Specialties performing paracentesis procedures at university hospitals: Implications for training and certification

Abstract

BACKGROUND Paracentesis procedure competency is not required for internal medicine or family medicine board certification, and national data show these procedures are increasingly referred to interventional radiology (IR). However, practice patterns at university hospitals are less clear. OBJECTIVE To evaluate which specialties perform paracentesis procedures at university hospitals, compare characteristics of patients within each specialty, and evaluate length of stay (LOS) and hospital costs. DESIGN, SETTING, PATIENTS Observational administrative database review of patients with liver disease who underwent paracentesis procedures in hospitals participating in the University HealthSystem Consortium (UHC) Database from January 2010 through December 2012. UHC is an alliance of 120 academic medical centers and their 290 affiliated hospitals. EXPOSURE Patients with liver disease who underwent inpatient paracentesis procedures. MEASUREMENTS We compared characteristics of patients who underwent paracentesis procedures by physician specialty, modeling the effects of patient characteristics on the likelihood of IR referral. We also analyzed LOS and hospital costs among patients with a >20% predicted probability of IR referral. RESULTS There were 97,577 paracentesis procedures performed during 70,862 hospital stays in 204 hospitals. IR performed 29% of paracenteses versus 49% by medicine and medicine subspecialties including gastroenterology/hepatology. Patients who were female, obese, and those with lower severity of illness were more likely to be referred to IR. Patients with a medicine or gastroenterology/hepatology paracentesis had a similar LOS compared to IR. Hospital costs were an estimated as $1308 less for medicine and $803 less for gastroenterology/hepatology compared to admissions with IR procedures (both P = 0.0001). CONCLUSIONS Internal medicine‐ and family medicine‐trained clinicians frequently perform paracentesis procedures on complex inpatients but are not currently required to be competent in the procedure. Increasing bedside paracentesis procedures may reduce healthcare costs. Journal of Hospital Medicine 2014;9:162–168. © 2014 Society of Hospital Medicine

Alfapump® system vs. large volume paracentesis for refractory ascites: A multicenter randomized controlled study

“…Although LVP is considered safe, it requires patient hospital contact as often as weekly and is associated with poor quality of life and malnutrition, which together increase morbidity and mortality [7,8].…”

Cost Savings of Performing Paracentesis Procedures at the Bedside After Simulation-based Education

“…30,31 Decisions on whether to perform paracentesis procedures at the bedside or to refer to IR are made frequently in US hospitals. 10 We are not certain why almost all surgical patients had paracentesis procedures performed in IR. This may be due to cultural factors such as preference of the attending surgeons, a belief that IR procedures are safer, or the fact that surgical residents did not receive training to perform paracentesis procedures.…”

“…We found that rates of IR referral for paracentesis procedures varied widely with a range of 0% to 100% and a mean (SD) IR referral rate of 32.41% (30.89%) among 204 University HealthSystem Consortium hospitals. 10 The decision to refer to IR at our institution was largely discretionary and did not reflect clinical parameters such as severity of liver disease or risk of bleeding in our models. 9 We also found that most clinical outcomes (procedure success rate, postprocedure bleeding, hospital readmission) were similar using either a bedside or an IR approach.…”

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“…Barsuk et al also found hospital costs to be lower when the procedure was performed by medicine, gastroenterology, or hepatology as compared with interventional radiology. 12 …”