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PERCUTANEOUS CHOLECYSTOSTOMY USE IN THE PALLIATIVE CARE SETTING: A NATIONWIDE ANALYSIS
Paul T. Kroner*2, Christopher C. Thompson1
1Brigham & Women's Hospital, Boston, MA; 2Mayo Clinic, Jacksonville, FL

Introduction
Percutaneous cholecystostomies (PC) are commonly placed to treat cholecystitis in severely ill patients in whom clinical status precludes surgery or as a palliative measure in patients with unresectable neoplastic processes. To date, no study has evaluated the use of PC in the palliative care setting at a national level. Therefore, the aim of our study was to explore the use, mortality and resource utilization of PC in patients on palliative care using a national database.

Methods
Case-control study using the National Inpatient Sample 2010 to 2014, the largest publically available inpatient database in the US. All patients on palliative care were included using ICD9CM codes. None were excluded. Patients undergoing PC placement were identified using ICD9CM codes. The primary outcome was determining the use of PC in palliative care patients. Secondary outcomes were determining the main reasons for procedure in this cohort, mortality, length of hospital stay (LOS), total hospitalization charges and costs across the past 5 years. Multivariate regression analyses were used to adjust for age, sex, income in patients' zip code, Charlson Comorbidity Index, hospital region, location, size and teaching status.

Results
A total of 2,641,031 patients received palliative care from 2010 to 2014 and were included in the study, of which 4,682 underwent PC placement. Mean age was 73 years and 54% were female. The total number of patients with PC placement increased from 146/100,000 patients on palliative care in 2010 to 195/100,000 patients on palliative care in 2014. All outcomes and most common principal diagnoses are displayed on Table 1 and 2, respectively. Patients who underwent PC placement had adjusted mortality odds of 1.39 (p<0.01) compared to patients who did not receive a PC. Hospital LOS was significantly longer in patients undergoing PC, which was confirmed after adjusting for confounders (Additional Adj. Mean: 8.0 days, p<0.01). Total costs and charges were substantially higher in patients undergoing PC (Additional Adj. Means: $32,688, p<0.01 and $128,422, p<0.01; respectively).

Conclusions
The use of PC in patients on palliative care has increased over the past five years and parallels the increase in number of cholecystitis cases. Increased mortality was noted in patients undergoing PC in this population. Length of hospital stay, total costs and charges were also strikingly increased in patients who underwent PC. Further study is warranted to better understand these findings, and other strategies that are more efficacious and lower cost should be considered.

Table 1
A.20102014p-value
Percutaneous Cholecystostomy use (per 100,000 patients on palliative care)146195<0.01
B. VariableAdjusted Values Ratio95% CIp-value
Additional Hospital Costs$32,688$28,347 - $37,028<0.01
Additional Hospital Charges$128,422$109,379-$147,465<0.01
Additional Length of Stay (days)8.06.97-9.1<0.01
Mortality1.381.21-1.61<0.01
C.Crude Values
VariableCholecystostomyNo Cholecystostomyp-value
Hospital Costs$18,837$53,557<0.01
Hospital Charges$67,879$201,476<0.01
Length of Stay (days)7.415.5<0.01

Table 1. A) Use of PC per 100,000 patients on palliative care in the past 5 years. B) Adjusted means and odds ratios for the evaluated parameters in palliative care patients undergoing PC placement compared to patients that did not undergo PC placement. C) Crude means for evaluated parameters in patients that underwent PC placement compared to patients that did not undergo PC.

Table 2. Main principal diagnoses in patients who underwent percutaneous cholecystostomy placement in the evaluated cohort of palliative care patients.
Admission ReasonsNumber
Acute Acalculous Cholecystitis1,960
Acute Calculous Cholecystitis1,285
Acute Pancreatitis445
Pancreatic Neoplasia245
Liver Neoplasia225


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