Comparative Analysis of ERCP and PTBD for Biliary Interventions for Readmission Rates and Patient Outcomes

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The utility of ERCP compared to PTBD is not fully understood from a utilization outcome standpoint. Our study compares readmission rates and hospitalization outcomes in ERCP and PTBD. Methods Using the National Readmission Database (NRD) 2016–2020, we identified all patients with an ERCP or PTBD completed during admission. The study cohort was first analyzed by three weighted study arms including those admitted with cholangitis, biliary/pancreatic malignancy, and choledocholithiasis. Second, we analyzed the cohort by a 1:1, unweighted propensity match. Primary outcome was 30 day, 90 day, and 6 month readmission. Secondary outcomes were readmission/overall mortality, cost, and length of stay. Outcomes were analyzed using multivariate analysis. Results A total of 621,735 admissions were identified associated with 589,796 ERCP and 31,939 PTBD. In the propensity matched cohort, PTBD had a higher readmission rate at 30 days (20.38% vs 13.71% p < 0.0001), 90 days (14.63% vs 13.14%, p < 0.0001), but lower rate at 6 months (8.50% vs 9.67%, p = 0.0003). Secondary outcomes included increased PTBD-associated hospital length of stay (9.01 days vs 6.74 days, p < 0.0001), hospitalization cost ( $ 106,947.97 vs $ 97602.25, p < 0.0001), and overall mortality (6.86% vs 4.35%, p < 0.0001). No major differences were found for mortality among readmissions at 30 days (7.19% vs 6.88%, p = 0.5382), 90 day (6.82% vs 6.51%, p = 0.5612), and 6 months (5.08% vs 5.91%, p = 0.1744). Conclusions Although both ERCP and PTBD had no major differences in mortality among readmissions, patients who had ERCP had lower readmission rates, length of stay, and overall mortality. While ERCP may be associated with a health systems benefit in routine indications, a multi-disciplinary approach may be of benefit for complex cases. ERCP PTBD biliary malignancy choledocholithiasis cholangitis Figures Figure 1 Figure 2 1. Introduction With over 450,000 endoscopic retrograde cholangiopancreatography (ERCP) procedures performed annually [ 1 ], ERCP is one of the most common endoscopic biliary duct procedures performed in the United States. In select cases, such as high risk patients with clinical instability, surgically altered anatomy or prior failed ERCP, percutaneous transhepatic biliary drainage (PTBD) is the preferred route for biliary decompression. The American Society for Gastrointestinal Endoscopy (ASGE) conditionally recommends ERCP over PTBD for management of cholangitis. This recommendation is based on data that demonstrates shorter hospitalization stay and reduced patient discomfort from the external catheter used in PTBD [ 2 ]. In patients with unresectable malignant hilar obstruction, the ASGE does not cite a preference for ERCP or PTBD [ 3 ]. The choice between procedures often remains situational. Data remains limited in understanding the health system implications of ASGE recommendations, and randomized clinical trials (RCTs) comparing both procedures are limited. In patients with malignancy and cholangitis, studies have shown varying outcomes, hence the acknowledgment of “very low quality of evidence” on the ASGE guidelines[ 2 , 3 ]. A recent meta-analysis suggested an improved PTBD clinical success rate in patients with malignant biliary tract obstruction [ 4 ]. However, in patients with cholangitis, the ASGE conducted a sensitivity analysis which showed no major difference in decompression success rate but a lower length of stay in patients who underwent ERCP [ 2 ]. Similarly, a national retrospective study in 2013 comparing the two procedures showed that ERCP had decreased mortality rates and shorter length of stay [ 5 ]. Variability over patient anatomy and individual case characteristics remained a major concern in prior studies. As limited evidence comparing ERCP and PTBD has prompted ASGE’s conditional recommendations, we propose this study to understand its implications on health systems level. In this study, we aimed to assess readmission rates in each procedure using the National Readmission (NRD) database from 2016–2020 in an unmatched and propensity matched analysis. 2. Materials and Methods Data Source We conducted a cross-sectional analysis of the National Readmission Database (NRD) from 2016–2020. The NRD is the largest inpatient readmission database in the United States. Our study extended to 2020 as this was the most recent year published. We gathered all admissions or readmissions associated with either PTBD or ERCP procedures based on International Classification of Disease 10th Edition (ICD 10) procedure codes (Supplemental Table 1a) Hospitalizations were tracked using a unique, but de-identified code across each year. All readmissions with the associated indication following when an initial ERCP or PTBD was completed were counted part of the cohort regardless of whether a repeat procedure was conducted. Admissions prior to the initial encounter when the ERCP or PTBD was conducted were excluded. In addition, all patients who had both an ERCP and PTBD completed were excluded from the cohort. The cohort was then subdivided into three separate arms of the most common indications for biliary drainage: biliary/pancreatic malignancy, choledocholithiasis, and cholangitis. Cohort was determined based on ICD 10 diagnosis codes (Supplemental Table 1a). From the initial cohort, we also conducted a propensity matched cohort analysis of 1:1 ERCP to PTBD readmissions. Cohort was matched based on age, sex, insurance, urban/rural location, median household income, Charlson Comorbidity Index (CCI) total score. We also matched for each variable (history of congestive heart failure, acute myocardial infarction, etc) used in calculating the CCI. Treatment was designated as those with PTBD, and the control was assigned as those treated with ERCP. Nearest neighbor matching was conducted with a caliper of 0.02 which is a similar method and threshold used in prior propensity matched studies on ERCP [ 6 , 7 ]. Cohort independent variables collected included age, sex, insurance, area of the county, household income. Diagnosis of heart failure, myocardial infarction, peripheral vascular disease, cerebrovascular accident, and other components of the CCI were also collected using previously published ICD10 diagnosis codes [ 8 ]. Of note, the presence of cancer affects the CCI. However, this involves all forms of cancer which is different than our subgroup analysis of patients that included only those with biliary/pancreatic malignancy. Assessment of Outcome In both the propensity matched and unmatched cohorts, readmissions were calculated at 30 day, 90 day and 6 month intervals. Ninety day readmission was defined as those with a readmission time greater than 30 days, and equal or under 90 days. Six months was defined as readmission time greater than 90 days and under 180 days. The primary outcome was assessed by calculating the readmission rate. Secondary outcomes assessed included mortality, length of stay, and hospitalization cost. Primary and secondary outcome significance were assessed through a Wilcox score. Due to the large difference in readmissions between ERCP and PTBD as well as differences in CCI, multivariate analysis was reserved for the propensity score matched cohort. Demonstration of propensity match was conducted using standardized mean differences between the ERCP and PTBD groups as this was the method used in the propensity matching algorithm. Categorical variables such as gender, insurance, urban/rural location, had a numerical indication was assigned to each outcome of the variable as defined by NRD. Due to the multiple variables matched, analysis was conducted strictly with only 1:1 matching with unweighted readmissions due to the risk for biasing other variables. Significance was determined using a chi square test or Wilcox score where appropriate, and p-value < 0.001. 