title: Evolution in the utilization of biliary interventions in the United States: results of a nationwide longitudinal study from 1998 to 2013.
abstract: OBJECTIVE
  Bile duct surgery (BDS), percutaneous transhepatic cholangiography (PTC), and ERCP are alternative interventions used to treat biliary disease. Our aim was to describe trends in ERCP, BDS, and PTC on a nationwide level in the United States.
  
  
  METHODS
  We used the National Inpatient Sample to estimate age-standardized utilization trends of inpatient diagnostic ERCP, therapeutic ERCP, BDS, and PTC between 1998 and 2013. We calculated average case fatality, length of stay, patient demographic profile (age, gender, payer), and hospital characteristics (hospital size and metropolitan status) for these procedures.
  
  
  RESULTS
  Total biliary interventions decreased over the study period from 119.8 to 100.1 per 100,000. Diagnostic ERCP utilization decreased by 76%, and therapeutic ERCP utilization increased by 35%. BDS rates decreased by 78% and PTC rates by 24%. ERCP has almost completely supplanted surgery for the management of choledocholithiasis. Fatality from ERCP, BDS, and PTC have all decreased, whereas mean length of stay has remained stable. The proportion of Medicare-insured, Medicaid-insured, and uninsured patients undergoing biliary procedures has increased over time. Most of the increase in therapeutic ERCP and decrease in BDS occurred in large, metropolitan hospitals.
  
  
  CONCLUSIONS
  Although therapeutic ERCP utilization has increased over time, the total volume of biliary interventions has decreased. BDS utilization has experienced the most dramatic decrease, possibly a consequence of the increased therapeutic capacity and safety of ERCP. ERCPs are now predominantly therapeutic in nature. Large urban hospitals are leading the shift from surgical to endoscopic therapy of the biliary system.
authors.affiliation: Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California, USA.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Huang
authors.affiliation: Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California, USA.
authors.forename: Nirav C
authors.initials: NC
authors.lastname: Thosani
authors.affiliation: Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California, USA.
authors.forename: Monique T
authors.initials: MT
authors.lastname: Barakat
authors.affiliation: Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California, USA.
authors.forename: Abhishek
authors.initials: A
authors.lastname: Choudhary
authors.affiliation: Institute of Clinical Outcomes Research and Education (ICORE), Woodside, California, USA.
authors.forename: Alka
authors.initials: A
authors.lastname: Mithal
authors.affiliation: Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California, USA; Institute of Clinical Outcomes Research and Education (ICORE), Woodside, California, USA.
authors.forename: Gurkirpal
authors.initials: G
authors.lastname: Singh
authors.affiliation: Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California, USA.
authors.forename: Saurabh
authors.initials: S
authors.lastname: Sethi
authors.affiliation: Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California, USA.
authors.forename: Subhas
authors.initials: S
authors.lastname: Banerjee
mesh_terms: D000368:Aged; D000553:Ambulatory Care / Q000639:trends; D001652:Bile Ducts / Q000601:surgery*; D001660:Biliary Tract Diseases / Q000000981:diagnostic imaging* / Q000401:mortality / Q000601:surgery*; D002758:Cholangiography / Q000706:statistics & numerical data* / Q000639:trends; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000706:statistics & numerical data* / Q000639:trends; D042883:Choledocholithiasis / Q000000981:diagnostic imaging / Q000601:surgery; D005260:Female; D006276:Health Facility Size / Q000706:statistics & numerical data; D006786:Hospitals, Urban / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000639:trends; D008137:Longitudinal Studies; D008297:Male; D008484:Medicaid / Q000639:trends; D017057:Medically Uninsured / Q000706:statistics & numerical data; D006278:Medicare / Q000639:trends; D008875:Middle Aged; D014481:United States