title: Variation in the use of intraoperative cholangiography during cholecystectomy.
abstract: BACKGROUND
  The role of intraoperative cholangiography (IOC) in prevention of common bile duct (CBD) injuries and the management of CBD stones is controversial, and current variation in use of IOC has not been well described.
  
  
  METHODS
  Multilevel hierarchical models using data from the Texas Hospital Inpatient Discharge Public Use data files (2001 to 2008) were used to evaluate the percentage of variance in the use of IOC that was attributable to patient, surgeon, and hospital factors.
  
  
  RESULTS
  A total of 176,981 cholecystectomies were performed in 212 hospitals in Texas. There was wide variation in IOC use, ranging from 2.4% to 98.4% of cases among surgeons and 3.7% to 94.8% of cases among hospitals, even after adjusting for case mix differences. The percentage of variance in IOC use attributable to the surgeon was 20.7% and an additional 25.7% was attributable to the hospital. IOC use was associated with increased age, gallstone pancreatitis or CBD stones, Hispanic race, decreased illness severity, insurance, and later year of cholecystectomy. ERCP (24.0% vs 14.9%, p < 0.0001) and CBD exploration (1.63% vs 0.42%, p < 0.0001) were more commonly performed in patients undergoing IOC.
  
  
  CONCLUSIONS
  Uncertainty regarding the benefit of IOC leads to wide variation in use across surgeons and hospitals. The surgeon and hospital are more important determinants of IOC use than measured patient characteristics. Our study highlights the need for further evaluation of comparative effectiveness of IOC in the prevention of CBD injuries and retained stones, taking into account patient risk factors, surgeon skill, cost, and availability of local expertise.
authors.affiliation: Department of Surgery, The University of Texas Medical Branch, Galveston, TX 77555-0541, USA.
authors.forename: Kristin M
authors.initials: KM
authors.lastname: Sheffield
authors.forename: Yimei
authors.initials: Y
authors.lastname: Han
authors.forename: Yong-Fang
authors.initials: YF
authors.lastname: Kuo
authors.forename: Courtney M
authors.initials: CM
authors.lastname: Townsend
authors.forename: James S
authors.initials: JS
authors.lastname: Goodwin
authors.forename: Taylor S
authors.initials: TS
authors.lastname: Riall
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002758:Cholangiography / Q000706:statistics & numerical data*; D002763:Cholecystectomy / Q000379:methods* / Q000706:statistics & numerical data; D015331:Cohort Studies; D005260:Female; D042882:Gallstones / Q000601:surgery*; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D007430:Intraoperative Care / Q000379:methods / Q000706:statistics & numerical data*; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D013781:Texas; D055815:Young Adult