3. Results From 2016 to 2020, over 87 million weighted admissions were analyzed, and a cohort of 621,735 patients identified out of which 589,796 had an ERCP and 31,939 had PTBD completed. The overall and propensity matched demographics and co-morbidities are presented in Table 1 , and the average CCI was 2.63 in ERCP and 4.72 in PTBD. The most common primary readmission diagnoses in ERCP were sepsis (9.12%), malignant neoplasm of the pancreatic head (3.04%), and acute pancreatitis (2.90%) (Supplemental table 1 b). In the PTBD cohort, the most common readmissions were for sepsis (11.66%), obstruction of bile duct (3.53%), and acute renal failure (3.75%). The malignancy cohort had the highest CCI (Procedure: CCI: ERCP: 5.76 vs PTBD: 5.69), followed by cholangitis (ERCP: 3.12 vs PTBD: 4.55), and choledocholithiasis (ERCP: 1.60 vs PTBD: 2.58) (Supplemental Table 1c). Table 1 Hospitalization Demographics For Unmatched And Propensity Matched Cohorts For ERCP And PTBD Across The United States In A National Cohort Between 2016–2020 Category Un-Matched Cohort Propensity Matched Cohort ERCP (n = 589796) PTBD (n = 31939) ERCP (n = 31456) PTBD (n = 31456) Standardized Difference Age (years) 62.51 ± 18.42 64.18 ± 15.48 65.62 ± 14.44 64.19 ± 15.46 -0.08378 Female 318641 (54.03%) 15422 (48.29%) 15004 (47.70%) 15197 (48.31%) -0.0123 Insurance 0.04568 Medicare 315787 (53.61%) 17671 (55.37%) 18122 (57.61%) 17430 (55.41%) Medicaid 85837 (14.57%) 3682 (11.54%) 3400 (10.81%) 3600 (11.44%) Private 154206 (26.18%) 9075 (28.44%) 8636 (27.45%) 8980 (28.55%) Self Pay 17094 (2.90%) 579 (1.81%) 568 (1.81%) 567 (1.80%) No charge 2153 (0.37%) 42 (0.13%) 65 (0.21%) 42 (0.13%) Other 14018 (2.38%) 865 (2.71%) 665 (2.11%) 837 (2.66%) Income -0.01102 0-25th Percentile 143638 (24.68%) 7259 (23.03%) 7029 (22.35%) 7207 (22.91%) 26-50th Percentile 156553 (26.90%) 8031 (25.48%) 8008 (25.46%) 8022 (25.50%) 51-75th Percentile 150793 (25.91%) 8265 (26.22%) 8441 (26.83%) 8259 (26.26%) 76-100th Percentile 131058 (22.52%) 7969 (25.28%) 7978 (25.36%) 7968 (25.33%) Patient Location -0.00678 >=1 million population central counties 172558 (29.34%) 9911 (31.12%) 9719 (30.90%) 9840 (31.28%) >=1 million population fringe counties 151842 (25.82%) 8659 (27.19%) 8681 (27.60%) 8585 (27.29%) 250,000-999,999 metro area 130767 (22.23%) 7175 (22.53%) 7004 (22.27%) 7085 (22.52%) 50,000-249,999 metro area 55920 (9.51%) 2443 (7.67%) 2434 (7.74%) 2408 (7.66%) Micropolitan counties 43912 (7.47%) 2025 (6.36%) 2061 (6.55%) 1956 (6.22%) Not metropolitan or micropolitan counties 33183 (5.64%) 1630 (5.12%) 1557 (4.95%) 1582 (5.03%) Overall Charlson Comorbidity Index 2.63 ± 2.96 4.72 ± 3.57 4.68 ± 3.60 4.72 ± 3.57 -0.0123 *Significance determined based on accepted practice of standardized difference of 0.10 [ 19 ] Prior to matching, readmission rates were lower for ERCP as compared to PTBD for hospitalizations overall and those associated with choledocholithiasis and cholangitis (p < 0.0001, Fig. 1). Except for those with malignancy, ERCP had lower rates of readmission at all time points. ERCP readmissions were significantly more within 30 days compared to within 90 days and 6 month time periods (p < 0.0001, Fig. 2a). Starting in 2019, there was no significant difference between ERCP and PTBD readmission rates among time intervals (Fig. 2b), otherwise ERCP readmissions more frequently happened within 30 days for choledocholithiasis and cholangitis compared to readmission rates at 90 days and 6 months. (p < 0.0001, Fig. 2c-d). Overall ERCP and PTBD readmission rates from 2016–2020 remained steady except for those associated with malignancy whose rates had a downtrend since 2017. Specific readmission frequencies and rates overall and by indications for 30 day, 90 day and 6 month time intervals are further presented by year in Supplemental Table 2. We conducted a propensity matched cohort analysis involving 62,912 admissions (31,456 ERCP and PTBD each) (Table 2 ). readmission rates for patients with PTBD were significantly higher at 30 days (20.38% vs 13.71%, p < 0.0001) and 90 days (14.63% vs 13.14%, p < 0.0001). A similar trend was noted in sub cohorts of patients with malignancy, choledocholithiasis, and cholangitis at all 3 readmission times assessed (Supplemental Table 2). PTBD was also associated with a significantly increased length of stay (9.01 days vs 6.74 days, p < 0.0001), overall mortality (6.86% vs 4.35%, p < 0.0001), and notably, overall hospitalization cost ( $ 106,947.97 vs $ 92602.25, p < 0.0001). However, overall, PTBD had a lower 6 month readmission rate (8.50% vs 9.67%, p < 0.0001). Specifically for readmission, no significant difference was found in 30 day readmission mortality (7.19% vs 6.88%, p = 0.5382), 90 day readmission mortality (6.82% vs 6.51%, p = 0.5612), or 6 month readmission mortality (5.08% vs 5.91%, p = 0.1744). Table 2 Readmissions After Propensity Score Matching For ERCP Vs. PTBD In A National Cohort Between 2016–2020 Category ERCP (n = 31456) PTBD (n = 31456) P value Length of Stay (Days ± SD) 6.74 ± 7.84 9.01 ± 10.63 < .0001 Overall mortality (%) 1367 (4.35%) 2158 (6.86%) < .0001 30 day readmission n(%) 4314 (13.71%) 6411 (20.38%) < .0001 90 day readmission n(%) 4133 (13.14%) 4602 (14.63%) < .0001 6 month readmission 3044 (9.67%) 2675 (8.50%) < .0001 30 day readmission mortality n(%) 297 (6.88%) 461 (7.19%) 0.5382 90 day readmission mortality n(%) 269 (6.51%) 314 (6.82%) 0.5612 6 month readmission mortality n (%) 180 (5.91%) 136 (5.08%) 0.1744 Hospitalization Cost ( $ ± SD) 92602.25 ± 129184.91 106947.97 ± 167390.89 < .0001 4. Discussion This study aimed to compare ERCP and PTBD under the lens of readmission rates. We provide the first study to assess readmission rates for this population using the largest federally supported database. This study found that inpatient ERCP was associated with lower readmission rates for routine indications compared to PTBD. This remained true after performing propensity matching