Outcomes of Endoscopic Retrograde Cholangiopancreatography in Patients with Non-Alcoholic Steatohepatitis: A Nationwide Analysis

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a frequently used therapeutic modality in the treatment of biliary disease, however limited data exists in its use in both non-alcoholic steatohepatitis (NASH) and decompensated cirrhosis (DC). We aim to compare outcomes in those undergoing ERCP with NASH and decompensated NASH cirrhosis. Methods: This project utilized the National Inpatient Sample (NIS) database. All patients 18 years or older with NASH with and without DC undergoing ERCP were identified from 2008 to 2015. Relevant patient characteristics and procedures were identified using ICD/CPT codes. Bivariate analyses were conducted using chi-square tests for categorical variables and t-tests for continuous measures. DC included ascites, varices, spontaneous bacterial peritonitis, hepatic encephalopathy, portal hypertension, hepatorenal syndrome and portal vein thrombosis. The outcomes of interest were mortality, length of stay (LOS), and total cost. Logistic and linear regression were used to analyze these outcomes. All analyses accounted for the complex sampling scheme of the NIS. P-values less than 0.05 were considered statistically significant (Table 1). Results: The total number of NASH patients undergoing ERCP was 42,388. Of those, 3,227 had decompensated NASH cirrhosis and 39,161 had NASH without evidence of DC. Patients with DC were older (57.5 vs 54, P< 0.0001), less female (50% vs 57.2%, P=0.0004), identified as white (68.7% vs 65.6%, P=0.0137) and had a higher Charlson comorbidity index (4.7 vs 2.1, P< 0.0001). A higher proportion of DC patients were on Medicare (44% vs 32.5%, P< 0.0001). Most DC patients had ERCPs in large (74.3% vs 64.5%, P< 0.0001) and urban teaching hospitals (69.4% vs 54.7%, P< 0.0001). Decompensated NASH cirrhosis patients had higher mortality (4.9% vs 0.5%, P< 0.0001), LOS (11.1 days vs 5.8 days, P< 0.0001) and increased inpatient cost ($120,186 vs $59,926, P< 0.0001). When controlling for all the above factors, regression analyses showed that DC had an increase in mortality (OR: 5.06, CI: 2.57-9.95) and LOS (β: 4.09, CI: 4.57-5.68). Conclusion: Decompensated NASH cirrhosis patients undergoing ERCP had a marked increase in mortality, LOS and inpatient cost compared to their non-cirrhotic or compensated counterparts. When controlling for all other factors, signs of decompensation were most predictive of mortality and LOS. Table 1. - Sample Characteristics All NASH with ERCP (n=42,388) Decompensated (n=3,227) Compensated (n=39,161) P-value Patient Characteristics Age (mean, SE) 54.3 (0.2) 57.5 (0.6) 54.0 (0.2) < .0001 Female Gender 56.7% (24,007) 50% (1,613) 57.2% (22,394) 0.0004 Race 1. White 65.8% (25,933) 68.7% (2,053) 65.6% (23,880) 2. Black 6.2% (2,446) 7.3% (219) 6.1% (2,227) 3. Hispanic 20.1% (7,908) 15.1% (451) 20.5% (7,457) 4. Other 7.9% (3,098) 8.8% (263) 7.8% (2,835) 0.0137 Insurance < .0001 1. Medicare 33.4% (14,140) 44% (1,420) 32.5% (12,720) 2. Medicaid 14.9% (6,296) 15.7% (506) 14.8% (5,790) 3. Private insurance 39.9% (16,873) 32.2% (1,040) 40.5% (15,833) 4. Other 11.9% (5,024) 8.1% (260) 12.2% (4,764) Zip Code Level Median Income 1. 0-25th percentile 26.5% (10,952) 29.9% (944) 26.2% (10,009) 2. 26th to 50th percentile 24.6% (10,182) 26.1% (824) 24.5% (9,358) 3. 51st to 75th percentile 26.2% (10,849) 24.6% (775) 26.4% (10,073) 4. 76th to 100th percentile 22.7% (9,382) 19.5% (615) 22.9% (8,767) 0.0651 Comorbidity Index (mean, SE) 2.3 (0.02) 4.7 (0.1) 2.1 (0.02) < .0001 Hospital Characteristics Bed Size 1. Small 10.7% (4,513) 8.3% (267) 10.9% (4,246) 2. Medium 24.1% (10,188) 17.4% (557) 24.7% (9,631) 3. Large 65.2% (27,570) 74.3% (2,383) 64.5% (25,187) < .0001 Location/Teaching Status 1. Rural 4% (1,687) 3.8% (121) 4.0% (1,566) 2. Urban nonteaching 40.2% (16,978) 26.8% (859) 41.3% (16,119) 3. Urban teaching 55.8% (23,606) 69.4% (2,227) 54.7% (21,379) < .0001 Region 1. Northeast 14.0% (5,923) 11.5% (372) 14.2% (5,551) 2. Midwest 21.2% (8,989) 27.3% (880) 20.7% (8,109) 3. South 37.2% (15,766) 39.2% (1,267) 37.0% (14,499) 4. West 27.6% (11,710) 21.9% (708) 28.1% (11,002) 0.0002 Hospital Control 1. Government, nonfederal 11.8% (5,008) 15.2% (487) 11.6% (4,521) 2. Private, not-profit 76.3% (32,244) 77.1% (2,474) 76.2% (29,770) 3. Private, invest-own 11.9% (5,019) 7.7% (246) 12.2% (4,772) 0.0006 Outcomes Mortality 0.8% (354) 4.9% (158) 0.5% (196) < .0001 LOS (mean, SE) 6.2 (0.07) 11.1 (0.4) 5.8 (0.06) < .0001 Total Charges (mean, SE) $64,595 ($1,060) $120,186 ($6,680) $59,926 ($866) < .0001