ORIGINAL ARTICLE
Trends and Outcomes of Hospitalizations
Related to Acute Pancreatitis
Epidemiology From 2001 to 2014 in the United States
Jonathan Gapp, MD,* Alexander G. Hall, MA,† Ryan W. Walters, PhD,‡ Darius Jahann, MD,§
Thamer Kassim, MD,* and Savio Reddymasu, MD||
Objectives: The aim of this study was to determine the recent trends of
the rates of hospitalization, mortality of hospitalized patients, and associ-
Downloaded from http://journals.lww.com/pancreasjournal by BhDMf5ePHKbH4TTImqenVO5mbfjSJnJQusd8VFcTsP3cKWqxpF/JddvcHGlPUUA+Ea9Ftom5yqo= on 12/08/2019
ated health care utilization in patients with acute pancreatitis (AP).
Methods: We identified adult patients with primary discharge diagnosis
of AP from the National Inpatient Sample database. Patients with chronic
pancreatitis and/or pancreatic cancer were excluded. Primary outcomes in-
cluded age-adjusted incidence of AP and in-hospital mortality based on US
standard population derived from the 2000 census data. Secondary out-
comes were length of stay, inflation-adjusted hospital costs in 2014 US dol-
lars, and procedural rates. Subgroup analysis included disease etiologies,
age, race, sex, hospital region, hospital size, and institution type.
Results: From 2001 to 2014, the rate of primary discharge diagnosis for
AP increased from 65.38 to 81.88 per 100,000 US adults per year. In-
hospital case fatality decreased from 1.68% to 0.69%. Mortality rate is
higher in patients with AP who are older than 65 years (3.4%). Length of
stay decreased, with a median of 3.8 days; cost per hospitalization de-
creased since 2007 from $7602 to $6766 in 2014.
Conclusions: The rate of hospitalization related to AP in the United
States continues to increase. Mortality, length of stay, and cost per hospital-
ization decrease. The increase in volume of hospitalization might contrib-
ute to an overall increase in health care resource utilization.
Key Words: acute pancreatitis, cost, epidemiology, incidence, mortality
(Pancreas 2019;48: 548–554)
A cute pancreatitis (AP) is a common indication for hospitaliza-
tion.1 Previous studies have illustrated an increasing inci-
dence of AP, while the trend in mortality has varied.2–4 It is
unclear whether emphasis on resuscitation in management of
From the *Department of Internal Medicine, Creighton University Medical
Center; †Biostatistics Core Facility and ‡Division of Internal Medicine, Depart-
ment of Medicine, Creighton University; and §Division of Gastroenterology,
Department of Medicine, Creighton University Medical Center, Omaha, NE;
and ||Division of Gastroenterology, Department of Internal Medicine, St
Joseph's Hospital and Medical Center/Creighton University School of Medi-
cine, Phoenix Campus, Phoenix, AZ.
Received for publication September 20, 2018; accepted February 17, 2019.
Address correspondence to: Jonathan Gapp, MD, Department of Medicine,
7710 Mercy Rd, Suite 301, Omaha, NE 68124
(e‐mail: jonathangapp@creighton.edu).
Author Contributions: J.G.: project design and drafting of abstract, introduction,
results, and conclusion. A.G.H.: project design, SAS programming for data
analysis, and drafting of materials and methods and results. R.W.W.: project
design, SAS programming for data analysis, and drafting of materials and
methods and results. D.J.: abstract review and manuscript editing. T.K.:
manuscript editing. S.R.: project design, drafting and editing manuscript,
and guarantor.
The authors declare no conflict of interest.
Supplemental digital contents are available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal’s Web site (www.pancreasjournal.com).
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/MPA.0000000000001275
548 www.pancreasjournal.com
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AP has led to improved outcomes or a decrease in health care uti-
lization over the past decade. Determining trends in the rate of AP,
and cost per AP hospitalization, is essential in assessing not only
health care utilization on a national level, but also whether ad-
vances in its management are having an impact on mortality. With
increased emphasis on high-value health care, it is important to
continually gauge current trends in cost of management while en-
suring economic pressure does not result in worse outcomes.
We interrogated data from the National (Nationwide) Inpa-
tient Sample (NIS) pertaining to AP from 2001 to 2014 to include
rate of primary discharge diagnosis of AP, in-hospital mortality,
length of stay (LOS), and hospital cost, with subgroup analysis
within etiology, US geographic region, age, hospital bed size,
and institution type. By analyzing epidemiologic data of AP in
the United States, this study may elucidate and encourage further
research as to why certain trends exist.
MATERIALS AND METHODS
Study Population
Hospitalization data were abstracted from the NIS from 2001
to 2014. The NIS is part of a family of databases within the
Healthcare Cost and Utilization Project sponsored by the Agency
for Healthcare Research and Quality. The NIS is the largest pub-
licly available, all-payer inpatient database in the United States
and uses stratified random sampling that, when weighted, estimates
approximately 35 million yearly hospitalizations nationally.5 The
study period from 2001 to 2014 was selected specifically to maintain
consistent International Classification of Disease, Ninth Revision,
Clinical Modification (ICD-9-CM)/Procedure Coding System cod-
ing. Although the ICD-9-CM crosswalk to ICD-10-CM is straight-
forward for AP etiologies, this is not true for procedural coding,
which precluded direct comparison before and after the October
2015 implementation of ICD-10-CM/Procedure Coding System.
Therefore, to prevent confusion that could result from using dif-
ferent end dates when discussing AP etiologies versus procedures,
we chose to present only results through 2014. However, we have
included the 2015 and 2016 NIS data in Supplementary Tables 1
and 2 and Supplementary Figures 1 to 4, (http://links.lww.com/
MPA/A714) for every result specific to AP etiology.
We identified hospitalizations with primary discharge diag-
nosis of AP (ICD-9-CM 577.0), excluding patients with a diagno-
sis of chronic pancreatitis and/or pancreatic cancer (ICD-9-CM
577.1 and 157.x, respectively) because these are different disease
processes and would likely confound the focused data on AP. For
each hospitalization, we identified concurrent diagnoses of alcohol
abuse, gallstones, and/or hypertriglyceridemia, which we treated as
a proxy for AP etiology (see Supplementary Table 1, http://links.
lww.com/MPA/A714, for ICD-9-CM codes). We extracted age, race
(white, black, Hispanic, other), biological sex, income quartile,
primary payer (Medicare, Medicaid, private, uninsured, other),
Pancreas • Volume 48, Number 4, April 2019
Pancreas • Volume 48, Number 4, April 2019 US Trends of Acute Pancreatitis: 2001 to 2014

