Racial and Ethnic Disparities Among Patients Hospitalized for Acute Cholangitis in the United States

Factors Associated With Delayed Endoscopic Retrograde Cholangiopancreatography Among Patients With Acute Cholangitis

BACKGROUND AND GOALS

Delayed ERCP is associated with increased morbidity and mortality from acute cholangitis (AC). We aimed to identify the factors associated with delayed receipt of early or urgent ERCP among patients with AC.

STUDY

For this retrospective cohort study, we analyzed data from the 2016 to 2020 iterations of the Nationwide Inpatient Sample. We stratified the study population as severe versus nonsevere AC and timing of ERCP as urgent (within 24 h of admission), early (between 24 and 48 h of admission), and late (after 48 h of admission). Using multivariable logistic regression, we examined for the factors associated with delay in urgent or early ERCP overall and delay in urgent ERCP among patients with severe AC.

RESULTS

Of the 12,613 participants included in this study, 3032 (24.0%) had severe AC. Blacks [aOR 1.53; 95% CI (1.27, 1.85)], Asians/Pacific Islanders [aOR 1.22; 95% CI (1.02, 1.46)], those with a history of bariatric surgery [aOR 2.10; 95% CI (1.40, 3.17)] and those with one [aOR 1.33; 95% CI (1.13, 1.58)] or more comorbidities were more likely to have a delay in receiving ERCP within 48 hours of admission when compared with non-Hispanic Whites and those with no comorbidities respectively. Racial disparities were not observed among patients with severe AC.

CONCLUSION

Black/AA and API's presenting with AC are more likely to have a delay in the receipt of ERCP within 48 hours of admission. Assessing the impact of medical comorbidities on procedural risk is important when deciding timing of ERCP.

Acute Pancreatitis: Presentation and Outcomes at a Safety Net Hospital

INTRODUCTION

Although acute pancreatitis is common and much is known about its management, further research could lead to targets identified for improvements in care. This study aimed to analyze factors, both medical and socioeconomic, associated with morbidity and mortality at a safety net hospital.

METHODS

This was a retrospective review of patients with acute pancreatitis admitted between 2015 and 2022. Variables were collected from the electronic medical record and primary outcomes of interest were morbidity and mortality. Standard statistics were used for analysis.

RESULTS

Of the 404 patients that met inclusion criteria, the average age was 48 y, 46% were female, the majority were English speaking, most were Black, and the majority had public insurance. Four percent of patients died and 19.6% had a complication within 30 d. Most patients were admitted to medicine. Public insurance or self-pay status was associated with complications, as was presence of comorbidities and interventional radiology consultation. Surgery and interventional radiology consultation, among other factors, were associated with mortality. Thirty-nine percent of patients with gallstone pancreatitis underwent cholecystectomy. Many patients were started on antibiotics, and of those, 44.1% had no clear indication.

CONCLUSIONS

This study reveals novel factors associated with morbidity and mortality in patients with acute pancreatitis, as well as demonstrating that best practices are not uniformly practiced. The study provides further areas of study, including investigations into best pathways for consultations of services and admission service, interventions for at risk patients to improve morbidity and mortality, and how to reduce inappropriate antibiotic use.

Impact of frailty on outcomes and biliary drainage strategies in acute cholangitis: A retrospective cohort analysis

BACKGROUND

Acute cholangitis (AC) is a potentially fatal infection of the biliary tract characterized by varying degrees of severity, with endoscopic retrograde cholangiopancreatography (ERCP) serving as the primary drainage modality. Though frailty is linked to poor outcomes in general, its implications for AC patients remain unexplored.

METHODS

Using the National Inpatient Sample Database 2017-2020, we identified adult AC hospitalizations, which were further stratified based on frailty. A multivariate regression model was used for analysis.

RESULTS

We included 32,310 AC patients, out of whom 11,230 (34.76 %) were frail. Frail patients had elevated AC severity as well as in-hospital mortality (adjusted odds ratio [aOR] 6.89; P < 0.01). Additionally, frail patients were found to have significantly higher odds of complications including septic shock (aOR 15.87), acute renal failure (aOR 5.67), acute respiratory failure (aOR 11.11) and need for mechanical ventilation (aOR 13.80). From a procedural viewpoint, frail patients had higher odds of undergoing percutaneous biliary drainage (PBD) but lower odds of undergoing "early" ERCP (ERCP within 24 h of admission). When compared to non-frail counterparts, frail patients were more likely to undergo PBD as opposed to early ERCP (aOR 1.46; P = 0.01).

