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Evaluation of socioeconomic and healthcare disparities on same admission cholecystectomy after endoscopic retrograde cholangiopancreatography among patients with acute gallstone pancreatitis. Surg Endosc 2021; 36:274-281. [PMID: 33481109 DOI: 10.1007/s00464-020-08272-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Despite literature and guidelines recommending same admission cholecystectomy (CCY) after endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute gallstone pancreatitis, clinical practice remains variable. The aim of this study was to investigate the role of clinical and socio-demographic factors in the management of acute gallstone pancreatitis. METHODS Patients with acute gallstone pancreatitis who underwent ERCP during hospitalization were reviewed from the U.S. Nationwide Inpatient Sample database between 2008 and 2014. Patients were classified by treatment strategy: ERCP + same admission CCY (ERCP + CCY) versus ERCP alone. Measured variables including age, race/ethnicity, Charlson Comorbidity Index (CCI), hospital type/region, insurance payer, household income, length of hospital stay (LOS), hospitalization cost, and in-hospital mortality were compared between cohorts using χ2 and ANOVA. Multivariable logistic regression was performed to identify specific predictors of same admission CCY. RESULTS A total of 205,012 patients (ERCP + CCY: n = 118,318 versus ERCP alone: n = 86,694) were analyzed. A majority (53.4%) of patients that did not receive same admission CCY were at urban-teaching hospitals. LOS was longer with higher associated costs for patients with same admission CCY [(6.8 ± 5.6 versus 6.4 ± 6.5 days; P < 0.001) and ($69,135 ± 65,913 versus $52,739 ± 66,681; P < 0.001)]. Mortality was decreased significantly for patients who underwent ERCP + CCY versus ERCP alone (0.4% vs 1.1%; P < 0.001). Multivariable regression demonstrated female gender, Black race, higher CCI, Medicare payer status, urban-teaching hospital location, and household income decreased the odds of undergoing same admission CCY + ERCP (all P < 0.001). CONCLUSION Based upon this analysis, multiple socioeconomic and healthcare-related disparities influenced the surgical management of acute gallstone pancreatitis. Further studies to investigate these disparities are indicated.
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Bilal M, Kline KT, Trieu JA, Saraireh H, Desai M, Parupudi S, Abougergi MS. Trends in same-admission cholecystectomy and endoscopic retrograde cholangiopancreatography for acute gallstone pancreatitis: A nationwide analysis across a decade. Pancreatology 2019; 19:524-530. [PMID: 31036491 DOI: 10.1016/j.pan.2019.04.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/05/2019] [Accepted: 04/18/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Gallstones are the leading cause of acute pancreatitis in developed countries. National and international guidelines recommend that a cholecystectomy should be performed during the index hospitalization for acute gallstone pancreatitis. We aimed to delineate the national trends for same-admission cholecystectomy and ERCP for acute gallstone pancreatitis over the last ten years. METHODS We used the 2004, 2009 and 2014 National Inpatient Sample database including patients with a principal diagnosis of acute pancreatitis and a secondary diagnosis of choledocholithiasis or cholelithiasis. Exclusion criteria were age <18 years and elective admission. Primary outcome was the trend in incidence rate of same admission cholecystectomy from 2004 to 2014. The secondary outcomes were: 10-year trend in 1) Incidence of gallstone pancreatitis, 2) proportion of gallstone pancreatitis compared to all other etiologies of acute pancreatitis, 3) incidence rate of same-admission ERCP, 4) length of hospital stay, and 5) total hospitalization costs and charges. RESULTS The proportion of admissions during which a same-admission cholecystectomy was performed decreased from 48.7% in 2004 to 46.9% in 2009 to 45% in 2014 (trend p < 0.01). During the same time interval, the percentage of admissions during which an ERCP was performed decreased from 25.1% to 18.7% (Trend p < 0.01). CONCLUSIONS Adherence to the guidelines for same-admission cholecystectomy for patients admitted with acute gallstone pancreatitis have been declining over the past decade. On the other hand, decline in rate of ERCP in patients with acute gallstone pancreatitis and no signs of cholangitis demonstrates adherence to guidelines in this regard.