for demographics, hospital size and CCI. However, over the long term, there was no difference for ERCP compared to PTBD in mortality and readmission rates. Our results suggest that both procedures play a key role in managing biliary obstruction. Our primary outcome demonstrated that ERCP is associated with lower readmission rates compared to PTBD for routine indications such as choledocholithiasis and cholangitis. Overall, sepsis has been noted to become a leading indication for readmission for both ERCP and PTBD cohorts [ 9 ]. Patients may benefit from close followup to evaluate for potential indicators of infection particularly within 30 days after procedure. While overall readmission rates over the years seem to be static, there appears to be lower readmission rates for those with biliary/pancreatic malignancy who have undergone ERCP or PTBD. We postulate that this trend may be due to advances in endoscopy and interventional radiology such as improvement in access devices and rescue endoscopic techniques such as EUS guided rendezvous [ 10 , 11 ]. Across the nation, we observed that hospitalizations requiring PTBD had coding of higher severity of illness. The CCI in our unmatched PTBD cohort was 4.72 compared to the 2.63 CCI in the ERCP cohort. Among mortality rates, ERCP had overall lower mortality rates than PTBD which suggests that patients who required interventional radiology support were sicker at index hospitalization and may have been too sick to undergo endoscopy. While inpatient PTBD generally had a higher readmission rate overall, it was associated with a trend of lower 90 day and 6 month readmission rates after hospitalizations for biliary or pancreatic malignancy. These results align with a prior meta-analysis of 3 randomized trials and 5 retrospective studies which suggested improved PTBD clinical success rate in patients with malignant biliary tract obstruction [ 4 ]. To anticipate complexity of hospitalizations requiring PTBD, we sought to reduce possible confounders via a propensity match for data comparable across health systems. In a 2021 study comparing ERCP and PTBD, it was noted that PTBD was utilized in more stage IV malignancies comparatively [ 12 ]. In addition, prior studies noted large volume centers were associated with superior outcomes. Therefore, we matched on 17 comorbidities used in validated CCI scoring and hospital characteristics. While more PTBD were readmitted within 30 days, there was no significant long term difference in readmission mortality. Although the National Comprehensive Cancer Network recommends ERCP over PTBD in cases of pancreatic cancer on chemotherapy [ 13 ], in unresectable major hilar obstructions, the ASGE does not prefer percutaneous or endoscopic approach [ 3 ]. We consider that PTBD may continue to offer advantages particularly for those with malignant obstruction after accounting for patient characteristics, multi-disciplinary discussions and local experiences. 4.1 Study strength and limitations The strength of this study is to provide an update using the largest contemporary federal database. We attempted to widen generalizability of findings by using scoring metrics within our propensity matching and explicitly targeted potential confounders such as age and hospital volume noted in prior studies [ 14 ]. Lastly, we use lower significance of p < 0.0001 as per prior as the accepted standard [ 15 – 17 ]. Our outcomes appear to validate early randomized controlled trial results as well as provide new support for ASGE recommendations. However, we acknowledge that there are several limitations of this study. First, this was a cross-sectional study contingent on ICD-10 coding. Therefore, this study is exposed to coding variable and limitation of the current accepted ICD-10 system. We attempted to increase granularity by using ICD-10 procedure codes with diagnostic codes and prioritizing the study design in lieu of paring multiple ICD-10 diagnostic codes, an alternative that may lead to loss of data[ 18 ] and is the cardinal critique of national database studies. Nevertheless, readmissions may not be distinctly driven from adverse events associated with ERCP or PTBD or biliary obstruction processes. While we control for hospital size as a proxy for volume, we highlight that the proceduralist experience should remain a key driver for choice and outcomes of procedures. Lastly, we note that PTBD may offer distinct advantages particularly in patients of anatomic limitations or complications of malignancy that this dataset does not capture. It would be challenging to link this dataset to procedural details, including extent of biliary drainage, procedural success rate, or if antibiotics were prescribed, nor does the dataset have specifics on patient anatomy or limitations on prior procedures. While we attempted to control for the heterogeneity of malignancy presentations by standardizing for metastatic cancer via CCI, an accepted readmission and hospital performance metric (24), we acknowledge that malignancy may be further stratified beyond the context of ICD-10 and CCI coding. 5. Conclusion Herein, we analyze trends of health system utilization for ERCP and PTBD with readmissions data. This study attempts to widen generalizability by performing a propensity match using CCI on the largest federal database. Our findings support prior ASGE recommendations for using ERCP in routine indications. However, PTBD may continue to hold potential advantages in managing complex patients with malignancies or anatomy. Most readmissions for both ERCP and PTBD occur within 30 days with an indication for sepsis, with the exception of malignancy. Recently discharged patients undergoing procedures for choledocholithiasis or cholangitis may benefit from a low threshold to consider infection for the first 30 days. Declarations Ethics approval was not required for this systematic, retrospective review of a public database. Disclosures Daniel Wang, Patrick Chang, Supisara Tintara, Frederick Chang, Jennifer Phan have no conflicts of interest or financial ties to disclose. Please refer to ICMJE disclosure forms for details. Funding information: none Author Contribution Study design, data analysis, and manuscript preparation: DW, PC, ST, FC, JP Acknowledgements None Data Availability Data is provided within the manuscript or supplementary information files. References Cohen S, Bacon BR, Berlin JA, Fleischer D, Hecht GA, Loehrer PJ, McNair AE, Mulholland M, Norton NJ, Rabeneck L, Ransohoff DF, Sonnenberg A, Vannier MW, Marciel K (2002) National Institutes of Health State-of-the-Science Conference Statement: ERCP for diagnosis and therapy, January 14–16, 2002. Gastrointest Endosc 56:803–809. https://doi.org/10.1016/S0016-5107(02)70351-9 Buxbaum JL, Buitrago C, Lee A, Elmunzer BJ, Riaz A, Ceppa EP, Al-Haddad M, Amateau SK, Calderwood AH, Fishman DS, Fujii-Lau LL, Jamil LH, Jue TL, Kwon RS, Law JK, Lee JK, Naveed M, Pawa S, Sawhney MS, Schilperoort H, Storm AC, Thosani NC, Qumseya BJ, Wani S (2021) ASGE guideline on the management of cholangitis. 