Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

Lower Provider Volume is Associated With Higher Failure Rates for Endoscopic Retrograde Cholangiopancreatography

Coté, Gregory A., MD, MS*; Imler, Timothy D., MD*,†; Xu, Huiping, PhD; Teal, Evgenia, MS; French, Dustin D., PhD§; Imperiale, Thomas F., MD*,†,∥; Rosenman, Marc B., MD†,¶; Wilson, Jeffery, PhD#; Hui, Siu L., PhD†,‡; Sherman, Stuart, MD*

doi: 10.1097/MLR.0b013e3182a502dc
Original Articles

Background: Among physicians who perform endoscopic retrograde cholangiopancreatography (ERCP), the relationship between procedure volume and outcome is unknown.

Objective: Quantify the ERCP volume-outcome relationship by measuring provider-specific failure rates, hospitalization rates, and other quality measures.

Research Design: Retrospective cohort.

Subjects: A total of 16,968 ERCPs performed by 130 physicians between 2001 and 2011, identified in the Indiana Network for Patient Care.

Measures: Physicians were classified by their average annual Indiana Network for Patient Care volume and stratified into low (<25/y) and high (≥25/y). Outcomes included failed procedures, defined as repeat ERCP, percutaneous transhepatic cholangiography or surgical exploration of the bile duct≤7 days after the index procedure, hospitalization rates, and 30-day mortality.

Results: Among 15,514 index ERCPs, there were 1163 (7.5%) failures; the failure rate was higher among low (9.5%) compared with high volume (5.7%) providers (P<0.001). A second ERCP within 7 days (a subgroup of failure rate) occurred more frequently when the original ERCP was performed by a low-volume (4.1%) versus a high-volume physician (2.3%, P=0.013). Patients were more frequently hospitalized within 24 hours when the ERCP was performed by a low-volume (28.3%) versus high-volume physician (14.8%, P=0.002). Mortality within 30 days was similar (low=1.9%, high=1.9%). Among low-volume physicians and after adjusting, the odds of having a failed procedure decreased 3.3% (95% confidence interval, 1.6%–5.0%, P<0.001) with each additional ERCP performed per year.

Conclusions: Lower provider volume is associated with higher failure rate for ERCP, and greater need for postprocedure hospitalization.

*Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN

Regenstrief Institute Inc.

Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN

§Department of Ophthalmology and Center for Healthcare Studies, VA Center of Excellence, Northwestern University Feinberg School of Medicine, Chicago, IL

Center of Excellence for Implementation of Evidence-based Practice, Roudebush VA Medical Center

Department of Pediatrics, Indiana University School of Medicine

#Department of Geography, Indiana University-Purdue University Indianapolis, Indianapolis, IN

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

G.A.C., S.L.H., and H.X. had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study design (G.A.C., T.D.I.), data collection (G.A.C., E.T., T.D.I., M.B.R.), data analysis (H.X., S.L.H., J.W.), manuscript drafting (G.A.C.), critical editing (G.A.C., T.D.I., S.S., M.B.R., D.D.F., T.F.I.).

Supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award number K23DK095148 (G.A.C.).

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

These data have been presented at the annual meeting at Digestive Diseases Week, 2013 (Orlando, FL).

The authors declare no conflict of interest.

Reprints: Gregory A. Coté, MD, MS, Division of Gastroenterology and Hepatology, Indianapolis University School of Medicine, University Hospital, 550N. University Blvd., UH 1634, Indianapolis, IN 46202. E-mail:

© 2013 by Lippincott Williams & Wilkins.