FIGURE 1. National volume and rate of AP per 100,000 US adults (Ptrend < 0.001).

hospital characteristics that included location and teaching status
(rural, urban nonteaching, urban teaching), region (Northeast,
Midwest, South, West), and bed size (small, medium, large). We
excluded hospitalizations in which the patient was younger than
18 years, transferred from another hospital, or died on the day
of admission; we also excluded hospitalizations with nonpositive
NIS weights and those missing any patient- or hospital-level charac-
teristics. This study was considered exempt research by the Creighton
University Institutional Review Board (IRBNet ID 1108005-1).
Outcomes
Primary outcomes included year-over-year trends in hospital-
izations related to AP incidence per 100,000 US population. Inci-
dence was calculated by dividing the NIS weighted frequency
estimate by the midyear census estimates for a given year (as pro-
vided by the US Census Bureau)6 and multiplying that quotient by
100,000. Secondary outcomes included in-hospital mortality,
LOS, inflation-adjusted hospital costs in 2014 US dollars,7 and
procedural rates (see Supplementary Table 1, http://links.lww.
com/MPA/A714, for procedures and ICD-9-CM codes). For all
outcomes, we conducted subgroup analyses across AP etiologies
and demographic characteristics.
Statistical Analysis
Continuous variables are presented as mean ± SE and com-
pared using linear regression to allow for NIS weighting, whereas
categorical variables are presented as frequency and percent and
compared using the Rao-Scott χ2 test using the estimated
proportions as the design correction. All linear trend analyses
were conducted using Spearman rank correlation on yearly esti-
mates (also known as Daniels test for trend). When appropriate,
Wilson confidence intervals (CIs) are provided for categorical
outcomes, whereas CIs for LOS and hospital cost were obtained
from log-linear regression models due to nonnormality and
heteroscedastic residuals. All analyses accounted for the NIS
sampling design using updated hospital trend weights. SAS version
9.4 (SAS Institute, Cary, NC) was used for statistical analysis, and
P < 0.05 indicates statistical significance.
RESULTS
From 2001 to 2014, there was an estimated 2,368,780 hospi-
talizations in the United States with a primary discharge diagnosis
of AP (95% CI, 2,298,204–2,439,357). Regarding the etiology of
these AP hospitalizations, 527,653 (22.5%) had an alcohol abuse
diagnosis, 533,253 (22.7%) had gallstones, 83,836 (3.7%) had
hypertriglyceridemia, and 70,199 (3.0%) had more than one of
these diagnoses; the remaining 1,134,428 (48.3%) hospitaliza-
tions did not have any of the aforementioned diagnoses.
Hospitalizations Related to AP
The national volume of AP-related hospitalizations increased
from 138,795 in 2001 to 200,600 in 2014, with overall rate of hos-
pitalizations due to AP increasing from 65.4 per 100,000 US
adults in 2001 to 81.9 per 100,000 US adults in 2014
(Ptrend < 0.001; Fig. 1). As shown in Table 1, from 2001 to 2014,
AP with an alcohol abuse diagnosis showed an increase from

