Decreasing hospitalization and in-hospital mortality related to cholangitis in the United States

Timing of Performing Endoscopic Retrograde Cholangiopancreatography and Inpatient Mortality in Acute Cholangitis: A Systematic Review and Meta-Analysis

Although early biliary drainage improves outcomes in patients with acute cholangitis, the optimal time to perform endoscopic retrograde cholangiopancreatography (ERCP) is controversial. Our aim was to evaluate the impact of timing of ERCP on mortality in hospitalized patients with acute cholangitis.

Timing of endoscopic retrograde cholangiopancreatography in acute biliary pancreatitis without cholangitis: a nationwide inpatient cohort study

Background

The timing of endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute biliary pancreatitis without cholangitis is unclear. We accessed a national database to analyze the outcomes of urgent (<24 h) and early (24-72 h) ERCP in this cohort.

Methods

The 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 2 cohorts.

Results

Overall, 105,433 admissions were evaluated. There was a significant rise in urgent ERCP performed over the study period. Older patients, males, patients with comorbidities, African American and Hispanic patient populations were less likely to receive urgent ERCP. High ERCP volume hospitals, teaching hospitals, and hospitals in the Midwest and West were more likely to perform urgent ERCP. There were no differences in mortality rates or complication rates between the 2 cohorts. However, there were significant differences in length of stay and healthcare cost analysis.

Conclusions

The increasing use of urgent ERCP did not result in a clinically significant benefit in terms of mortality, length of stay, or healthcare cost analysis. The use of urgent ERCP is also not uniform across various demographic and hospital cohorts. Urgent ERCP may be over-utilized, and it may be reasonable to perform ERCP in this patient population based on the physician’s suspicion about the severity of disease.

A Statistically Significant Reduction in Length of Stay and Hospital Costs with Equivalent Quality of Care Metrics for ERCPs Performed During the Weekend Versus Postponed to Weekdays: A 6-Year Study of 533 ERCPs at Four Teaching Hospitals

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic/therapeutic endoscopic procedure for numerous pancreaticobiliary diseases. Data regarding performing ERCP on weekend (WE; Saturday/Sunday) versus postponing ERCP to first two available weekdays (WD; Monday/Tuesday) are scarce. ERCP requires costly resources including specialized nurses, endoscopy room equipped with fluoroscopy, anesthesia services, and highly trained therapeutic endoscopists. Hospitals frequently do not have these resources readily available during WE, leading to postponing ERCPs to WD.

AIMS

This study analyzes the effect of performing ERCP on WE versus postponement to WD on hospital efficiency, and on patient safety/outcomes.

METHODS

A computerized search of electronic medical records, January 2011-December 2016, at four Beaumont Hospitals retrospectively identified all gastroenterology consults performed on Friday or Saturday before 12:00 noon, which resulted in ERCP performed for any indication on WE versus postponing ERCP to WD. Length of stay (LOS), hospital costs, hospital charges, and hospital reimbursements were compared between both groups, as were quality of care measures.

RESULTS

Among 5196 patients undergoing ERCPs, 533 patients were identified, including 315 patients in the WE group and 218 patients in the WD group. Comparing WE versus WD groups, median LOS was shorter (4.5 days vs. 6.9 days, p < 0.0001); median hospital costs were less ($9208 vs. $11,657, p < 0.0001); and median hospital charges were less ($28,026 vs. $37,899, p < 0.0001). Median hospital reimbursements were not significantly different in WE versus WD groups ($10,277 vs. $10,362, p = 0.65). Median hospital charges were lower than median hospital reimbursements (net profit) in WE but not in WD. WE versus WD had no significant differences in morbidity, mortality, ≤ 30-day readmission rates, need for repeat ERCP ≤ 30 days, or post-ERCP complications.

LIMITATIONS

This is a retrospective study.

CONCLUSIONS

Performing ERCPs during weekends significantly reduced LOS, hospital costs, and hospital charges compared to postponing ERCP to WD and resulted in net hospital profits, without impairing quality of medical care.

Biliary drainage method and temporal trends in patients admitted with cholangitis: a national audit

BACKGROUND

In patients presenting with ascending cholangitis, better outcomes are reported in those undergoing endoscopic retrograde cholangiopancreatography (ERCP) compared with surgical drainage.

OBJECTIVE

To identify factors associated with the type of intervention, and to examine temporal trends in the treatment of ascending cholangitis.

METHODS

Data were extracted from the Nationwide Inpatient Sample. Patients ≥18 years of age with a diagnosis of cholangitis between 1998 and 2009 were selected. Temporal trends were assessed using Poisson regression models. Multivariable models were fitted to predict the likelihood of a patient undergoing ERCP, percutaneous or surgical drainage, or no drainage.

RESULTS

A weighted estimate of 248,942 patients admitted for cholangitis was identified. Overall, 131,052 patients were treated with ERCP (52.6%), 10,486 with percutaneous drainage (4.2%) and 12,460 with surgical drainage (5.0%); 43.0% did not receive drainage during the admission. Temporal trends between 1998 and 2009 showed a decline in surgical and percutaneous drainage, and a rise in ERCP. In multivariable analyses adjusted for clustering, ERCP and percutaneous drainage were more often performed in institutions with a high volume of admissions for cholangitis, those with a greater bed number and hospitals located in urban areas.

CONCLUSION

Over the past decade, the use of surgical and percutaneous drainage has decreased while that of ERCP has risen. Patients treated at institutions with a low volume of admissions for cholangitis, small bed number and in rural areas were less likely to undergo ERCP or percutaneous drainage.

Clinical utility of a standardized electronic order set for the management of acute upper gastrointestinal hemorrhage in patients with cirrhosis

BACKGROUND & AIMS

Recent reductions in mortality after acute upper gastrointestinal hemorrhage among patients with cirrhosis have been attributed to early and aggressive use of guideline-recommended pharmacologic agents, antibiotics, and endoscopic therapy. Studies have shown, however, that adherence to recommended guidelines is low. We investigated whether use of a standardized electronic order set would improve adherence to treatment and timeliness of delivery.

METHODS

We performed a prospective observational study, implementing an electronic order set for 123 patients with known or suspected cirrhosis who presented with symptoms/signs of upper gastrointestinal hemorrhage at Parkland Memorial Hospital (in Dallas, TX) from July 2011 through June 2012. The order set included standard nursing orders, laboratory tests, medications, orders for consultative services, and a brief evidence-based review of the benefits of octreotide and antibiotics in patients with cirrhosis. Primary outcomes included overall adherence to the administration of octreotide and antibiotics and the performance of upper endoscopy, as well as time to these interventions.

RESULTS

Administration of antibiotics increased in patients for whom the order set was used (100% vs 89% for whom it was not used; P = .01); the use of the order set significantly reduced the time to administration of antibiotics (3 h 28 min vs 10 h 4 min; P < .001). The time to administration of octreotide also significantly was reduced for patients for whom the order set was used (2 h 16 min vs 6 h 21 min; P < .002). Although all patients underwent endoscopy, there was no significant difference in the time to procedure between patients for whom the order set was used and not used (17 h 54 min vs 18 h 5 min; P = .95).

CONCLUSIONS

The use of a standardized electronic order set improved not only overall adherence, but also the timeliness of administration of recommended therapies for patients with known or suspected cirrhosis presenting with upper gastrointestinal hemorrhage.