title: Choledocholithiasis management in rural America: health disparity or health opportunity?
abstract: BACKGROUND
  Choledocholithiasis (CDL) management is dictated by local expertise, individual training, and availability of appropriate staff. This study evaluates the management of CDL between urban and rural communities.
  
  
  METHODS
  Patients undergoing inpatient management of CDL were identified from the 2007 Healthcare Cost and Utilization Project. Availability of endoscopic retrograde cholangiopancreatography (ERCP) was determined from the 2007 American Hospital Association survey. The proportion of common bile duct exploration (CBDE), ERCP, or percutaneous (PERC) interventions were compared across census regions and National Centers for Health Statistics (NCHS) urban-rural classes. The NCHS urban-rural classification scheme divides counties from most populous (NCHS 1) to rural (NCHS 6). Proportions were compared using the 95% confidence interval (95%CI) approach.
  
  
  RESULTS
  We estimated 111,021 CDL hospitalizations in the U.S. in 2007. Of these, 67% had a coded intervention. Intervention frequencies were similar across census regions. Comparisons across NCHS classes revealed higher proportions of ERCP in urban areas (NCHS 1-4) while a higher proportion of CBDE was seen in rural areas (NCHS 5-6). ERCP availability was high in metropolitan areas (available in 35%-44% of hospitals NCHS 1-4) and low in rural areas (25% of NCHS 5 hospitals and 5% NCHS 6). PERC management was similar across NCHS classes.
  
  
  CONCLUSIONS
  Rural hospitals and communities need surgeons trained in CBDE, where ERCP expertise may not be readily available. Feasible ways of expanding ERCP coverage to the nation's rural areas need to be explored. These observations may impact surgical training at least for those targeting careers in rural surgery.
authors.affiliation: Department of Surgery, Vanderbilt University Medical Center Nashville, Tennessee 37232, USA. benjamin.poulose@vanderbilt.edu
authors.forename: Benjamin K
authors.initials: BK
authors.lastname: Poulose
authors.forename: Sharon
authors.initials: S
authors.lastname: Phillips
authors.forename: William
authors.initials: W
authors.lastname: Nealon
authors.forename: Julia
authors.initials: J
authors.lastname: Shelton
authors.forename: Kristy
authors.initials: K
authors.lastname: Kummerow
authors.forename: David
authors.initials: D
authors.lastname: Penson
authors.forename: Michael D
authors.initials: MD
authors.lastname: Holzman
mesh_terms: D002321:Career Choice; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000706:statistics & numerical data*; D042883:Choledocholithiasis / Q000453:epidemiology* / Q000601:surgery*; D003135:Common Bile Duct / Q000601:surgery; D013502:General Surgery / Q000193:education / Q000706:statistics & numerical data; D019538:Health Care Surveys / Q000706:statistics & numerical data; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006780:Hospitals, Rural / Q000706:statistics & numerical data; D006786:Hospitals, Urban / Q000706:statistics & numerical data; D006801:Humans; D012424:Rural Population / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology; D014505:Urban Population / Q000706:statistics & numerical data