Variation in the use of intraoperative cholangiography during cholecystectomy

Kristin M. Sheffield, Yimei Han, Yong Fang Kuo, Courtney Townsend, James Goodwin, Taylor S. Riall

Research output: Contribution to journalArticle

31 Citations (Scopus)

Abstract

Background: The role of intraoperative cholangiography (IOC) in prevention of common bile duct (CBD) injuries and the management of CBD stones is controversial, and current variation in use of IOC has not been well described. Study Design: Multilevel hierarchical models using data from the Texas Hospital Inpatient Discharge Public Use data files (2001 to 2008) were used to evaluate the percentage of variance in the use of IOC that was attributable to patient, surgeon, and hospital factors. Results: A total of 176,981 cholecystectomies were performed in 212 hospitals in Texas. There was wide variation in IOC use, ranging from 2.4% to 98.4% of cases among surgeons and 3.7% to 94.8% of cases among hospitals, even after adjusting for case mix differences. The percentage of variance in IOC use attributable to the surgeon was 20.7% and an additional 25.7% was attributable to the hospital. IOC use was associated with increased age, gallstone pancreatitis or CBD stones, Hispanic race, decreased illness severity, insurance, and later year of cholecystectomy. ERCP (24.0% vs 14.9%, p < 0.0001) and CBD exploration (1.63% vs 0.42%, p < 0.0001) were more commonly performed in patients undergoing IOC. Conclusions: Uncertainty regarding the benefit of IOC leads to wide variation in use across surgeons and hospitals. The surgeon and hospital are more important determinants of IOC use than measured patient characteristics. Our study highlights the need for further evaluation of comparative effectiveness of IOC in the prevention of CBD injuries and retained stones, taking into account patient risk factors, surgeon skill, cost, and availability of local expertise.

Original languageEnglish (US)
Pages (from-to)668-679
Number of pages12
JournalJournal of the American College of Surgeons
Volume214
Issue number4
DOIs
StatePublished - Apr 2012

Fingerprint

Cholangiography
Cholecystectomy
Common Bile Duct
Endoscopic Retrograde Cholangiopancreatography
Information Storage and Retrieval
Diagnosis-Related Groups
Wounds and Injuries
Gallstones
Insurance
Hispanic Americans
Pancreatitis
Uncertainty
Surgeons
Inpatients
Costs and Cost Analysis

Keywords

  • CBD
  • common bile duct
  • ICC
  • interquartile range
  • intraclass correlation coefficient
  • intraoperative cholangiography
  • IOC
  • IQR

ASJC Scopus subject areas

  • Surgery

Cite this

Variation in the use of intraoperative cholangiography during cholecystectomy. / Sheffield, Kristin M.; Han, Yimei; Kuo, Yong Fang; Townsend, Courtney; Goodwin, James; Riall, Taylor S.

In: Journal of the American College of Surgeons, Vol. 214, No. 4, 04.2012, p. 668-679.

Research output: Contribution to journalArticle

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abstract = "Background: The role of intraoperative cholangiography (IOC) in prevention of common bile duct (CBD) injuries and the management of CBD stones is controversial, and current variation in use of IOC has not been well described. Study Design: Multilevel hierarchical models using data from the Texas Hospital Inpatient Discharge Public Use data files (2001 to 2008) were used to evaluate the percentage of variance in the use of IOC that was attributable to patient, surgeon, and hospital factors. Results: A total of 176,981 cholecystectomies were performed in 212 hospitals in Texas. There was wide variation in IOC use, ranging from 2.4{\%} to 98.4{\%} of cases among surgeons and 3.7{\%} to 94.8{\%} of cases among hospitals, even after adjusting for case mix differences. The percentage of variance in IOC use attributable to the surgeon was 20.7{\%} and an additional 25.7{\%} was attributable to the hospital. IOC use was associated with increased age, gallstone pancreatitis or CBD stones, Hispanic race, decreased illness severity, insurance, and later year of cholecystectomy. ERCP (24.0{\%} vs 14.9{\%}, p < 0.0001) and CBD exploration (1.63{\%} vs 0.42{\%}, p < 0.0001) were more commonly performed in patients undergoing IOC. Conclusions: Uncertainty regarding the benefit of IOC leads to wide variation in use across surgeons and hospitals. The surgeon and hospital are more important determinants of IOC use than measured patient characteristics. Our study highlights the need for further evaluation of comparative effectiveness of IOC in the prevention of CBD injuries and retained stones, taking into account patient risk factors, surgeon skill, cost, and availability of local expertise.",
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