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Surg Endosc 27:4449–4456. https://doi.org/10.1007/S00464-013-3127-9 Khera R, Angraal S, Couch T, Welsh JW, Nallamothu BK, Girotra S, Chan PS, Krumholz HM (2017) Adherence to Methodological Standards in Research Using the National Inpatient Sample. JAMA 318:2011–2018. https://doi.org/10.1001/JAMA.2017.17653 Rosenbaum PR, Rubin DB (1985) Constructing a Control Group Using Multivariate Matched Sampling Methods That Incorporate the Propensity Score. Am Stat 39:33. https://doi.org/10.2307/2683903 Additional Declarations No competing interests reported. Supplementary Files SupplementalTable1a.docx SupplementalTable1b.docx Supplementaltable1c.docx Supplementaltable1d.docx SupplementalTable2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIie3RMWrDMBSA4WcE6aJ6jinkDA8yuodJlmiRSqFgQik0U7IEuhoy9ArNDWwEyeJGWxGkg7NnMHTJ0JY+G692PBaiHyGE0IcQAnC5/mNJOe6rpZcDsHq7d45gtWTYmUBNev1OxN++p0mBMH5ZLT4e7TQENDqHItKNJMjuRmlMJP7Mor3MBKCdoBfvmgkmEjVHUDMrJ3s110Q4sOt5CzFH1N9EXok8qF8iJgP200Ys3ULPV29WbJia6fJeYF4LCewR0yX2n9dWshu5ETygt6TLnWgkvpHD4jS9HQ6sOHzJp3DgG33IT1HYSOroR4BXv8PLKTl3vu4q73jQ5XK5Lq0/8CFdyHOFSlkAAAAASUVORK5CYII=","orcid":"","institution":"University of Southern California","correspondingAuthor":true,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Wang","suffix":""},{"id":301624902,"identity":"f26c179c-7b1e-443d-a6bd-9e32b515c07f","order_by":1,"name":"Patrick Chang","email":"","orcid":"","institution":"University of Southern 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California","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"","lastName":"Phan","suffix":""}],"badges":[],"createdAt":"2024-05-06 01:38:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4373407/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4373407/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":56564235,"identity":"63ab51d5-9cb5-44df-b7db-e361d6c88c4d","added_by":"auto","created_at":"2024-05-15 22:42:59","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":82585,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4373407/v1/ea8f7153a79e2965301db567.jpg"},{"id":56564238,"identity":"bf10a7dd-ad6d-4a4b-b205-4d6a17a72245","added_by":"auto","created_at":"2024-05-15 22:42:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":709497,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4373407/v1/33f1e336da3e7d85f0e87c29.png"},{"id":56567333,"identity":"25079942-a7be-4556-b95e-f78c8ec55013","added_by":"auto","created_at":"2024-05-16 01:12:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1189402,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4373407/v1/8b0bb077-adc8-4823-90d8-e78c89a8f576.pdf"},{"id":56564645,"identity":"27baf3ec-35c7-4493-af65-db203402deae","added_by":"auto","created_at":"2024-05-15 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22:42:59","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":14503,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaltable1c.docx","url":"https://assets-eu.researchsquare.com/files/rs-4373407/v1/5f6d7593e6d49a4e786d8548.docx"},{"id":56564240,"identity":"11f3f4ab-fe95-4041-b2e1-34d6fbebb19b","added_by":"auto","created_at":"2024-05-15 22:42:59","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":25852,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaltable1d.docx","url":"https://assets-eu.researchsquare.com/files/rs-4373407/v1/2593e1c15ea498f72e1b0a7f.docx"},{"id":56564239,"identity":"5166c473-31c8-4243-a0b4-88452f33a9eb","added_by":"auto","created_at":"2024-05-15 22:42:59","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":28362,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalTable2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4373407/v1/fd2718cae9f29c5fc08c7a43.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative Analysis of ERCP and PTBD for Biliary Interventions for Readmission Rates and Patient Outcomes","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eWith over 450,000 endoscopic retrograde cholangiopancreatography (ERCP) procedures performed annually [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], ERCP is one of the most common endoscopic biliary duct procedures performed in the United States. In select cases, such as high risk patients with clinical instability, surgically altered anatomy or prior failed ERCP, percutaneous transhepatic biliary drainage (PTBD) is the preferred route for biliary decompression. The American Society for Gastrointestinal Endoscopy (ASGE) conditionally recommends ERCP over PTBD for management of cholangitis. This recommendation is based on data that demonstrates shorter hospitalization stay and reduced patient discomfort from the external catheter used in PTBD [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In patients with unresectable malignant hilar obstruction, the ASGE does not cite a preference for ERCP or PTBD [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The choice between procedures often remains situational.\u003c/p\u003e \u003cp\u003eData remains limited in understanding the health system implications of ASGE recommendations, and randomized clinical trials (RCTs) comparing both procedures are limited. In patients with malignancy and cholangitis, studies have shown varying outcomes, hence the acknowledgment of \u0026ldquo;very low quality of evidence\u0026rdquo; on the ASGE guidelines[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A recent meta-analysis suggested an improved PTBD clinical success rate in patients with malignant biliary tract obstruction [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, in patients with cholangitis, the ASGE conducted a sensitivity analysis which showed no major difference in decompression success rate but a lower length of stay in patients who underwent ERCP [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Similarly, a national retrospective study in 2013 comparing the two procedures showed that ERCP had decreased mortality rates and shorter length of stay [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Variability over patient anatomy and individual case characteristics remained a major concern in prior studies.\u003c/p\u003e \u003cp\u003eAs limited evidence comparing ERCP and PTBD has prompted ASGE\u0026rsquo;s conditional recommendations, we propose this study to understand its implications on health systems level. In this study, we aimed to assess readmission rates in each procedure using the National Readmission (NRD) database from 2016\u0026ndash;2020 in an unmatched and propensity matched analysis.