TABLE 1. Rate of AP by Etiology per 100,000 US Adults

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Ptrend
Alcohol 15.0 15.4 14.6 15.7 15.3 16.4 16.1 18.4 18.9 21.0 21.2 22.7 22.6 23.4 <0.001
Biliary 15.8 16.4 17.0 17.1 17.1 18.2 17.3 18.0 18.8 20.1 20.3 20.1 19.5 19.3 <0.001
Biliary + ERCP 1.8 1.7 1.6 1.3 1.2 1.1 0.8 0.7 0.6 0.6 0.5 0.5 0.5 0.4 <0.001
Hypertriglyceridemia 2.1 2.4 2.6 2.6 2.9 2.8 3.0 3.6 4.1 4.6 4.8 5.0 4.6 4.9 <0.001
No etiology 33.8 31.2 32.6 35.1 33.6 33.5 31.0 36.2 36.0 38.3 38.3 39.3 38.5 37.6 <0.001
No etiology + ERCP 1.5 1.1 1.0 0.9 0.8 0.7 0.5 0.5 0.4 0.4 0.3 0.4 0.3 0.3 <0.001
Data reported as number of patients per 100,000 US adults.

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Gapp et al Pancreas • Volume 48, Number 4, April 2019

15.0 to 23.4 per 100,000 US adults, biliary AP increased from
15.8 to 19.3 per 100,000 US adults, and AP with hypertriglyc-
eridemia increased from 2.1 to 4.9 per 100,000 US adults (all
Ptrend < 0.001; Table 1). Further, the use of endoscopic retrograde
cholangiopancreatography (ERCP) both in biliary AP and in AP
in the absence of the etiologies under study also decreased sub-
stantially (both Ptrend < 0.001).
As shown in Table 2, AP with an alcohol abuse diagnosis
occurred more frequently in those aged 25 to 54 years, males,
non-Hispanic blacks, and those in which the primary payer was
Medicaid, self-pay, or another form of insurance. Biliary AP
occurred more frequently in females, those aged 18 to 24 years,
and those older than 64 years, which coincided with the higher
rates observed in Medicare beneficiaries. Acute pancreatitis with
hypertriglyceridemia was more frequent in those aged 35 to 44 years,
males, Hispanics, the privately insured, and in facilities in the
Western United States.
Mortality, LOS, Hospital Cost, and Procedures
Although the rates of AP-related hospitalizations increased
from 2001 to 2014, the overall mortality rate in these patients de-
creased from 1.7% to 0.7% (Ptrend < 0.001). As shown in Figure 2,
similar trends were observed with a concurrent diagnosis of alco-
hol abuse or gallstones (both Ptrend < 0.001), but no statistically