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Affiliation(s)
- Mohammad Bilal
- Division of Gastroenterology & Hepatology, The University of Texas Medical Branch, Galveston, TX, USA.
| | - Kevin T Kline
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Judy A Trieu
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Hamzeh Saraireh
- Division of Gastroenterology & Hepatology, Virginia Commonwealth University, Richmond, VA, USA
| | - Madhav Desai
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Sreeram Parupudi
- Division of Gastroenterology & Hepatology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Marwan S Abougergi
- Catalyst Medical Consulting, Simpsonville, SC, USA; University of South Carolina School of Medicine, Columbia, SC, USA
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Ridtitid W, Kulpatcharapong S, Piyachaturawat P, Angsuwatcharakon P, Kongkam P, Rerknimitr R. The impact of empiric endoscopic biliary sphincterotomy on future gallstone-related complications in patients with non-severe acute biliary pancreatitis whose cholecystectomy was deferred or not performed. Surg Endosc 2018; 33:3325-3333. [PMID: 30535937 DOI: 10.1007/s00464-018-06622-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 12/04/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Early cholecystectomy (EC) is recommended in patients with acute biliary pancreatitis (ABP). In real-life practice, cholecystectomy is frequently deferred due to various reasons and delayed cholecystectomy (DC) is performed instead. Endoscopic sphincterotomy (ES) is an alternative to prevent recurrent pancreatitis, however other gallstone-related complications (GCs) may still develop. We aimed to determine the impact of ES on future GCs in patients with non-severe acute biliary pancreatitis whose cholecystectomy was deferred or not performed. METHODS During 2006-2016, we included patients with non-severe ABP while those with severe pancreatitis and concurrent cholangitis were excluded. GC events were compared between those who had DC with ES and those who had DC without ES. A similar comparison was made in patients with and without ES who did not receive cholecystectomy. RESULTS Of 266 patients with ABP, non-severe ABP was identified in 146. Only 16 (11%) had EC. Of patients with non-severe ABP who underwent DC (n = 88), recurrent ABP in the ES group was lower than those from the non-ES group (2% vs. 17%; p = 0.01). Acute cholecystitis was found in 0%, 6% and 10% of patients with EC, DC and those without cholecystectomy (p = 0.39). Of those who did not undergo cholecystectomy (n = 42), recurrent ABP in the ES group was still lower than the non-ES group (4% vs. 36%; p = 0.006). ES related complications were mild pancreatitis (4%) and post sphincterotomy bleeding (5%). CONCLUSIONS In patient with non-severe ABP, ES is an alternative to reduce recurrent ABP, however without EC, future cholecystitis may still develop.
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Affiliation(s)
- Wiriyaporn Ridtitid
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.,Excellence Center in GI Endoscopy, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Santi Kulpatcharapong
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.,Excellence Center in GI Endoscopy, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Panida Piyachaturawat
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.,Excellence Center in GI Endoscopy, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Phonthep Angsuwatcharakon
- Department of Anatomy, Faculty of Medicine, Chulalongkorn University, Bangkok, 10400, Thailand.,Excellence Center in GI Endoscopy, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Pradermchai Kongkam
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.,Excellence Center in GI Endoscopy, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Rungsun Rerknimitr
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand. .,Excellence Center in GI Endoscopy, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand.