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003eData Source\u003c/p\u003e \u003cp\u003eWe conducted a cross-sectional analysis of the National Readmission Database (NRD) from 2016\u0026ndash;2020. The NRD is the largest inpatient readmission database in the United States. Our study extended to 2020 as this was the most recent year published. We gathered all admissions or readmissions associated with either PTBD or ERCP procedures based on International Classification of Disease 10th Edition (ICD 10) procedure codes (Supplemental Table\u0026nbsp;1a) Hospitalizations were tracked using a unique, but de-identified code across each year. All readmissions with the associated indication following when an initial ERCP or PTBD was completed were counted part of the cohort regardless of whether a repeat procedure was conducted. Admissions prior to the initial encounter when the ERCP or PTBD was conducted were excluded. In addition, all patients who had both an ERCP and PTBD completed were excluded from the cohort.\u003c/p\u003e \u003cp\u003eThe cohort was then subdivided into three separate arms of the most common indications for biliary drainage: biliary/pancreatic malignancy, choledocholithiasis, and cholangitis. Cohort was determined based on ICD 10 diagnosis codes (Supplemental Table\u0026nbsp;1a).\u003c/p\u003e \u003cp\u003eFrom the initial cohort, we also conducted a propensity matched cohort analysis of 1:1 ERCP to PTBD readmissions. Cohort was matched based on age, sex, insurance, urban/rural location, median household income, Charlson Comorbidity Index (CCI) total score. We also matched for each variable (history of congestive heart failure, acute myocardial infarction, etc) used in calculating the CCI. Treatment was designated as those with PTBD, and the control was assigned as those treated with ERCP. Nearest neighbor matching was conducted with a caliper of 0.02 which is a similar method and threshold used in prior propensity matched studies on ERCP [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCohort independent variables collected included age, sex, insurance, area of the county, household income. Diagnosis of heart failure, myocardial infarction, peripheral vascular disease, cerebrovascular accident, and other components of the CCI were also collected using previously published ICD10 diagnosis codes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Of note, the presence of cancer affects the CCI. However, this involves all forms of cancer which is different than our subgroup analysis of patients that included only those with biliary/pancreatic malignancy.\u003c/p\u003e \u003cp\u003eAssessment of Outcome\u003c/p\u003e \u003cp\u003eIn both the propensity matched and unmatched cohorts, readmissions were calculated at 30 day, 90 day and 6 month intervals. Ninety day readmission was defined as those with a readmission time greater than 30 days, and equal or under 90 days. Six months was defined as readmission time greater than 90 days and under 180 days. The primary outcome was assessed by calculating the readmission rate. Secondary outcomes assessed included mortality, length of stay, and hospitalization cost.\u003c/p\u003e \u003cp\u003ePrimary and secondary outcome significance were assessed through a Wilcox score. Due to the large difference in readmissions between ERCP and PTBD as well as differences in CCI, multivariate analysis was reserved for the propensity score matched cohort. Demonstration of propensity match was conducted using standardized mean differences between the ERCP and PTBD groups as this was the method used in the propensity matching algorithm. Categorical variables such as gender, insurance, urban/rural location, had a numerical indication was assigned to each outcome of the variable as defined by NRD. Due to the multiple variables matched, analysis was conducted strictly with only 1:1 matching with unweighted readmissions due to the risk for biasing other variables. Significance was determined using a chi square test or Wilcox score where appropriate, and p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eFrom 2016 to 2020, over 87\u0026nbsp;million weighted admissions were analyzed, and a cohort of 621,735 patients identified out of which 589,796 had an ERCP and 31,939 had PTBD completed. The overall and propensity matched demographics and co-morbidities are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, and the average CCI was 2.63 in ERCP and 4.72 in PTBD. The most common primary readmission diagnoses in ERCP were sepsis (9.12%), malignant neoplasm of the pancreatic head (3.04%), and acute pancreatitis (2.90%) (Supplemental table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). In the PTBD cohort, the most common readmissions were for sepsis (11.66%), obstruction of bile duct (3.53%), and acute renal failure (3.75%). The malignancy cohort had the highest CCI (Procedure: CCI: ERCP: 5.76 vs PTBD: 5.69), followed by cholangitis (ERCP: 3.12 vs PTBD: 4.55), and choledocholithiasis (ERCP: 1.60 vs PTBD: 2.58) (Supplemental Table\u0026nbsp;1c).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHospitalization Demographics For Unmatched And Propensity Matched Cohorts For ERCP And PTBD Across The United States In A National Cohort Between 2016\u0026ndash;2020\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eUn-Matched Cohort\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003ePropensity Matched Cohort\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERCP (n\u0026thinsp;=\u0026thinsp;589796)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePTBD (n\u0026thinsp;=\u0026thinsp;31939)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eERCP (n\u0026thinsp;=\u0026thinsp;31456)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePTBD (n\u0026thinsp;=\u0026thinsp;31456)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStandardized Difference\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.51\u0026thinsp;\u0026plusmn;\u0026thinsp;18.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.18\u0026thinsp;\u0026plusmn;\u0026thinsp;15.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e 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(27.45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8980 (28.55%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf Pay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17094 (2.90%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e579 (1.81%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e568 (1.81%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e567 (1.80%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo charge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2153 (0.37%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (0.13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65 (0.21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42 (0.13%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14018 (2.38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e865 (2.71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e665 (2.11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e837 (2.66%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e-0.01102\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0-25th Percentile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e143638 (24.68%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7259 (23.03%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7029 (22.35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7207 (22.91%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26-50th Percentile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e156553 (26.90%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8031 (25.48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8008 (25.46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8022 (25.50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e51-75th Percentile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150793 (25.91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8265 (26.22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8441 (26.