Lower provider volume is associated with higher failure rates for endoscopic retrograde cholangiopancreatography.
BACKGROUND
Among physicians who perform endoscopic retrograde cholangiopancreatography (ERCP), the relationship between procedure volume and outcome is unknown.


OBJECTIVE
Quantify the ERCP volume-outcome relationship by measuring provider-specific failure rates, hospitalization rates, and other quality measures.


METHODS
Retrospective cohort.


METHODS
A total of 16,968 ERCPs performed by 130 physicians between 2001 and 2011, identified in the Indiana Network for Patient Care.


METHODS
Physicians were classified by their average annual Indiana Network for Patient Care volume and stratified into low (<25/y) and high (≥25/y). Outcomes included failed procedures, defined as repeat ERCP, percutaneous transhepatic cholangiography or surgical exploration of the bile duct≤7 days after the index procedure, hospitalization rates, and 30-day mortality.


RESULTS
Among 15,514 index ERCPs, there were 1163 (7.5%) failures; the failure rate was higher among low (9.5%) compared with high volume (5.7%) providers (P<0.001). A second ERCP within 7 days (a subgroup of failure rate) occurred more frequently when the original ERCP was performed by a low-volume (4.1%) versus a high-volume physician (2.3%, P=0.013). Patients were more frequently hospitalized within 24 hours when the ERCP was performed by a low-volume (28.3%) versus high-volume physician (14.8%, P=0.002). Mortality within 30 days was similar (low=1.9%, high=1.9%). Among low-volume physicians and after adjusting, the odds of having a failed procedure decreased 3.3% (95% confidence interval, 1.6%-5.0%, P<0.001) with each additional ERCP performed per year.


CONCLUSIONS
Lower provider volume is associated with higher failure rate for ERCP, and greater need for postprocedure hospitalization.
*Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN †Regenstrief Institute Inc. ‡Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN §Department of Ophthalmology and Center for Healthcare Studies, VA Center of Excellence, Northwestern University Feinberg School of Medicine, Chicago, IL ∥Center of Excellence for Implementation of Evidence-based Practice, Roudebush VA Medical Center ¶Department of Pediatrics, Indiana University School of Medicine #Department of Geography, Indiana University-Purdue University Indianapolis, Indianapolis, IN.
Gregory A
GA
Coté
Timothy D
TD
Imler
Huiping
H
Xu
Evgenia
E
Teal
Dustin D
DD
French
Thomas F
TF
Imperiale
Marc B
MB
Rosenman
Jeffery
J
Wilson
Siu L
SL
Hui
Stuart
S
Sherman
D000328:Adult; D000368:Aged; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000706:statistics & numerical data*; D005260:Female; D005762:Gastroenterology / Q000706:statistics & numerical data*; D006302:Health Services Research; D006801:Humans; D007196:Indiana; D007345:Insurance Claim Review; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome