Age, socioeconomic features, and clinical factors predict receipt of endoscopic retrograde cholangiopancreatography in pancreatic cancer

Table 1 International Classification of Disease, 9^th Edition and Healthcare Common Procedure Coding System codes for claims data

	ICD-9	HCPCS
Endoscopic ultrasound	NA	76975, 43231, 43232, 43237, 43238, 43242, 43259
Endoscopic retrograde cholangiopancreatography	51.10, 51.11, 51.84-51.87, 51.99, 52.13, 52.93	74328-74330, 43260-43269, 43271, 43272
Surgery	52.51, 52.6, 52.7	48150, 48152, 48153, 48154, 48155
Jaundice	782.4	NA
Cholangitis	576.1	NA
Pruritus	698.9	NA

NA: Not applicable; ICD-9: International Classification of Disease, 9^th Edition; HCPCS: Healthcare Common Procedure Coding System.

Table 2 Characteristics of patients with pancreatic cancer by receipt of endoscopic retrograde cholangiopancreatography n (%)

	Total	Received ERCP	No ERCP	P value
Total	32510 (100.0)	14704 (45.2)	17806 (54.8)
Sex				0.49
Male	14147 (43.5)	6368 (45.0)	7779 (55.0)
Female	18363 (56.5)	8336 (45.4)	10027 (54.6)
Age				< 0.01
65-75	14205 (43.7)	6665 (46.9)	7540 (53.1)
76+	18305 (56.3)	8039 (43.9)	10266 (56.1)
Marital status				< 0.01
Married	15928 (49.0)	7370 (46.3)	8558 (53.7)
Not married	16582 (51.0)	7334 (44.2)	9248 (55.8)
Race				< 0.01
White	27399 (84.3)	12534 (45.8)	14865 (54.3)
Black	3349 (10.3)	1418 (42.3)	1931 (57.7)
Other	1762 (5.4)	752 (42.7)	1010 (57.3)
Year of diagnosis				< 0.01
2000-2003	10388 (32.0)	4955 (47.7)	5433 (52.3)
2004-2007	11134 (34.3)	4949 (44.5)	6185 (55.6)
2008-2011	10988 (33.8)	4800 (43.7)	6188 (56.3)
Residence				0.06
Metropolitan	27161 (83.6)	12346 (45.5)	14815 (54.6)
Non-metropolitan	5346 (16.5)	2356 (44.1)	2990 (55.9)
SEER registry region				< 0.01
Northeast	7153 (22.0)	3326 (46.5)	3827 (53.5)
Southeast	8128 (25.0)	3688 (45.4)	4440 (54.6)
Midwest	4243 (13.1)	1835 (43.3)	2408 (56.8)
West Coast	12986 (39.9)	5855 (45.1)	7131 (54.9)
Income (zip code)				0.96
High income	7948 (25.0)	3591 (45.2)	4357 (54.8)
Low income	23841 (75.0)	10780 (45.2)	13061 (54.8)
Education (zip code)				0.02
Low education	10188 (32.0)	4702 (46.2)	5486 (53.9)
High education	21638 (68.0)	9687 (44.8)	11951 (55.2)
SEER historic stage				< 0.01
Localized	3042 (9.4)	1806 (59.4)	1236 (40.6)
Regional	9178 (28.2)	5946 (64.8)	3232 (35.2)
Distant	16846 (51.8)	5170 (30.7)	11676 (69.3)
Unstaged	3400 (10.5)	1758 (51.7)	1642 (48.3)
Region of pancreas				< 0.01
Head	16670 (71.2)	10710 (64.3)	5960 (35.8)
Body/Tail	6744 (28.8)	1080 (16.0)	5664 (84.0)
Symptoms
Jaundice	14189 (43.7)	11076 (78.1)	3113 (21.9)	< 0.01
Cholangitis	3970 (12.2)	3471 (87.4)	499 (12.6)	< 0.01
Pruritus	1832 (5.6)	1297 (70.8)	535 (29.2)	< 0.01
Charlson Comorbidity score				0.12
0	14423 (46.6)	6616 (45.9)	7807 (54.1)
1	9049 (29.3)	4181 (46.2)	4868 (53.8)
2	3964 (12.8)	1760 (44.4)	2204 (55.6)
3+	3487 (11.3)	1550 (44.5)	1937 (55.6)
Therapeutic treatment
Chemotherapy	13235 (40.7)	6679 (50.5)	6556 (49.5)	< 0.01
Radiation	7298 (22.5)	4198 (57.5)	3100 (42.5)	< 0.01
Surgery	3259 (10.0)	2368 (72.7)	891 (27.3)	< 0.01