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8259 (26.26%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e76-100th Percentile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e131058 (22.52%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7969 (25.28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7978 (25.36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7968 (25.33%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient Location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e-0.00678\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;=1\u0026nbsp;million population central counties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e172558 (29.34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9911 (31.12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9719 (30.90%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9840 (31.28%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;=1\u0026nbsp;million population fringe counties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e151842 (25.82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8659 (27.19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8681 (27.60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8585 (27.29%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e250,000-999,999 metro area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e130767 (22.23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7175 (22.53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7004 (22.27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7085 (22.52%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50,000-249,999 metro area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55920 (9.51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2443 (7.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2434 (7.74%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2408 (7.66%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMicropolitan counties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43912 (7.47%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2025 (6.36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2061 (6.55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1956 (6.22%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot metropolitan or micropolitan counties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33183 (5.64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1630 (5.12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1557 (4.95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1582 (5.03%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall Charlson Comorbidity Index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.63\u0026thinsp;\u0026plusmn;\u0026thinsp;2.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.72\u0026thinsp;\u0026plusmn;\u0026thinsp;3.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.68 \u0026plusmn; 3.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.72\u0026thinsp;\u0026plusmn;\u0026thinsp;3.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.0123\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003e*Significance determined based on accepted practice of standardized difference of 0.10\u003c/em\u003e [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePrior to matching, readmission rates were lower for ERCP as compared to PTBD for hospitalizations overall and those associated with choledocholithiasis and cholangitis (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, Fig.\u0026nbsp;1). Except for those with malignancy, ERCP had lower rates of readmission at all time points. ERCP readmissions were significantly more within 30 days compared to within 90 days and 6 month time periods (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, Fig.\u0026nbsp;2a). Starting in 2019, there was no significant difference between ERCP and PTBD readmission rates among time intervals (Fig.\u0026nbsp;2b), otherwise ERCP readmissions more frequently happened within 30 days for choledocholithiasis and cholangitis compared to readmission rates at 90 days and 6 months. (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, Fig.\u0026nbsp;2c-d). Overall ERCP and PTBD readmission rates from 2016\u0026ndash;2020 remained steady except for those associated with malignancy whose rates had a downtrend since 2017. Specific readmission frequencies and rates overall and by indications for 30 day, 90 day and 6 month time intervals are further presented by year in Supplemental Table\u0026nbsp;2.\u003c/p\u003e \u003cp\u003eWe conducted a propensity matched cohort analysis involving 62,912 admissions (31,456 ERCP and PTBD each) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). readmission rates for patients with PTBD were significantly higher at 30 days (20.38% vs 13.71%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and 90 days (14.63% vs 13.14%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). A similar trend was noted in sub cohorts of patients with malignancy, choledocholithiasis, and cholangitis at all 3 readmission times assessed (Supplemental Table\u0026nbsp;2). PTBD was also associated with a significantly increased length of stay (9.01 days vs 6.74 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), overall mortality (6.86% vs 4.35%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and notably, overall hospitalization cost (\u003cspan\u003e$\u003c/span\u003e106,947.97 vs \u003cspan\u003e$\u003c/span\u003e92602.25, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). However, overall, PTBD had a lower 6 month readmission rate (8.50% vs 9.67%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Specifically for readmission, no significant difference was found in 30 day readmission mortality (7.19% vs 6.88%, p\u0026thinsp;=\u0026thinsp;0.5382), 90 day readmission mortality (6.82% vs 6.51%, p\u0026thinsp;=\u0026thinsp;0.5612), or 6 month readmission mortality (5.08% vs 5.91%, p\u0026thinsp;=\u0026thinsp;0.1744).