Racial Disparities in All-Cause Inpatient Endoscopic Retrograde Cholangiopancreatography in the United States: How Important Is Race?

Introduction: Endoscopic Retrograde Cholangiopancreatography (ERCP) has evolved into a vital endoscopic technique for managing numerous pancreaticobiliary disorders. Studies have reported higher rates of adverse outcomes and post-ERCP complications in ethnic minorities, making race an important risk factor for ERCP utilization. In this study, we aimed to identify the influence of race on clinical outcomes of all-cause inpatient ERCPs in the United States (US). Methods: We used the National Inpatient Sample (NIS) to identify all adult (≥18 years) hospitalizations that underwent ERCP in the US from 2007–2019. The study population was further subdivided into 3 groups based on race (Whites, Blacks, and Hispanics). Hospitalization characteristics and clinical outcomes were highlighted and compared. P-values ≤0.05 were considered statistically significant. Results: Between 2007–2019, there were 1,515,516 White, 205,338 Black and 348,269 Hispanic hospitalizations that underwent inpatient ERCP in the US. Whites had a higher mean age (62.5 vs 54.8 vs 50.7 years, P< 0.0001) and higher proportion of patients ≥65 years of age compared to Blacks and Hispanics, respectively. Overall, a female predominance was noted for all-cause inpatient ERCPs (Table 1). The household income for a higher proportion of Blacks and Hispanics was in the first (low-income) Quartile, while most White hospitalizations had household incomes in the second, third and fourth Quartiles (Table 1). A higher proportion of Black hospitalizations that underwent inpatient ERCP had a higher Charlson Comorbidity Index (CCI) ≥3 (32.37% vs 26.76% vs 18.36%, P< 0.0001) compared to Whites and Hispanics, respectively. All-cause inpatient mortality (2.03% vs 1.51% vs 0.99%, P< 0.0001) and longer mean length of stay [LOS] (7.62 vs 6.23 vs 6.04 days, P< 0.0001) was higher for Black hospitalizations that underwent inpatient ERCPs compared to Whites and Hispanics, respectively. However, Hispanic hospitalizations had the highest mean total healthcare charge at $80,569 (Table 1). Conclusion: Our study demonstrates the influence of race on hospitalization characteristics and clinical outcomes for hospitalizations that underwent inpatient ERCP. Black hospitalizations had a significant comorbidity burden, higher all-cause inpatient mortality, and longer mean LOS. Ethnic minorities i.e. Hispanics and Blacks also had a higher total healthcare charge compare to White hospitalizations. There is an urgent need for large, prospective studies to investigate these findings. Table 1. - Comparative analysis for racial distribution of all-cause inpatient endoscopic retrograde cholangiopancreatography (ERCP) in the United States from 2007 – 2019 Variable Whites Blacks Hispanics P-value Total number of Hospitalizations 1,9777,674 527,843 300,516 Mean Age (years)± Standard Error 67.91 ( 0.05) 62.92 (0.08) 61.91 (0.18) P< 0.0001 Age groups (years) P< 0.0001 18-34 3.77% 5.20% 7.02% 34-49 9.65% 14.71% 17.18% 50-64 23.41% 31.30% 27.46% 65-79 35.80% 32.79% 30.19% ≥80 27.37% 16.00% 17.54% Gender P< 0.0001 Male 46.24% 43.93% 47.40% Female 53.76% 56.07% 52.60% Charlson Comorbidity Index (CCI) P< 0.0001 CCI = 0 25.83% 21.72% 26.07% CCI = 1 22.60% 20.74% 21.55% CCI = 2 17.38% 16.51% 15.06% CCI ≥ 3 34.19% 41.04% 37.32% Hospital Region P< 0.0001 Northeast 21.55% 18.18% 15.85% Midwest 23.50% 20.62% 6.43% South 38.63% 52.68% 40.03% West 16.32% 8.51% 37.69% Hospital Bed-Size P< 0.0001 Small 15.63% 12.86% 12.81% Medium 27.43% 28.47% 29.35% Large 56.93% 58.67% 57.84% Hospital Location and Teaching status P< 0.0001 Rural 11.22% 6.33% 3.72% Urban Non-teaching 37.76% 28.04% 39.62% Urban teaching 51.03% 65.63% 56.66% Median Household Income (Quartile) P< 0.0001 1st (0-25th) 24.34% 53.29% 39.26% 2nd (26th -50th) 27.31% 21.35% 24.61% 3rd (51st - 75th) 25.46% 15.46% 23.03% 4th ( 76th - 100th) 22.89% 9.90% 13.10% Discharge Home 65.68% 66.97% 73.28% P< 0.0001 Inpatient Mortality 1.55% 1.38% 1.57% P = 0.0006 Length of Stay (days) 6.66 7.58 6.99 P< 0.0001 Total Healthcare Charge ($) 60,024 65,825 78,781 P< 0.0001