title: The clinical impact and cost implication of endoscopic ultrasound on use of endoscopic retrograde cholangiopancreatography in a Canadian university hospital.
abstract: BACKGROUND
  Endoscopic ultrasound (EUS) is a safe alternative to endoscopic retrograde cholangiopancreatography (ERCP) for diagnostic biliary imaging in choledocholithiasis. Evidence linking a decline in diagnostic ERCP with the introduction of EUS in clinical practice is limited.
  
  
  OBJECTIVE
  To assess the clinical impact and cost implications of a new EUS program on diagnostic ERCP at a tertiary referral centre.
  
  
  METHODS
  A retrospective review was performed of data collected during the first year of EUS at the University of Alberta Hospital (Edmonton, Alberta). Patients were referred for ERCP because of suspicion of choledocholithiasis based on clinical, biochemical and/or radiological parameters. If they were assessed to have an intermediate probability of choledocholithiasis, EUS was performed first. ERCP was performed if EUS suggested choledocholithiasis, whereas patients were clinically followed for six months if their EUS was normal. Cost data were assessed from a third-party payer perspective, and cost savings were expressed in terms of ERCP procedures avoided.
  
  
  RESULTS
  Over 12 months, 90 patients (63 female, mean age 58 years) underwent EUS for suspected biliary tract abnormalities. EUS suggested choledocholithiasis in 20 patients (22%), and this was confirmed by ERCP in 17 of the 20 patients. EUS was normal in 69 patients, and none underwent a subsequent ERCP during a six-month follow-up period. One patient had pancreatic cancer and did not undergo ERCP. The sensitivity and specificity of EUS for choledocholithiasis were 100% and 96%, respectively. A total of 440 ERCP procedures were performed over the same 12-month period, suggesting that EUS resulted in a 14% reduction in ERCP procedures (70 of 510). There were no complications of EUS. The cost of 90 EUS procedures was $42,840, compared with $108,854 for 70 ERCP procedures. The cost savings for the first year were $66,014.
  
  
  CONCLUSIONS
  EUS appears to be accurate, safe and cost effective in diagnostic biliary imaging for suspected choledocholithiasis. The impact of EUS is the avoidance of ERCP in selected cases, thereby preventing the risk of complications. Diagnostic ERCP should not be performed in centres and regions with physicians trained in EUS.
authors.affiliation: Department of Internal Medicine, University of Alberta Hospital, Edmonton, Canada.
authors.forename: N
authors.initials: N
authors.lastname: Alhayaf
authors.forename: E
authors.initials: E
authors.lastname: Lalor
authors.forename: V
authors.initials: V
authors.lastname: Bain
authors.forename: J
authors.initials: J
authors.lastname: McKaigney
authors.forename: G Singh
authors.initials: GS
authors.lastname: Sandha
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002170:Canada; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000191:economics / Q000706:statistics & numerical data*; D042883:Choledocholithiasis / Q000000981:diagnostic imaging* / Q000628:therapy; D003362:Cost-Benefit Analysis; D019160:Endosonography / Q000191:economics*; D005260:Female; D017048:Health Care Costs; D006760:Hospitalization / Q000191:economics; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation; D012189:Retrospective Studies