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReadmissions After Propensity Score Matching For ERCP Vs. PTBD In A National Cohort Between 2016\u0026ndash;2020\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eERCP (n\u0026thinsp;=\u0026thinsp;31456)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePTBD (n\u0026thinsp;=\u0026thinsp;31456)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of Stay (Days\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.74\u0026thinsp;\u0026plusmn;\u0026thinsp;7.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.01\u0026thinsp;\u0026plusmn;\u0026thinsp;10.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall mortality (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1367 (4.35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2158 (6.86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30 day readmission n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4314 (13.71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6411 (20.38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e90 day readmission n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4133 (13.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4602 (14.63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 month readmission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3044 (9.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2675 (8.50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30 day readmission mortality n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e297 (6.88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e461 (7.19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5382\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e90 day readmission mortality n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e269 (6.51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e314 (6.82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5612\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 month readmission mortality n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e180 (5.91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e136 (5.08%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1744\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospitalization Cost (\u003cspan\u003e$\u003c/span\u003e \u0026plusmn; SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92602.25\u0026thinsp;\u0026plusmn;\u0026thinsp;129184.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e106947.97\u0026thinsp;\u0026plusmn;\u0026thinsp;167390.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study aimed to compare ERCP and PTBD under the lens of readmission rates. We provide the first study to assess readmission rates for this population using the largest federally supported database. This study found that inpatient ERCP was associated with lower readmission rates for routine indications compared to PTBD. This remained true after performing propensity matching for demographics, hospital size and CCI. However, over the long term, there was no difference for ERCP compared to PTBD in mortality and readmission rates. Our results suggest that both procedures play a key role in managing biliary obstruction.\u003c/p\u003e \u003cp\u003eOur primary outcome demonstrated that ERCP is associated with lower readmission rates compared to PTBD for routine indications such as choledocholithiasis and cholangitis. Overall, sepsis has been noted to become a leading indication for readmission for both ERCP and PTBD cohorts [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Patients may benefit from close followup to evaluate for potential indicators of infection particularly within 30 days after procedure. While overall readmission rates over the years seem to be static, there appears to be lower readmission rates for those with biliary/pancreatic malignancy who have undergone ERCP or PTBD. We postulate that this trend may be due to advances in endoscopy and interventional radiology such as improvement in access devices and rescue endoscopic techniques such as EUS guided rendezvous [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAcross the nation, we observed that hospitalizations requiring PTBD had coding of higher severity of illness. The CCI in our unmatched PTBD cohort was 4.72 compared to the 2.63 CCI in the ERCP cohort. Among mortality rates, ERCP had overall lower mortality rates than PTBD which suggests that patients who required interventional radiology support were sicker at index hospitalization and may have been too sick to undergo endoscopy. While inpatient PTBD generally had a higher readmission rate overall, it was associated with a trend of lower 90 day and 6 month readmission rates after hospitalizations for biliary or pancreatic malignancy. These results align with a prior meta-analysis of 3 randomized trials and 5 retrospective studies which suggested improved PTBD clinical success rate in patients with malignant biliary tract obstruction [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo anticipate complexity of hospitalizations requiring PTBD, we sought to reduce possible confounders via a propensity match for data comparable across health systems. In a 2021 study comparing ERCP and PTBD, it was noted that PTBD was utilized in more stage IV malignancies comparatively [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In addition, prior studies noted large volume centers were associated with superior outcomes. Therefore, we matched on 17 comorbidities used in validated CCI scoring and hospital characteristics. While more PTBD were readmitted within 30 days, there was no significant long term difference in readmission mortality. Although the National Comprehensive Cancer Network recommends ERCP over PTBD in cases of pancreatic cancer on chemotherapy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], in unresectable major hilar obstructions, the ASGE does not prefer percutaneous or endoscopic approach [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. We consider that PTBD may continue to offer advantages particularly for those with malignant obstruction after accounting for patient characteristics, multi-disciplinary discussions and local experiences.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Study strength and limitations\u003c/h2\u003e \u003cp\u003eThe strength of this study is to provide an update using the largest contemporary federal database. We attempted to widen generalizability of findings by using scoring metrics within our propensity matching and explicitly targeted potential confounders such as age and hospital volume noted in prior studies [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Lastly, we use lower significance of p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001 as per prior as the accepted standard [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Our outcomes appear to validate early randomized controlled trial results as well as provide new support for ASGE recommendations.