, and other minority racial groups), median household income and insurance status. Methods: Using the Nationwide Inpatient Sample from 2002 through 2011, ERCPs were identified using International Classification of Diseases (ICD-9) codes; procedure codes 51.10, 51.11, 51.12, 51.13 for diagnostic and 51.84-51.89, 52.92-52.98 for therapeutic indications were studied. We stratified patients by Age, sex, race (White, Black, Hispanic, and other minority racial groups), median household income and insurance status. Results: 368, 267 patients underwent ERCP from 2002 - 2011 nationwide in the US with increase of 30 %. The mean age was 59 ± 19 years, 69 % of which were performed in patients greater than 50 years of age. 62 % were female and 64 % were white. In 2002-2003, 38% of ERCP performed were in patients with highest quartile median household income and only 14% in the lowest quartile. This variation was eliminated in the recent years where the rate equalized to approximately 24 % by 2011. ERCP utilization decreased from 93% to 90% in insured patients (Medicare, Medicaid and private), and increased from 7 % to 10% in uninsured patients. Conclusion: We identified highest rates of ERCP utilization among white patients even after correction of other factors such as insurance. ERCP utilization has increased in lowest socio-economic strata, and in uninsured patients. The disparity between high and low socio-economic strata has closed, but insurance disparity still exists.Figure 1

Tu1715 Biliary Drainage Method and Temporal Trends in Patients Admitted With Cholangitis: A National Audit

Biliary drainage is the crucial step in the management of ascending cholangitis. Better outcomes are reported in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) relative to surgical drainage. The objective of this study was to identify factors associated with (1) ERCP, (2) percutaneous drainage and (3) surgical drainage utilization, and to examine national temporal trends in the treatment of ascending cholangitis.

Effect of ERCP Utilization and Biliary Complications on Post-Liver-Transplantation Mortality and Graft Survival

Biliary complications after liver transplant are a frequent source of morbidity. However, little recent mortality data exists related to endoscopic management of these complications. To determine the effect of endoscopic retrograde cholangiopancreatography (ERCP) utilization and biliary complications on patient and graft survival after liver transplantation. This study was a retrospective cohort study at the University of North Carolina Hospitals from 2004 to 2007. One hundred thirty-two consecutive liver transplant patients were included. Recipient, donor, and clinical data were extracted from electronic resources. The main outcome measurements were all-cause mortality and graft failure. Of 132 transplants, 59 (45%) required ERCP post transplant, and 49 (37%) were found to have a biliary complication by ERCP. The 1-year patient survival for those treated by ERCP with a biliary complication was 90% compared with 81% in those without a biliary complication [P = 0.018; unadjusted hazard ratio (HR) = 0.32; 95% confidence interval (CI) 0.11-0.93]. The 1-year graft survival in those with and without a biliary complication was 94% and 73%, respectively (P < 0.001; unadjusted HR 0.19; 95% CI 0.07-0.56). This effect on patient and graft survival persisted after multivariate analysis. Similar results were seen for ERCP utilization alone, and when early deaths within the first 30 days were excluded. Patients who underwent ERCP for a biliary complication post liver transplantation had better overall and graft survival than patients who did not have an ERCP. Biliary complications and ERCP utilization are common after liver transplant, but they do not confer excess mortality.