Some lines do not sum to 100% due to rounding or missing data. Other race: Neither white nor black race. Not married includes single, divorced and widowed. Metropolitan area defined as counties in metropolitan areas with population of 250000 or more; urban area defined as counties with populations of 2500 or more, both adjacent to metropolitan areas and not adjacent to metropolitan areas; rural defined as counties either completely rural or with populations < 2500. High income defined as > 75^th percentile of income, or $74147. Low income defined as < 75^th percentile or $74147. High education defined as living in a zip code where > 50% of the population has completed some college or more. Low education is defined as living in a zip code where > 50% of the population has no college education. ERCP: Endoscopic retrograde cholangiopancreatography; SEER: Surveillance, Epidemiology and End Results.

Table 3 Use of endoscopic retrograde cholangiopancreatography over time using Cochran Armitage trend n (%)

	Total	ERCP	P value
Year of diagnosis			< 0.01
2000-2003	10388	4955 (47.73)
2004-2007	11134	4949 (44.45)
2008-2011	10988	4800 (43.68)
Total	32510	14704 (45.2)

ERCP: Endoscopic retrograde cholangiopancreatography.

Table 4 Multivariable analysis of use of endoscopic retrograde cholangiopancreatography

	Adjusted OR of receiving ERCP (95%CI)
Sex
Male	1.00 (REF)
Female	1.03 (0.96-1.11)
Age
65-75	1.00 (REF)
76+	0.88 (0.82-0.95)
Marital status
Married	1.00 (REF)
Not married	0.90 (0.85-0.97)
Race
White	1.00 (REF)
Black	0.92 (0.82-1.04)
Other	0.83 (0.70-0.97)
Education (zip code)
> 50% high school only	1.14 (1.04-1.24)
> 50% some college	1.00 (REF)
Income (zip code)
< 75th percentile	1.10 (1.00-1.20)
> 75th percentile	1.00 (REF)
Year of diagnosis
2000-2003	1.00 (REF)
2004-2007	0.85 (0.78-0.92)
2008-2011	0.76 (0.70-0.83)
Metropolitan area
Metropolitan area	1.00 (REF)
Non-metropolitan area	0.87 (0.79-0.97)
United States region
Southeast	1.00 (REF)
Northeast	1.07 (0.96-1.20)
Midwest	0.96 (0.86-1.09)
West Coast	1.03 (0.93-1.13)
Comorbid conditions
Charlson score 0	1.00 (REF)
Charlson score 1	1.06 (0.98-1.15)
Charlson score 2	0.96 (0.86-1.07)
Charlson score 3+	0.99 (0.88-1.11)
Cancer site
Body or tail	1.00 (REF)
Head of the Pancreas	3.27 (2.99-3.57)
Symptoms1
Jaundice	7.59 (7.06-8.17)
Cholangitis	4.22 (3.71-4.81)
Pruritus	1.42 (1.22-1.66)
SEER historic stage
Localized	1.00 (REF)
Regional	1.01 (0.89-1.14)
Distant	0.52 (0.46-0.58)
Unstaged	0.85 (0.73-1.00)
Cancer directed therapies1
Chemotherapy	1.39 (1.28-1.51)
Radiation	1.21 (1.11-1.33)
Surgery	0.82 (0.73-0.92)

¹Referent category is not having those symptoms, conditions or treatments. Other race is neither white nor black race. Not married includes single, divorced and widowed. Metropolitan area defined as counties in metropolitan areas with population of 250000 or more. High income defined as > 75^th percentile of income, or $74147. Low income defined as < 75^th percentile or $74147. High education defined as living in a zip code where > 50% of the population has completed some college or more. Low education is defined as living in a zip code where > 50% of the population has no college education. OR: Odds ratio; CI: Confidence interval; Endoscopic retrograde cholangiopancreatography.

