Department of Surgery, Vanderbilt University Medical Center Nashville, Tennessee 37232, USA.
J Surg Res. 2011 Oct;170(2):214-9. doi: 10.1016/j.jss.2011.03.040. Epub 2011 Apr 15.
Choledocholithiasis (CDL) management is dictated by local expertise, individual training, and availability of appropriate staff. This study evaluates the management of CDL between urban and rural communities.
Patients undergoing inpatient management of CDL were identified from the 2007 Healthcare Cost and Utilization Project. Availability of endoscopic retrograde cholangiopancreatography (ERCP) was determined from the 2007 American Hospital Association survey. The proportion of common bile duct exploration (CBDE), ERCP, or percutaneous (PERC) interventions were compared across census regions and National Centers for Health Statistics (NCHS) urban-rural classes. The NCHS urban-rural classification scheme divides counties from most populous (NCHS 1) to rural (NCHS 6). Proportions were compared using the 95% confidence interval (95%CI) approach.
We estimated 111,021 CDL hospitalizations in the U.S. in 2007. Of these, 67% had a coded intervention. Intervention frequencies were similar across census regions. Comparisons across NCHS classes revealed higher proportions of ERCP in urban areas (NCHS 1-4) while a higher proportion of CBDE was seen in rural areas (NCHS 5-6). ERCP availability was high in metropolitan areas (available in 35%-44% of hospitals NCHS 1-4) and low in rural areas (25% of NCHS 5 hospitals and 5% NCHS 6). PERC management was similar across NCHS classes.
Rural hospitals and communities need surgeons trained in CBDE, where ERCP expertise may not be readily available. Feasible ways of expanding ERCP coverage to the nation's rural areas need to be explored. These observations may impact surgical training at least for those targeting careers in rural surgery.
胆总管结石（CDL）的治疗方法取决于当地的专业知识、个人培训和合适人员的可用性。本研究评估了城乡社区之间 CDL 的治疗方法。
从 2007 年医疗保健成本和利用项目中确定了接受 CDL 住院治疗的患者。从 2007 年美国医院协会调查中确定了内镜逆行胰胆管造影术（ERCP）的可用性。比较了普查区和国家卫生统计中心（NCHS）城乡分类的胆总管探查术（CBDE）、ERCP 或经皮（PERC）干预的比例。NCHS 城乡分类方案将各县从人口最多的县（NCHS1）到农村县（NCHS6）进行分类。使用 95%置信区间（95%CI）方法比较比例。
我们估计 2007 年美国有 111,021 例 CDL 住院患者。其中，67%的患者有编码干预。普查区的干预频率相似。NCHS 分类比较显示，城市地区（NCHS1-4）的 ERCP 比例较高，而农村地区（NCHS5-6）的 CBDE 比例较高。大都市地区的 ERCP 可用性较高（NCHS1-4 中有 35%-44%的医院提供），而农村地区的可用性较低（NCHS5 医院中有 25%，NCHS6 医院中有 5%）。PERC 管理在 NCHS 分类中相似。
农村医院和社区需要接受 CBDE 培训的外科医生，因为 ERCP 专业知识可能不容易获得。需要探索向全国农村地区扩大 ERCP 覆盖范围的可行方法。这些观察结果可能会影响外科培训，至少会影响那些针对农村手术职业的培训。