TABLE 2. Rate of AP Etiology by Demographic and Clinical Characteristics

n Alcohol Biliary Hypertriglyceridemia No Etiology

Overall 2,368,780 25.2 24.7 4.9 47.9
Age, y
18–24 104,410 16.0 33.9 4.6 46.6
25–34 290,377 36.9 20.8 7.9 37.8
35–44 410,701 37.7 16.0 9.0 40.9
45–54 529,844 36.9 17.4 5.9 43.8
55–64 387,882 21.0 25.0 3.2 53.2
≥65 645,567 6.2 36.2 1.1 57.3
Biological sex
Male 1,192,713 36.4 19.3 6.4 42.2
Female 1,175,895 13.8 30.2 3.4 53.7
Race
Non-Hispanic white 1,543,790 23.6 24.7 4.8 49.0
Non-Hispanic black 383,295 35.3 16.3 2.5 48.5
Hispanic 313,092 21.9 32.4 7.5 41.9
Other 128,446 21.1 28.6 6.4 47.1
Insurance status
Medicare 776,839 11.2 30.4 1.9 57.6
Medicaid 350,254 35.1 21.1 4.8 42.0
Private 822,837 23.5 23.6 6.9 48.9
Self-pay 293,927 47.7 18.6 6.7 31.5
Other 123,954 41.7 20.8 6.0 36.0
Income quartile
First 663,940 26.8 22.9 4.5 48.4
Second 610,655 25.0 23.8 5.0 48.6
Third 565,171 24.9 25.3 5.2 47.3
Fourth 528,676 23.6 27.2 4.9 47.0
Region
Northeast 474,298 27.3 25.7 3.8 44.2
Midwest 385,102 23.9 23.1 5.0 50.8
South 1,004,725 23.9 23.1 5.1 50.8
West 504,656 26.8 28.0 5.5 43.4
Facility location
Rural 352,530 21.5 20.9 4.5 54.9
Urban teaching 887,242 27.0 26.3 5.0 44.7
Urban nonteaching 1,129,008 24.9 24.5 5.0 48.2
Bed size
Small 366,575 25.3 22.5 4.9 49.7
Medium 670,006 25.8 24.7 4.9 47.2
Large 1,332,200 24.8 25.2 4.9 47.7
Procedure rate 2,368,780 32.8 15.9 5.6 49.2
Values under each etiology are percentages of n for the particular demographic group.

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Pancreas • Volume 48, Number 4, April 2019
FIGURE 2. Crude mortality rate by etiology.
significant trend was observed in the presence of hypertriglyc-
eridemia (Ptrend = 0.503). When considering demographic charac-
teristics, mortality rates were higher in whites and Medicare
beneficiaries and continually increase with age with greatest mor-
tality in those 65 years or older (Table 2).
In addition, median LOS decreased from 4.4 days in 2001 to
3.4 days in 2014 (Ptrend < 0.001); similar rates of decrease were
observed within concurrent diagnoses of alcohol abuse, gallstones,
and hypertriglyceridemia (Fig. 3; all Ptrend < 0.001). Median LOS
for the entire cohort over the duration of the study was 3.8 days.
Longer lengths of stay were observed in Medicare beneficiaries,
the Northeast region, urban teaching facilities, and facilities with
large bed sizes (Table 3).
Median hospital cost (in 2014 US dollars) showed a nonlin-
ear trend as it increased from $6820 in 2001 to $7602 in 2007
(Ptrend < 0.001 for increase) and then decreased to $6766 in
2014 (Ptrend < 0.001 for decrease). As shown in Figure 4, a similar
increasing followed by decreasing trend was observed within con-
current diagnoses of alcohol abuse and gallstones (Ptrend < 0.001
for increase and decrease); the trend for AP with hypertriglyc-
eridemia was mostly flat from 2004 to 2010 (Ptrend < 0.001 for in-
crease and 0.030 for decrease). In general, costs were higher in the
FIGURE 3. Crude LOS in days by etiology.
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US Trends of Acute Pancreatitis: 2001 to 2014
presence of biliary pancreatitis, in those older than 54 years, in
Hispanics and those of other races, those in the highest income
quartile, and in facilities in the Northeast and West (Table 3). An
estimated 99,886 hospitalizations included a pancreas-specific
procedure (95% CI, 96,245–103,528). The procedure rate was
highest in hospitalizations with a concurrent alcohol abuse di-
agnosis, in those aged 35 to 64 years, males, in those of white
or other races, in those living in higher-income zip codes, and
in large or urban teaching facilities (Table 3).
DISCUSSION
This study explores the recent trends of AP in the United
States from 2001 to 2014 using a national database of hospital dis-
charges. Our results show a consistent increase in the rate of hos-
pitalizations related to AP. The general incidence trends observed
in our study are in keeping with other previously reported studies.
Brown et al3 studied NIS trends from 1997 to 2003, which showed
an increase in frequency of primary discharge diagnosis of AP of
30.2% (from 493 per 100,000 to 642 per 100,000). In another re-
view in trends of AP from 1998 to 2006, NIS data from Singla
et al8 showed a continued annual increase in incidence of AP, with
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Gapp et al Pancreas • Volume 48, Number 4, April 2019

TABLE 3. Crude Mortality Rate, LOS, Hospital Cost, and Procedure Rate by Clinical and Demographic Characteristics

