Evolution in the utilization of biliary interventions in the United States: results of a nationwide longitudinal study from 1998 to 2013

Abstract

Background and aims: Bile duct surgery (BDS), percutaneous transhepatic cholangiography (PTC), and ERCP are alternative interventions used to treat biliary disease. Our aim was to describe trends in ERCP, BDS, and PTC on a nationwide level in the United States.

Methods: We used the National Inpatient Sample to estimate age-standardized utilization trends of inpatient diagnostic ERCP, therapeutic ERCP, BDS, and PTC between 1998 and 2013. We calculated average case fatality, length of stay, patient demographic profile (age, gender, payer), and hospital characteristics (hospital size and metropolitan status) for these procedures.

Results: Total biliary interventions decreased over the study period from 119.8 to 100.1 per 100,000. Diagnostic ERCP utilization decreased by 76%, and therapeutic ERCP utilization increased by 35%. BDS rates decreased by 78% and PTC rates by 24%. ERCP has almost completely supplanted surgery for the management of choledocholithiasis. Fatality from ERCP, BDS, and PTC have all decreased, whereas mean length of stay has remained stable. The proportion of Medicare-insured, Medicaid-insured, and uninsured patients undergoing biliary procedures has increased over time. Most of the increase in therapeutic ERCP and decrease in BDS occurred in large, metropolitan hospitals.

Conclusions: Although therapeutic ERCP utilization has increased over time, the total volume of biliary interventions has decreased. BDS utilization has experienced the most dramatic decrease, possibly a consequence of the increased therapeutic capacity and safety of ERCP. ERCPs are now predominantly therapeutic in nature. Large urban hospitals are leading the shift from surgical to endoscopic therapy of the biliary system.

Figure 1

A, Age-standardized trends in the rate of diagnostic ERCP, therapeutic ERCP, BDS, and PTC per 100,000 United States residents. “All biliary interventions” is defined as the sum of diagnostic ERCP, therapeutic ERCP, BDS, and PTC. B, Age-standardized trends in the rate of ERCP (51.88), BDS (51.41), and PTC (51.96) for the management of bile duct stones. ‘All interventions for bile duct stones’ is defined as the sum of 51.88, 51.41, and 51.96. C, Age-standardized rates of endoscopic sphincterotomy and papillotomy (51.85), endoscopic insertion of stent into bile duct (51.87) and endoscopic removal of stone(s) from biliary tract (51.88). D, Age-standardized rates of BDS per 100,000 United States residents by primary type of surgery: anastomosis of bile duct (51.32, 51.36), incision for relief of bile duct obstruction (51.41, 51.42, 51.43, 51.49), other incision of bile duct (51.51, 51.59), and repair of bile ducts (51.71, 51.72, 51.79). See Supplemental Tables 2 and 3 for corresponding data tables.

Figure 2

A, Trends in case fatality (defined as in-hospital deaths per 100 discharges) for hospitalizations in which ERCP, BDS, or PTC is listed as the principal procedure. B, Trends in average length of stay for hospitalizations in which ERCP, BDS, or PTC is listed as principle procedure. See Supplementary Tables 4 and 5 for corresponding data tables.

Figure 3

Trends in the rate of therapeutic ERCP. (A), BDS (B), and PTC (C) by age. Age-standardized trends in the rate of therapeutic ERCP (D), BDS (E), and PTC (F) by gender. See Supplementary Tables 6 and 7 for corresponding data tables.

Figure 4

Age-standardized trends in payer profile for therapeutic ERCP (A), BDS (B), and PTC (C). See Supplementary Table 8 for corresponding data table.

Figure 5

Age-standardized trends in the rate of therapeutic ERCP (A), BDS (B), and PTC (C) by hospital size. Age-standardized trends in the rate of therapeutic ERCP (D), BDS (E), and PTC (F) by hospital metropolitan status. See text for description of classifications of hospital characteristics. See Supplementary Tables 9 and 10 for corresponding data tables. Metro; metropolitan-located hospital; non-metro; non-metropolitan located hospital.

Figure 6

Rate of therapeutic and diagnostic ERCPs in outpatient settings based on the State Ambulatory Surgery Databases (California year 2011, Florida year 2013, and New York year 2013) compared with inpatient rates based on the National Inpatient Sample (year 2013).