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THE CLINICAL AND COST IMPACT OF ENDOSCOPIC ULTRASOUND (EUS) ON THE PATTERN OF ERCP IN A TERTIARY REFERRAL CENTRE

N Alhayaf, G Sandha
University of Alberta Hospital, Edmonton, Alberta

AIM: EUS is a safe alternative to ERCP for diagnostic imaging of the common bile duct (CBD) for choledocholithiasis. Whether there has been a shift in the pattern of ERCP since the introduction of EUS in clinical practice is unknown. The purpose of this study is to assess the clinical and cost impact of a new EUS program on diagnostic ERCP at a tertiary referral centre.
METHODS: This study represents a retrospective review of data collected during the first complete year of implementing EUS as a new program in the Capital Health region. Patients were initially referred for ERCP for suspicion of choledocholithiasis but based on clinical, biochemical and radiologic parameters were deemed to have a low likelihood for undergoing therapeutic intervention and thus referred for EUS. ERCP was done if EUS suggested CBD stones and clinical follow-up for 6 months if EUS was normal. Cost data reflects Alberta Health and Wellness reciprocal billing per diem and physician reimbursements.
RESULTS: During its first year of implementation, 329 pts underwent EUS at the UAH. Of these, 90 pts (63 F, mean age 58 yrs) had EUS for suspicion of a CBD stone based on pain, elevated LFTs and/or unexplained CBD dilation. EUS suggested a CBD stone in 20/90 pts and this was confirmed on ERCP in 17/20 pts. EUS was normal in 69 pts of which none underwent a subsequent ERCP during a 6 month follow-up. One pt was found to have pancreatic cancer on EUS. Overall sensitivity for EUS was 100% and specificity 96% for CBD stones. A total of 440 ERCPs were done during this year reflecting a 14% reduction in diagnostic ERCP at the UAH. There were no complications of EUS.
The cost of 89 EUS ($476 each) procedures was $42,364 compared to $103,538 for 69 ERCPs ($1,213 per procedure + $1,917/d x 3d for cost of hospitalization related to 5% risk of pancreatitis). The total cost savings was $61,174/yr for the UAH. Extrapolating this to Capital Health region with ~1,500 ERCPs/yr, the cost savings amount to $183,522/yr.
CONCLUSION: EUS is an accurate, safe and cost-effective investigation for CBD imaging for suspected choledocholithiasis. Diagnostic ERCP should not be performed in centres that are equipped with EUS with physicians trained in accurate interpretation.

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