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Early cholecystectomy and ERCP are associated with reduced readmissions for acute biliary pancreatitis: a nationwide, population-based study. Gastrointest Endosc 2012; 75:47-55. [PMID: 22100300 DOI: 10.1016/j.gie.2011.08.028] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Accepted: 08/14/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Cholecystectomy is recommended during hospitalizations for acute biliary pancreatitis (ABP). OBJECTIVE We sought to assess the population-based effectiveness of index cholecystectomy by using nationwide data. DESIGN Retrospective, cohort study. SETTING All acute-care hospitals in Canada from 2007 to 2010. PATIENTS This study involved patients admitted for ABP in the Canadian Institutes for Health Information hospital discharge database. INTERVENTION Cholecystectomy and therapeutic ERCP during the index admission. MAIN OUTCOME MEASUREMENTS Rate of hospital readmissions for ABP. RESULTS Among 5646 patients with ABP, 32% underwent cholecystectomy and 22% ERCP during the index admissions. Patients admitted to hospitals in the highest quartile for cholecystectomy volume were more than 10-fold likely to undergo cholecystectomy during the index admission (adjusted odds ratio 11.0; 95% confidence interval [CI], 7.4-16.5). The 12-month readmission rate for ABP was lower with cholecystectomy (5.6% vs 14.0%; P < .0001) and therapeutic ERCP (5.1% vs 13.1%; P < .0001). After multivariate adjustment, lower readmission rates were independently associated with both cholecystectomy (adjusted hazard ratio [HR] 0.39; 95% CI, 0.32-0.48) and ERCP (adjusted HR 0.37; 95% CI, 0.29-0.50). After excluding early readmissions (within 28 days of discharge), the adjusted HR for cholecystectomy was 0.43 (95% CI, 0.34-0.57). The admitting hospital's cholecystectomy volume was inversely associated with 12-month readmission rates for ABP (quartile 1, 15.9%; quartile 2, 13.9%; quartile 3, 11.3%; quartile 4, 10.0%; P < .001). LIMITATIONS The study was based on hospital administrative data. CONCLUSION Cholecystectomy and ERCP during the index admission were associated with reduced readmission rates for ABP, providing population-based evidence to support consensus guidelines that recommend early biliary intervention.
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Judkins SE, Moore EE, Witt JE, Barnett CC, Biffl WL, Burlew CC, Johnson JL. Surgeons provide definitive care to patients with gallstone pancreatitis. Am J Surg 2011; 202:673-7; discussion 677-8. [DOI: 10.1016/j.amjsurg.2011.06.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Revised: 06/14/2011] [Accepted: 06/28/2011] [Indexed: 12/25/2022]
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De Rai P, Zerbi A, Castoldi L, Bassi C, Frulloni L, Uomo G, Gabbrielli A, Pezzilli R, Cavallini G, Di Carlo V. Surgical management of acute pancreatitis in Italy: lessons from a prospective multicentre study. HPB (Oxford) 2010; 12:597-604. [PMID: 20961367 PMCID: PMC2999786 DOI: 10.1111/j.1477-2574.2010.00201.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This study aimed to evaluate the surgical treatment of acute pancreatitis in Italy and to assess compliance with international guidelines. METHODS A series of 1173 patients in 56 hospitals were prospectively enrolled and their data analysed. RESULTS Twenty-nine patients with severe pancreatitis underwent surgical intervention. Necrosectomy was performed in 26 patients, associated with postoperative lavage in 70% of cases. A feeding jejunostomy was added in 37% of cases. Mortality was 21%. Of the patients with mild pancreatitis, 714 patients with a biliary aetiology were evaluated. Prophylactic treatment of relapses was carried out in 212 patients (36%) by cholecystectomy and in 161 using a laparoscopic approach. Preoperative endoscopic retrograde cholangiopancreatography was associated with cholecystectomy in 83 patients (39%). Forty-seven patients (22%) were treated at a second admission, with a median delay of 31 days from the onset of pancreatitis. Eighteen patients with severe pancreatitis underwent cholecystectomy 37.9 days after the first admission. There were no deaths. DISCUSSION The results indicate poor compliance with published guidelines. In severe pancreatitis, early surgical intervention is frequently performed and enteral feeding is seldom used. Only a small number of patients with mild biliary pancreatitis undergo definitive treatment (i.e. cholecystectomy) within 4 weeks of the onset of pancreatitis.