\u003c/p\u003e \u003cp\u003eHowever, we acknowledge that there are several limitations of this study. First, this was a cross-sectional study contingent on ICD-10 coding. Therefore, this study is exposed to coding variable and limitation of the current accepted ICD-10 system. We attempted to increase granularity by using ICD-10 procedure codes with diagnostic codes and prioritizing the study design in lieu of paring multiple ICD-10 diagnostic codes, an alternative that may lead to loss of data[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and is the cardinal critique of national database studies. Nevertheless, readmissions may not be distinctly driven from adverse events associated with ERCP or PTBD or biliary obstruction processes. While we control for hospital size as a proxy for volume, we highlight that the proceduralist experience should remain a key driver for choice and outcomes of procedures.\u003c/p\u003e \u003cp\u003eLastly, we note that PTBD may offer distinct advantages particularly in patients of anatomic limitations or complications of malignancy that this dataset does not capture. It would be challenging to link this dataset to procedural details, including extent of biliary drainage, procedural success rate, or if antibiotics were prescribed, nor does the dataset have specifics on patient anatomy or limitations on prior procedures. While we attempted to control for the heterogeneity of malignancy presentations by standardizing for metastatic cancer via CCI, an accepted readmission and hospital performance metric (24), we acknowledge that malignancy may be further stratified beyond the context of ICD-10 and CCI coding.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eHerein, we analyze trends of health system utilization for ERCP and PTBD with readmissions data. This study attempts to widen generalizability by performing a propensity match using CCI on the largest federal database. Our findings support prior ASGE recommendations for using ERCP in routine indications. However, PTBD may continue to hold potential advantages in managing complex patients with malignancies or anatomy. Most readmissions for both ERCP and PTBD occur within 30 days with an indication for sepsis, with the exception of malignancy. Recently discharged patients undergoing procedures for choledocholithiasis or cholangitis may benefit from a low threshold to consider infection for the first 30 days.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval\u003c/h2\u003e \u003cp\u003ewas not required for this systematic, retrospective review of a public database.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDisclosures\u003c/strong\u003e \u003cp\u003eDaniel Wang, Patrick Chang, Supisara Tintara, Frederick Chang, Jennifer Phan have no conflicts of interest or financial ties to disclose. Please refer to ICMJE disclosure forms for details.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding information:\u003c/h2\u003e \u003cp\u003enone\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eStudy design, data analysis, and manuscript preparation: DW, PC, ST, FC, JP\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNone\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData is provided within the manuscript or supplementary information files.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCohen S, Bacon BR, Berlin JA, Fleischer D, Hecht GA, Loehrer PJ, McNair AE, Mulholland M, Norton NJ, Rabeneck L, Ransohoff DF, Sonnenberg A, Vannier MW, Marciel K (2002) National Institutes of Health State-of-the-Science Conference Statement: ERCP for diagnosis and therapy, January 14\u0026ndash;16, 2002. 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Am Stat 39:33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2307/2683903\u003c/span\u003e\u003cspan address=\"10.2307/2683903\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"ERCP, PTBD, biliary malignancy, choledocholithiasis, cholangitis","lastPublishedDoi":"10.21203/rs.3.rs-4373407/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4373407/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEndoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) are interventions used to relieve biliary obstruction. The utility of ERCP compared to PTBD is not fully understood from a utilization outcome standpoint. Our study compares readmission rates and hospitalization outcomes in ERCP and PTBD.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eUsing the National Readmission Database (NRD) 2016\u0026ndash;2020, we identified all patients with an ERCP or PTBD completed during admission. The study cohort was first analyzed by three weighted study arms including those admitted with cholangitis, biliary/pancreatic malignancy, and choledocholithiasis. Second, we analyzed the cohort by a 1:1, unweighted propensity match. Primary outcome was 30 day, 90 day, and 6 month readmission. Secondary outcomes were readmission/overall mortality, cost, and length of stay. Outcomes were analyzed using multivariate analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 621,735 admissions were identified associated with 589,796 ERCP and 31,939 PTBD. In the propensity matched cohort, PTBD had a higher readmission rate at 30 days (20.38% vs 13.71% p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), 90 days (14.63% vs 13.14%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), but lower rate at 6 months (8.50% vs 9.67%, p\u0026thinsp;=\u0026thinsp;0.0003). Secondary outcomes included increased PTBD-associated hospital length of stay (9.01 days vs 6.74 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), hospitalization cost (\u003cspan\u003e$\u003c/span\u003e106,947.97 vs \u003cspan\u003e$\u003c/span\u003e97602.25, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and overall mortality (6.86% vs 4.35%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). No major differences were found for mortality among readmissions at 30 days (7.19% vs 6.88%, p\u0026thinsp;=\u0026thinsp;0.5382), 90 day (6.82% vs 6.51%, p\u0026thinsp;=\u0026thinsp;0.5612), and 6 months (5.08% vs 5.91%, p\u0026thinsp;=\u0026thinsp;0.1744).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAlthough both ERCP and PTBD had no major differences in mortality among readmissions, patients who had ERCP had lower readmission rates, length of stay, and overall mortality. While ERCP may be associated with a health systems benefit in routine indications, a multi-disciplinary approach may be of benefit for complex cases.\u003c/p\u003e","manuscriptTitle":"Comparative Analysis of ERCP and PTBD for Biliary Interventions for Readmission Rates and Patient Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-15 22:42:54","doi":"10.21203/rs.3.rs-4373407/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"600140aa-1d90-4389-bee4-b6e83acbfb56","owner":[],"postedDate":"May 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-16T01:04:09+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-15 22:42:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4373407","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4373407","identity":"rs-4373407","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}