Racial disparities in cholecystectomy rates during hospitalizations for acute gallstone pancreatitis: a national survey.
ABSTRACT 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.
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.
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.
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.
Article: Gallstone Pancreatitis: A Review.[Show abstract] [Hide abstract]
ABSTRACT: Gallstone disease is the most common cause of acute pancreatitis in the Western world. In most cases, gallstone pancreatitis is a mild and self-limiting disease, and patients may proceed without complications to cholecystectomy to prevent future recurrence. Severe disease occurs in about 20% of cases and is associated with significant mortality; meticulous management is critical. A thorough understanding of the disease process, diagnosis, severity stratification, and principles of management is essential to the appropriate care of patients presenting with this disease. This article reviews these topics with a focus on surgical management, including appropriate timing and choice of interventions.Surgical Clinics of North America 04/2014; 94(2):257-280. DOI:10.1016/j.suc.2014.01.006 · 1.93 Impact Factor
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ABSTRACT: The management of acute biliary diseases often involves endoscopic retrograde cholangiopancreatography (ERCP). The effectiveness of ERCP on reducing mortality has not previously been shown. To determine whether mortality from acute biliary diseases requiring ERCP has improved over time and to explore factors associated with mortality. We conducted a cohort study using the Nationwide Inpatient Sample for the years 1998-2008. Hospitalizations for choledocholithiasis, cholangitis and acute pancreatitis involving an ERCP were identified. Multivariate analyses were used to determine the effects of time period, patient factors, hospital characteristics, ERCP procedure features and types of cholecystectomies on mortality, length of stay and costs. From 1998 to 2008, there were 166,438 admissions for acute biliary conditions that met the inclusion criteria, corresponding to over 800,000 patients nationwide. During this interval, mortality decreased from 1.1% to 0.6% (adjusted odds ratio [aOR] 0.7; 95% confidence interval [CI] 0.6-0.8), diagnostic ERCPs decreased from 28.8% to 10.0%, hospitals performing < 100 ERCPs per year decreased from 38.4% to 26.9%, open cholecystectomies decreased from 12.4% to 5.8%, and unsuccessful ERCPs decreased from 6.3% to 3.2% (p<0.0001 for all trends). Unsuccessful ERCP (aOR 1.7, 95% CI 1.4-2.2), open cholecystectomy (aOR 3.4, 95% CI 2.7-4.3), cholangitis (aOR 1.9, 95% CI 1.5-2.3), older age, having Medicare health insurance and comorbidity were associated with increased mortality. In-hospital mortality from acute biliary conditions requiring ERCP in the United States has decreased over time. Reductions in the rate of unsuccessful ERCPs and open cholecystectomies are associated with this trend.Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 10/2013; 12(7). DOI:10.1016/j.cgh.2013.09.054 · 6.53 Impact Factor
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ABSTRACT: Introduction Current guidelines for the management of acute gallstone pancreatitis recommend cholecystectomy as definitive treatment during primary admission or within 2 weeks of discharge, with the aim of preventing recurrent pancreatitis. However, cholecystectomy during the inflammatory phase may increase surgical complication rates. This study aimed to determine whether adherence to the guidelines prevents recurrent pancreatitis while minimising surgical complications. Methods Multi-centre review of seven UK hospitals, indentifying patients presenting with their first episode of gallstone pancreatitis between 2006 and 2008. Results A total of 523 patients with gallstone pancreatitis were identified, of which 363 (69%) underwent cholecystectomy (72 during the primary admission or within 2 weeks of discharge; 291 following this). Overall, 7% of patients had a complication related to cholecystectomy of which a greater proportion occurred when cholecystectomy was performed within guideline parameters (13% vs 6%; p = 0.07). 11% of patients were readmitted with recurrent pancreatitis prior to surgery, with those undergoing cholecystectomy outside guideline parameters being most at risk (p = 0.006). Conclusion This study suggests cholecystectomy within guideline parameters significantly reduces recurrence of pancreatitis but may increase the risk of surgical complications. A prospective randomised study to assess the associated morbidity is required to inform future guidelines.The surgeon: journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 01/2013; DOI:10.1016/j.surge.2013.07.006 · 2.21 Impact Factor