Mortality LOS Hospital Cost Procedure Rate

Overall 1.0 (1.0–1.1) 3.8 (3.8–3.8) 7242 (7175–7310) 4.1 (4.1–4.2)
Age, y
18–24 0.1 (0.1–0.2) 3.4 (3.3–3.4) 6582 (6482–6683) 3.0 (2.8–3.3)
25–34 0.3 (0.2–0.3) 3.5 (3.4–3.5) 6506 (6430–6583) 4.2 (4.0–4.4)
35–44 0.4 (0.3–0.4) 3.6 (3.6–3.6) 6601 (6523–6678) 4.6 (4.4–4.8)
45–54 0.6 (0.6–0.7) 3.7 (3.6–3.7) 6818 (6746–6891) 4.6 (4.5–4.8)
55–64 1.0 (0.9–1.0) 3.9 (3.8–3.9) 7504 (7427–7583) 4.5 (4.4–4.7)
≥65 3.4 (3.3–3.5) 4.3 (4.3–4.4) 8430 (8345–8517) 3.6 (3.5–3.8)
Biological sex
Male 1.1 (1.1–1.2) 3.7 (3.7–3.8) 7045 (6977–7114) 5.1 (5.0–5.2)
Female 1.0 (0.9–1.0) 3.9 (3.9–3.9) 7450 (7378–7522) 3.4 (3.3–3.4)
Race
Non-Hispanic white 1.2 (1.1–1.2) 3.8 (3.8–3.9) 7259 (7192–7326) 4.6 (4.5–4.7)
Non-Hispanic black 0.8 (0.8–0.9) 3.7 (3.7–3.7) 6474 (6365–6586) 3.4 (3.3–3.6)
Hispanic 0.7 (0.7–0.8) 3.8 (3.8–3.9) 7912 (7769–8057) 3.4 (3.2–3.6)
Other 1.0 (0.9–1.2) 3.8 (3.8–3.9) 8064 (7880–8251) 4.1 (3.9–4.4)
Insurance status
Medicare 2.0 (1.9–2.1) 4.2 (4.2–4.3) 8035 (7956–8114) 3.7 (3.6–3.8)
Medicaid 0.7 (0.6–0.7) 3.8 (3.7–3.8) 7105 (7004–7207) 4.3 (4.1–4.5)
Private 0.6 (0.6–0.6) 3.6 (3.6–3.7) 7010 (6934–7086) 4.6 (4.5–4.7)
Self-pay 0.4 (0.4–0.5) 3.4 (3.4–3.5) 6269 (6182–6356) 4.3 (4.1–4.4)
Other 0.6 (0.5–0.7) 3.7 (3.6–3.7) 7007 (6865–7152) 4.7 (4.4–5.1)
Income quartile
First 1.0 (0.9–1.0) 3.8 (3.7–3.8) 6752 (6673–6833) 3.8 (3.7–4.0)
Second 1.0 (0.9–1.1) 3.8 (3.8–3.8) 7070 (6999–7143) 4.1 (3.9–4.2)
Third 1.1 (1.0–1.1) 3.8 (3.8–3.9) 7450 (7353–7549) 4.5 (4.3–4.6)
Fourth 1.2 (1.1–1.2) 3.9 (3.9–3.9) 7907 (7759–8057) 4.6 (4.4–4.7)
Region
Northeast 1.2 (1.1–1.2) 4.1 (4.0–4.1) 7961 (7750–8177) 4.2 (4.0–4.3)
Midwest 0.9 (0.8–1.0) 3.6 (3.6–3.6) 6808 (6712–6906) 4.4 (4.1–4.6)
South 1.1 (1.0–1.1) 3.9 (3.8–3.9) 6665 (6576–6756) 4.2 (4.0–4.3)
West 1.0 (0.9–1.1) 3.6 (3.6–3.7) 8273 (8108–8441) 4.2 (4.1–4.4)
Facility location
Rural 0.9 (0.8–0.9) 3.4 (3.4–3.5) 6337 (6239–6437) 3.0 (2.9–3.2)
Urban teaching 1.1 (1.1–1.2) 4.0 (3.9–4.0) 7558 (7445–7673) 5.0 (4.9–5.2)
Urban nonteaching 1.0 (1.0–1.1) 3.8 (3.8–3.9) 7314 (7208–7422) 4.0 (3.9–4.1)
Bed size
Small 0.8 (0.7–0.9) 3.5 (3.4–3.5) 6918 (6799–7038) 3.5 (3.3–3.7)
Medium 1.1 (1.0–1.1) 3.8 (3.7–3.8) 7211 (7097–7326) 4.0 (3.8–4.1)
Large 1.1 (1.1–1.2) 3.9 (3.9–4.0) 7349 (7249–7450) 4.5 (4.4–4.7)
Risk factor etiology
Alcohol 0.7 (0.6–0.7) 3.7 (3.7–3.7) 6605 (6535–6676) 5.5 (5.4–5.7)
Biliary 1.1 (1.0–1.2) 4.5 (4.5–4.5) 10,392 (10,282–10,503) 2.7 (2.6–2.8)
Hypertriglyceridemia 0.4 (0.4–0.5) 4.1 (4.1–4.1) 7544 (7445–7645) 4.9 (4.6–5.1)
No etiology 1.2 (1.2–1.3) 3.6 (3.5–3.6) 6411 (6350–6473) 4.3 (4.2–4.4)
All values in parentheses represent 95% CIs.

