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ERCP by low-volume endoscopists exposes patients to more radiation
Endoscopic retrograde cholangiopancreatography, or ERCP, performed by low-volume endoscopists was associated with higher patient radiation exposure compared with ERCPs performed by high-volume endoscopists despite their increased complexity, according to research data.
To investigate the association between an endoscopist’s ERCP volume and patient exposure to radiation in the era of advanced fluoroscopy machines, researchers performed a retrospective study involving 197 patients (mean age, 60 years; 53% women) who underwent 331 ERCPs in the endoscopy unit at Stanford University School of Medicine between June 2010 and February 2011. The procedures were performed by two high-volume endoscopists (≥ 200 ERCPs per year) and seven low-volume endoscopists (< 200 ERCPS per year).
The researchers assessed patient radiation exposure during ERCP based on fluoroscopy time, total radiation dose, dose area product and effective dose. These parameters were adjusted for procedural and fluoroscopic complexity using a validated procedure complexity scale and the Stanford Fluoroscopy Complexity Score, which was created to account for the number of endoscopic interventions requiring additional fluoroscopy exposure.
High-volume endoscopists performed more ERCPs with greater complexity compared with low-volume endoscopists (43% vs. 15%; P ≤ .001), and performed ERCPs that were 100% more fluoroscopically demanding compared with those performed by low-volume endoscopists (P ≤ .001). Median fluoroscopy time overall was not significantly different between high-volume (3.3 minutes; interquartile range [IQR], 2.1-5.8) and low-volume endoscopists (4 minutes; IQR, 2.4-6.72).
Median total radiation dose was 32.6% higher in procedures performed by low-volume compared with high-volume endoscopists (98.3 mGy; IQR, 56.37-191.61 vs. 74.13 mGy; IQR, 42.92-125.54; P = .018). Median dose area product was 58.86% higher in procedures performed by low-volume compared with high-volume endoscopists (13.98 Gy-cm2; IQR, 8.66-23.15 vs. 8.8 Gy-cm2; IQR, 5.26-14.37; P < .001). Median effective dose was 59.21% higher in procedures performed by low-volume compared with high-volume endoscopists (3.63 mSv; IQR, 2.28-6 vs. 2.28 mSv; IQR, 1.36-3.76; P < .001).
The median dose area product/procedure complexity score ratio was 90.18% higher in procedures performed by low-volume compared with high-volume endoscopists (7.55; IQR, 4.62-12.31 vs. 3.97; IQR, 2.51-6.32; P < .001). The median dose area product/Stanford Fluoroscopy Complexity Score ratio was 127.54% higher in procedures performed by low-volume compared with high-volume endoscopists (3.8; IQR, 2.5-6.15 vs. 1.67; IQR, 0.98-2.69; P < .001).
“We established that patients undergoing ERCP performed by [low-volume endoscopists] were exposed to higher doses of radiation than patients undergoing ERCP performed by [high-volume endoscopists],” the researchers wrote.
“As the balance of the health care system in the United States shifts in favor of accountable care organizations that are reimbursed through bundled payments, the quality and efficiency of ERCP services will fall under increasing scrutiny,” Gregory A. Coté, MD, MS, from the Medical University of South Carolina, wrote in an accompanying editorial. “Gastroenterologists should ask themselves whether they are providing the best ERCP service to their patients. Following the lead of colonoscopy, where reporting adenoma detection rates is increasingly the norm, ERCP providers ought to begin disseminating relevant benchmarks: success rates, adverse events including length of stay when relevant, frequency of early repeat ERCPS, or related interventions such as percutaneous transhepatic cholangiogram, and now average radiation exposure—from the patient’s perspective—per procedure.” – by Adam Leitenberger
Disclosure: The researchers and Coté report no relevant financial disclosures.