Table 5 Analysis stratified by symptoms/conditions

	Adjusted OR of receiving ERCP (95%CI), amongst patients with Jaundice	Adjusted OR of receiving ERCP (95%CI), amongst patients with Cholangitis	Adjusted OR of receiving ERCP (95%CI), amongst patients with Pruritus
Sex
Male	1.00 (REF)	1.00 (REF)	1.00 (REF)
Female	1.17 (1.05-1.30)	0.99 (0.77-1.27)	1.00 (0.75-1.33)
Age
65-75	1.00 (REF)	1.00 (REF)	1.00 (REF)
76+	0.98 (0.88-1.09)	0.86 (0.67-1.10)	0.97 (0.73-1.29)
Marital status
Married	1.00 (REF)	1.00 (REF)	1.00 (REF)
Not married	0.85 (0.76-0.94)	0.97 (0.75-1.26)	0.94 (0.70-1.26)
Race
White	1.00 (REF)	1.00 (REF)	1.00 (REF)
Black	0.80 (0.67-0.95)	0.87 (0.58-1.28)	0.88 (0.52-1.51)
Other	0.73 (0.58-0.91)	0.64 (0.42-0.98)	1.00 (0.59-1.70)
Education (zip code)
> 50% high school only	1.00 (0.88-1.13)	0.79 (0.59-1.06)	1.23 (0.88-1.71)
> 50% some college	1.00 (REF)	1.00 (REF)	1.00 (REF)
Income (zip code)
< 75th percentile	1.13 (0.99-1.30)	1.50 (1.12-2.01)	0.84 (0.60-1.17)
> 75th percentile	1.00 (REF)	1.00 (REF)	1.00 (REF)
Year of diagnosis
2000-2003	1.00 (REF)	1.00 (REF)	1.00 (REF)
2004-2007	0.97 (0.86-1.10)	0.94 (0.70-1.26)	0.96 (0.67-1.39)
2008-2011	1.00 (0.88-1.13)	1.02 (0.76-1.37)	0.76 (0.54-1.06)
Metropolitan area
Metropolitan area	1.00 (REF)	1.00 (REF)	1.00 (REF)
Non-metropolitan area	0.79 (0.68-0.91)	1.30 (0.87 -1.95)	0.83 (0.56-1.24)
United States region
Southeast	1.00 (REF)	1.00 (REF)	1.00 (REF)
Northeast	0.94 (0.80-1.11)	1.23 (0.83-1.83)	0.73 (0.46-1.14)
Midwest	0.91 (0.76-1.07)	1.09 (0.71-1.69)	1.01 (0.61-1.67)
West Coast	0.95 (0.82-1.09)	1.02 (0.72-1.43)	0.75 (0.51-1.11)
Comorbid conditions
Charlson score 0	1.00 (REF)	1.00 (REF)	1.00 (REF)
Charlson score 1	1.06 (0.94-1.20)	1.24 (0.92-1.67)	1.24 (0.90-1.70)
Charlson score 2	0.93 (0.80-1.09)	0.69 (0.50-0.96)	0.77 (0.52-1.16)
Charlson score 3+	0.98 (0.83-1.16)	0.84 (0.58-1.21)	1.14 (0.72-1.80)
Cancer site
Body or tail	1.00 (REF)	1.00 (REF)	1.00 (REF)
Head of the pancreas	3.82 (3.23-4.50)	2.92 (1.98-4.31)	8.03 (5.57-11.56)
SEER historic stage
Localized	1.00 (REF)	1.00 (REF)	1.00 (REF)
Regional	0.85 (0.71-1.01)	0.79 (0.52-1.21)	1.21 (0.80-1.82)
Distant	0.51 (0.43-0.60)	0.44 (0.29-0.66)	0.83 (0.54-1.28)
Unstaged	0.75 (0.60-0.94)	0.46 (0.28-0.77)	0.88 (0.47-1.65)
Cancer directed therapies1
Chemotherapy	1.68 (1.48-1.90)	1.578 (1.20-2.07)	0.91 (0.66-1.26)
Radiation	1.21 (1.06-1.39)	1.25 (0.94-1.67)	1.19 (0.86-1.64)
Surgery	0.60 (0.52-0.69)	0.48 (0.35-0.67)	0.84 (0.5-1.20)

¹Referent category is not undergoing these treatments. OR: Odds ratio; CI: Confidence interval; Endoscopic retrograde cholangiopancreatography.