CONCLUSION

Frailty independently predicts poor AC outcomes and has a notable impact on the choice of biliary drainage procedure. Recognizing frailty instead of age alone as a determinant of AC outcomes can aid clinicians in risk stratification and guide tailored interventions in this population.

ACUTE KIDNEY INJURY FOLLOWING ACUTE CHOLANGITIS: A RISK MULTIPLIER FOR ADVERSE OUTCOMES AND HEALTHCARE UTILIZATION

ABSTRACT

Background: Acute kidney injury (AKI) is a common, fatal complication of acute cholangitis (AC). The link between AC and AKI is poorly understood. Aims: To delineate the incidence trends, clinical outcomes and healthcare utilization of inpatients with AKI following AC and to explore the risk factors for AKI following AC. Methods: This population-based retrospective study used the National Inpatient Sample database from 2010 to 2018 to compare the demographics, complications, in-hospital mortality and healthcare utilization between AC patients with and without AKI. Predictors of AKI and the prognostic impact of AKI on in-hospital outcomes were defined using multivariate logistic regression. Results: The overall incidence of AKI was 24.06% among AC patients. Its trend generally increased annually. AKI was associated with more complications, greater invasive therapy requirements, longer hospital stays, costlier total hospital charges, and higher in-hospital mortality. The risk factors for AKI following AC were advanced age, Black race, multiple comorbidities, large hospitals, teaching hospitals, urban hospitals, hospitals in the southern and western United States, choledocholithiasis/cholelithiasis, surgery, percutaneous transhepatic biliary drainage, deficiency anemia, congestive heart failure, coagulopathy, diabetes, hypertension, chronic liver disease, obesity, chronic kidney disease excluding end-stage renal disease, weight loss, acute pancreatitis, and severe sepsis. Female sex, private insurance, elective admission, and endoscopic retrograde cholangiopancreatography were protective factors against AKI in AC patients. Conclusion: AKI often follows AC and is strongly associated with poor prognosis and increased healthcare utilization. Healthcare professionals should make more efforts to identify patients with AC at risk of AKI and start management promptly to limit adverse outcomes.

On-site ERCP availability and cholangitis outcomes: Retrospective cohort study

Background and study aims

Endoscopic retrograde cholangiopancreatography (ERCP) is important in acute cholangitis (AC) management but is not available at all hospitals. The association between on-site ERCP availability and cholangitis outcomes is unknown.

Patients and methods

We included adults diagnosed with AC at 27 hospitals in Ontario through the GEMINI network. We collected data on demographics, clinical and laboratory values, and interventions. The primary outcome was in-hospital mortality. Secondary outcomes were length of stay, intensive care unit (ICU) admission, readmission rates, and requirement for percutaneous or surgical decompression. We used multivariable regression analyses to assess the impact of on-site ERCP availability on the primary and secondary outcomes with adjustment for relevant variables.

Results

Our cohort included 4492 patients with a median age of 75. Patients at ERCP sites had higher unadjusted rates of undergoing ERCP (55.7% at ERCP sites, 40.8% at non-ERCP sites). Patients at ERCP sites compared with non-ERCP sites did not have significantly different in-hospital mortality (adjusted odds ratio [aOR] = 2.19, 95% confidence interval [CI] = 0.86-5.55). Compared with non-ERCP sites, patients at ERCP sites with underlying stricturing biliary disease or pancreaticobiliary malignancy (aOR = 1.94, 95% CI = 1.14-13.58) or severe cholangitis (aOR = 2.17, 95% CI = 1.17-4.02) had higher odds of in-hospital mortality. In a post-hoc propensity score-based analysis, there was no significant difference between patients at ERCP sites compared with those at non-ERCP sites for in-hospital mortality.

Conclusions

Patients at ERCP sites compared with non-ERCP sites did not have significantly different mortality. Subgroups of patients with underlying stricturing biliary disease or pancreaticobiliary malignancy and severe cholangitis, who have higher mortality at ERCP sites, warrant further study.