Abstract
Background
Two treatment options exist for choledocholithiasis (CDL): endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct exploration (CBDE). Resource utilization measured by total in-hospital charges (THC) and length of stay (LOS) was compared using the propensity score (PS). In this study, PS was the probability that a patient received CBDE based on comorbidities and demographics. The power of this method lies in balancing groups on variables by PS, resulting in 90% bias reduction and improved inferential validity compared to traditional analytic techniques.
Methods
Laparoscopic cholecystectomy (LC) patients with CDL who had ERCP or CBDE were identified in the 2002 U.S. Nationwide Inpatient Sample. Patients were ordered into five PS balanced strata. Mean THC, LOS, and estimated costs were compared. A linear regression model was used to estimate the contribution that LOS had on estimated costs. Monetary values were adjusted to 2004 dollars.
Results
A total of 40,982 patients underwent LC with CDL in 2002; 27,739 had either ERCP (93%) or CBDE (7%). Mean age was 52.7 ± 0.4 years, with 74% women. Mean THC were less for CBDE ($25,200 ± $1,800) than for ERCP ($29,900 ± $800, p < 0.05). Mean LOS was less for CBDE (4.9 ± 0.2 days) than for ERCP (5.6 ± 0.1 days, p < 0.05). PS adjusted analysis revealed an estimated overall cost savings of $4,500 ± $1,600 and reduced LOS (0.6 ± 0.2 days) per hospitalization for CBDE. Mean THC, LOS, and estimated costs across PS score balanced strata were generally higher in the ERCP group compared to the CBDE group. LOS contributed 53% to increased THC and 62% of estimated costs. A higher cumulative incidence of complications was evident with CBDE (0.5–4.6%) compared to ERCP (0.3–3.6%).
Conclusions
Based on this PS analysis, CBDE incurs less THC, reduces LOS, and has less estimated costs for CDL compared to ERCP. Furthermore, CBDE appears to be dramatically underutilized.
Similar content being viewed by others
References
Agency for Healthcare Research and Quality (2002) Healthcare Cost and Utilization Project (HCUP-2002). Nationwide Inpatient Sample. Agency for Healthcare Research and Quality, Rockville, MD, USA
Becker SO, Ichino A (2002) Estimation of average treatment effects based on propensity scores. Stata J 2: 358–377
Centers for Medicare & Medicaid Services (2004) Available at http://www.cms.hhs.gov/providers/hipps/ippspufs.asp
Cuschieri A, Lezoche E, Morino M, et al. (1999) E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 13: 952–957
Deyo RA, Cherkin DC, Ciol MA (1992) Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 45: 613–619
Elixhauser A, Steiner C, Harris DR, Coffey RM (1998) Comorbidity measures for use with administrative data. Medical Care 36: 8–27
Fielding GA, (2002) The case for laparoscopic common bile duct exploration. J Hepato-Biliary-Pancreatic Surg 9: 723–728
Guller U, Hervey S, Purves H, Muhlbaier LH, Peterson ED, Eubanks S, Pietrobon R (2004) Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database. Ann Surg 239: 43–52
Joffe MM, Rosenbaum PR (1999) Invited commentary: propensity scores. Am J Epidemiol 150: 327–333
Kapoor R, Kaushik SP, Saraswat VA, Choudhuri G, Sikora SS, Saxena R, Kapoor VK (1996) Prospective randomized trial comparing endoscopic sphincterotomy followed by surgery with surgery alone in good risk patients with choledocholithiasis. HPB Surg 9: 145–148
Liberman MA, Phillips EH, Carroll BJ, Fallas MJ, Rosenthal R, Hiatt J (1996) Cost-effective management of complicated choledocholithiasis: laparoscopic transcystic duct exploration or endoscopic sphincterotomy. J Am Coll Surg 182: 488–494
National Institutes of Health (2002) NIH state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy. NIH Consensus State-of-the-Science Statements 19: 1–26
Paganini AM, Feliciotti F, Guerrieri M, Tamburini A, De Sanctis A, Campagnacci R, Lezoche E (2001) Laparoscopic common bile duct exploration. J Laparoendosc Adv Surg Techniques A 11: 391–400
Petelin JB (2003) Laparoscopic common bile duct exploration. Surg Endosc 17: 1705–1715
Radensky PW, Berliner E, Archer JW, Dournaux SF (2001) Inpatient costs of major cardiovascular events. Am J Cardiovasc Drugs 1: 205–217
Rhodes M, Sussman L, Cohen L, Lewis MP (1998) Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet 351: 159–161
Rosenbaum PR, Rubin DB (1984) Reducing bias in observational studies using subclassification on the propensity score. J Am Statistical Assoc 79: 516–524
Sahai AV, Mauldin PD, Marsi V, Hawes RH, Hoffman BJ (1999) Bile duct stones and laparoscopic cholecystectomy: a decision analysis to assess the roles of intraoperative cholangiography, EUS, and ERCP. Gastrointest Endosc 49: 334–343
Sgourakis G, Karaliotas K (2002) Laparoscopic common bile duct exploration and cholecystectomy versus endoscopic stone extraction and laparoscopic cholecystectomy for choledocholithiasis. A prospective randomized study. Minerva Chir 57: 467–474
Stain SC, Cohen H, Tsuishoysha M, Donovan AJ (1991) Choledocholithiasis. Endoscopic sphincterotomy or common bile duct exploration. Ann Surg 213: 627-634
Suc B, Escat J, Cherqui D, Fourtanier G, Hay JM, Fingerhut A, Millat B (1998) Surgery vs endoscopy as primary treatment in symptomatic patients with suspected common bile duct stones: a multicenter randomized trial. French Associations for Surgical Research. Arch Surg 133: 702–708
Urbach DR, Khajanchee YS, Jobe BA, Standage BA, Hansen PD, Swanstrom LL (2001) Cost-effective management of common bile duct stones: a decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration. Surg Endosc 15: 4–13
U.S. Department of Labor, Bureau of Labor Statistics (2004) Consumer price index for medical care. Available at http://www.bls.gov/cpi . U.S. Department of Labor, Bureau of Labor Statistics, Washington, DC
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Poulose, B.K., Arbogast, P.G. & Holzman, M.D. National analysis of in-hospital resource utilization in choledocholithiasis management using propensity scores. Surg Endosc 20, 186–190 (2006). https://doi.org/10.1007/s00464-005-0235-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-005-0235-1