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Better ERCP outcomes achieved by high volume endoscopists, centers
Endoscopists and centers that performed a high volume of endoscopic retrograde cholangiopancreatography procedures showed higher rates of overall procedural success and lower rates of adverse events in a recent study.
These findings led investigators to suggest that consolidation of ERCP to high volume endoscopists may improve outcomes.
“Over the past 3 decades, the use of diagnostic [ERCP] has decreased 7-fold whereas therapeutic ERCP use has increased 30-fold,” Rajesh N. Keswani, MD, of the division of gastroenterology and hepatology at Northwestern University Feinberg School of Medicine in Chicago, and colleagues wrote. “The shift of ERCP toward a predominantly therapeutic intervention is associated with a resultant increase in complexity ... [which] likely raises the requisite expertise needed to complete the procedure successfully and also increases the risk of adverse events (AEs).”
Given the relationship between procedure volume and outcomes with most complex procedures, Keswani and colleagues performed a systematic review and meta-analysis to evaluate this relationship with ERCP.
After reviewing the available medical literature published up to January 2017, they included 13 studies reporting on 59,437 ERCP procedures. The definition of “low volume” varied across studies for both endoscopists (ranging from fewer than 25 to fewer than 156 ERCPs per year) and centers (fewer than 87 to fewer than 200 ERCPs per year).
The investigators found that high volume endoscopists showed significantly higher rates of procedural success vs. low volume endoscopists (OR = 1.6; 95% CI, 1.2-2.1), as did high volume centers (OR = 2; 95% CI, 1.6-2.5). Further, high volume endoscopists showed a lower rate of post-procedural AEs (OR = 0.7; 95% CI, 0.5-0.8).
“Given these compelling findings, we propose that providers and payers consider consolidating ERCP to high-volume endoscopists and centers to improve ERCP outcomes and value,” Keswani and colleagues concluded.
In a related editorial Peter B. Cotton, MD, FRCS, FRCP, of the Digestive Disease Center at the Medical University of South Carolina, provided recommendations on adequate volume and procedural quality. He recommended:
- that “hospital credentialing committees should have guidelines for credentialing and recredentialing,” based on overall experience and performance data;
- that the GI Quality Improvement Consortium (GIQuIC) “should include an ERCP platform to facilitate collecting the key data;”
- that “practices should publish their quality data on their websites, and have them available when requested;”
- that the American Society for Gastrointestinal Endoscopy (ASGE) “should develop a STAR system for recognizing advanced ERCPists;” and
- that providers should “continue to educate the public that ERCP is not just another routine procedure. It is much more challenging and dangerous.” – by Adam Leitenberger
Disclosures: The authors report no relevant financial disclosures.