Post-ERCP mortality and provider volume

▶ Bodger K, Bowering K, Sarkar S, et al. All-cause mortality after first ERCP in England: clinically guided analysis of hospital episode statistics with linkage to registry of death. Gastrointest Endosc 2011;74:825–33.

A large body of published evidence in a variety of surgical disciplines supports the notion that doing more is better—that high procedural volume centres and, indeed, high-volume operators have superior outcomes. Intuitively, a volume–outcome relationship might be expected to apply to the practice of endoscopic retrograde cholangipancreatography (ERCP) from the well-recognised complexity of this procedure, which has relatively high attendant risks and requirements for a dedicated highly skilled multidisciplinary team. As far as procedural morbidity is concerned, the evidence suggests that this is indeed the case, but there are little data on whether variations in ERCP provider volume could also impact mortality. In the UK, the 2004 National Confidential Enquiry into Patient Outcome and Death and British Society of Gastroenterology's audit of ERCP have both highlighted concerns about the quality of ERCP practice. One of the most commonly used quality benchmarks in surgical and endoscopic practice is postprocedure 30-day mortality. The present study assessed risk factors for 30-day post-ERCP mortality and variations in this end point by hospital volume among 40 938 procedures carried out over an 18 month period, using a database including all hospital procedures in England linked to the National Death Register. All-cause 30-day mortality was 5.3%, with the predictors of death being advancing age, male gender, emergency admission, diagnosis of cancer and other co-morbidities. A funnel-shaped correlation of 30-day mortality with hospital volume was found, but somewhat surprisingly, none of the 150 hospitals included in the analysis had a statistically significant divergent outcome. Furthermore, only 13 out of 1078 post-ERCP deaths within 30 days could be ascribed to the procedure. This contrasts with 20 …