Lower Provider Volume is Associated With Higher Failure Rates for Endoscopic Retrograde Cholangiopancreatography

Abstract

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. Research Design Retrospective Cohort Subjects 16,968 ERCPs performed by 130 physicians between 2001-2011, identified in the Indiana Network for Patient Care (INPC) Measures Physicians were classified by their average annual INPC volume and stratified into low (<25/year) and high (≥25/year). 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 1,163 (7.5%) failures; the failure rate was higher among low (9.5%) compared to 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 (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 (28.3%) vs. 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% CI 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 post-procedure hospitalization.

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