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Affiliation(s)
- Paolo De Rai
- Department of Surgery and Emergency Surgery, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS [Institute for Scientific Care and Treatment]) Ca' Granda – Ospedale Maggiore PoliclinicoMilan, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Section, Department of Surgery, IRCCS Istituto Clinico Humanitas (Humanitas Clinical Institute)Rozzano, Italy
| | - Laura Castoldi
- Department of Surgery and Emergency Surgery, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS [Institute for Scientific Care and Treatment]) Ca' Granda – Ospedale Maggiore PoliclinicoMilan, Italy
| | - Claudio Bassi
- Department of Surgery, University of VeronaVerona, Italy
| | - Luca Frulloni
- Department of Gastroenterology, University of VeronaVerona, Italy
| | - Generoso Uomo
- Department of Internal Medicine, Cardarelli HospitalNaples, Italy
| | | | - Raffaele Pezzilli
- Pancreas Unit, Department of Digestive Diseases and Internal Medicine, Sant'Orsola-Malpighi HospitalBologna, Italy
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Gabbrielli A, Pezzilli R, Uomo G, Zerbi A, Frulloni L, Rai PD, Castoldi L, Costamagna G, Bassi C, Carlo VD. ERCP in acute pancreatitis: What takes place in routine clinical practice? World J Gastrointest Endosc 2010; 2:308-13. [PMID: 21160762 PMCID: PMC2999033 DOI: 10.4253/wjge.v2.i9.308] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Revised: 08/19/2010] [Accepted: 08/26/2010] [Indexed: 02/05/2023] Open
Abstract
AIM: To evaluate the data from a survey carried out in Italy regarding the endoscopic approach to acute pancreatitis in order to obtain a picture of what takes place after the release of an educational project on acute pancreatitis sponsored by the Italian Association for the Study of the Pancreas.
METHODS: Of the 1 173 patients enrolled in our survey, the most frequent etiological category was biliary forms (69.3%) and most patients had mild pancreatitis (85.8%).
RESULTS: 344/1 173 (29.3%) underwent endoscopic retrograde cholangiopancreatography (ERCP). The mean interval between the onset of symptoms and ERCP was 6.7 ± 5.0 d; only 89 examinations (25.9%) were performed within 72 h from the onset of symptoms. The main indications for ERCP were suspicion of common bile duct stones (90.3%), jaundice (44.5%), clinical worsening of acute pancreatitis (14.2%) and cholangitis (6.1%). Biliary and pancreatic ducts were visualized in 305 patients (88.7%) and in 93 patients (27.0%) respectively. The success rate in obtaining a cholangiogram was statistically higher (P = 0.003) in patients with mild acute pancreatitis (90.6%) than in patients with severe disease (72.2%). Biliary endoscopic sphincterotomy was performed in 295 of the 305 patients (96.7%) with no difference between mild and severe disease (P = 0.985). ERCP morbidity was 6.1% and mortality was 1.7%; the mortality was due to the complications of acute pancreatitis and not the endoscopic procedure.
CONCLUSION: The results of this survey, as with those carried out in other countries, indicate a lack of compliance with the guidelines for the indications for interventional endoscopy.
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Affiliation(s)
- Armando Gabbrielli
- Armando Gabbrielli, Luca Frulloni, Claudio Bassi, Department of Surgical and Gastroenterological Sciences, University of Verona, Verona 37100, Italy
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Overby DW, Apelgren KN, Richardson W, Fanelli R. SAGES guidelines for the clinical application of laparoscopic biliary tract surgery. Surg Endosc 2010; 24:2368-86. [PMID: 20706739 DOI: 10.1007/s00464-010-1268-7] [Citation(s) in RCA: 177] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 05/27/2010] [Indexed: 12/13/2022]
Affiliation(s)
- D Wayne Overby
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.
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Abstract
OBJECTIVE We explored whether admission volumes for cholecystectomy (CCY) and pancreatitis were associated with receiving CCY after hospitalization for acute biliary pancreatitis (ABP). METHODS We identified admissions for ABP in the Nationwide Inpatient Sample between 1998 and 2003. We used multivariate analysis to assess the association between likelihood of CCY and hospital volumes of CCY, pancreatitis, and endoscopic retrograde cholangiopancreatography (ERCP). RESULTS The overall rate of CCY for ABP was 50%. After adjustment for confounders, the likelihood of CCY increased with every quartile of CCY volume relative to the bottom quartile (adjusted odds ratios of 4.36, 7.92, and 12.51 for quartiles 2, 3, and 4, respectively, P < 0.0001). Pancreatitis volume was inversely correlated with likelihood of CCY (adjusted odds ratios of 0.72, 0.62, and 0.48 for quartiles 2, 3, and 4, respectively, vs bottom quartile, P < 0.01). Admissions to hospitals in the top quartile for ERCP volume (>35 ERCPs/yr) had 15% lower odds of CCY than the lowest quartile. Patients from rural areas and with lower income were disproportionately admitted to hospitals with lower CCY volumes. CONCLUSIONS US hospitals are not achieving targets for CCY after ABP as set by national and international guidelines. Centers with smaller CCY volumes are the least adherent to recommendations for CCY possibly because of hospital-level resource limitations.
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Abstract
BACKGROUND/AIM It is now 60 years since early cholecystectomy was advocated for acute cholecystitis (AC). Yet, surgical opinion remains divided regarding its optimal timing. Furthermore, recent surveys have shown low utilization of early laparoscopic cholecystectomy (LC) for AC. AIM This survey aimed to assess the current management of AC in Eastern Saudi Arabia. MATERIALS AND METHODS A postal survey was conducted by means of a questionnaire sent to 95 surgeons practicing LC. The questionnaire addressed the surgical management of AC in relation to the subspecialty of interest, duration of consultant status, number of cholecystectomies performed per year, and the percentage performed laparoscopically. RESULTS There were 87 responders (92%); two were excluded from the analysis for different reasons. Early LC was preferred by 71% of the responders. With regard to the timing of LC, there was no significant difference in relation to the surgeon's subspecialty of interest or duration of consultant status. However, increased number of cholecystectomies and percentage of cholecystectomies performed with a laparoscopic approach were significantly associated with early LC. CONCLUSION Early LC for AC is practiced by th e majority of surgeons in Eastern Saudi Arabia. This practice is significantly associated with increased number of cholecystectomies performed as well as with the percentage performed with a laparoscopic approach. According to the current literature, early LC for AC results in a shorter total hospital stay and reduced cost of treatment.
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Affiliation(s)
- Abdulmohsen A. Al-Mulhim
- Department of Surgery, King Fahd Hospital of the University, Al-Khobar, Saudi Arabia,Address for correspondence: Dr. Abdulmohsen A. Al-Mulhim, P.O. Box 1917, Al-Khobar 31952, Saudi Arabia. E-mail:
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Nguyen GC, Tuskey A, Jagannath SB. Racial disparities in cholecystectomy rates during hospitalizations for acute gallstone pancreatitis: a national survey. Am J Gastroenterol 2008; 103:2301-7. [PMID: 18844616 DOI: 10.1111/j.1572-0241.2008.01949.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Practice guidelines advocate performing cholecystectomy for acute gallstone pancreatitis during the same hospitalization stay. Our objectives were to determine nationwide rates of adherence to these guidelines in the United States and whether this varied with race and ethnicity. METHODS We queried the Nationwide Inpatient Sample (NIS) to identify admissions for acute gallstone pancreatitis between 1998 and 2003. We calculated overall and race-specific proportions of patients who underwent cholecystectomy or endoscopic retrograde cholangiopancreatography (ERCP) prior to discharge. We used multivariate analysis to determine racial effects while adjusting for age, comorbidity, health insurance payer, and hospital factors. RESULTS The overall rate of cholecystectomy was 51% and that of either cholecystectomy or ERCP was 62%. Cholecystectomy rates were lower among African Americans (AAs) and Asians compared to Whites (44% and 43%, respectively, vs 50%, P < 0.001). After multivariate adjustment, the odds of cholecystectomy was lower in AAs (OR 0.68, 95% CI 0.63-0.73) and Asians/Pacific Islanders (OR 0.75, 95% CI 0.65-0.87) relative to Whites, while rates were modestly higher among Hispanics (OR 1.12, 95% CI 1.03-1.22). AAs were less likely to receive ERCP than Whites (OR 0.71, 95% CI 0.65-0.78). In contrast, Asians/Pacific Islanders (OR 1.40, 95% CI 1.16-1.69) and Hispanics (OR 1.19, 95% CI 1.09-1.29) were more likely to receive ERCP than Whites. CONCLUSIONS Despite practice guidelines, about only half of admissions for gallstone pancreatitis receive cholecystectomy during the same hospitalization, and cholecystectomy rates vary substantially by race. These findings raise concerns regarding suboptimal healthcare delivery.
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Affiliation(s)
- Geoffrey C Nguyen
- Mount Sinai Hospital, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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