incidence rising 29.6% from 1998 to 2006. A study using the Na-
tional Hospital Discharge Survey, conducted by Fagenholz et al9 from
1988 to 2003, noted the number of cases as rising from 101,000 to
201,000 during that study period. A recent study reporting AP data
until 2012 using the NIS without exclusion of chronic pancreatitis
or pancreatic malignancy also showed that the rates of AP-related
hospitalization are rising (15% from 2003 to 2012).1 Our study dem-
onstrates that the increase in rate of hospitalization due to AP persists.
Because the NIS database is a stratified random sample, our re-
sults are likely indicative of the incidence rate of AP, given that
a vast majority of patients with AP have to be hospitalized.
There was an overall trend of decreasing mortality rate from
1.7% in 2001 to 0.7% in 2014, and the mortality benefit was seen
among patients with AP of all etiologies. Overall, biliary pancre-
atitis AP was associated with higher mortality compared with
other etiologies. Although the mortality in biliary pancreatitis

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Pancreas • Volume 48, Number 4, April 2019
FIGURE 4. Crude hospital cost by etiology (in 2014 US dollars).
did decrease from 2001 to 2007, improvements in subsequent
years were less notable. The reason for this is unclear. When con-
sidering demographic patterns related to mortality, increasing age
is associated with significant increase in mortality with relative
mortality increasing from 0.1 to 3.4 in the higher age group. It
is very likely that the increase in mortality is due to the presence
of other comorbid conditions.8,10 Racial comparison indicated
that whites were at higher risk of mortality from AP compared
with blacks or Hispanics. The clinical significance of this is un-
clear as a previous study also suggested increased rate of mortality
in African Americans with AP.11 Academic medical centers also
appeared to have higher mortality rate, cost, number of proce-
dures, and longer LOS; however, this probably relates to a more
complex patient population being managed in these facilities.
In reviewing primary discharge diagnosis of AP by etiology,
the rates of alcoholic, biliary, and hypertriglyceridemia-related
AP have all increased. Although AP with hypertriglyceridemia
accounted for only a small portion of all AP discharges, it nearly
doubled over the 14-year study period. This is probably a reflec-
tion of the obesity epidemic. Etiology of AP for a sizeable num-
ber of patients was not identified based on information contained
in this database, probably due to lack of accurate coding. In light
of this, it is difficult to draw accurate conclusions regarding the
trends of AP etiology in this study. Over the 14-year period,
the total median LOS decreased by 23.3% from 4.4 days in
2001 to 3.4 days in 2014. During this period, the cost per hospital-
ization related to AP also reduced to around $6766 in 2014 com-
pared with 2007. However, biliary pancreatitis and AP from
hypertriglyceridemia were associated with higher hospitalization-
related cost compared with the rest of the cohort, and it is likely
due to need for interventions such as cholecystectomy and plasma-
pheresis in these patients. The driving factor for cost in AP-related
hospitalizations appears to be LOS as pointed out in a previous
study.11 It is plausible that the continued reduction in LOS is con-
tributing to reduction of cost per each hospitalization related to
AP in recent years. Another significant finding of our study is that
the use of ERCP has decreased consistently over the study period.
We suspect that this decrease in ERCP usage is related to use of
other noninvasive diagnostic modalities such as magnetic resonance
cholangiopancreatography and endoscopic ultrasound in the man-
agement of patients with AP.
Limitations of this study are rooted both in its retrospective
nature and its dependence on administrative data. Because of the
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US Trends of Acute Pancreatitis: 2001 to 2014
deidentified nature of the data, there was no ability to obtain fur-
ther clinical information on patients. Instead, this study makes
use of ICD-9 codes, which are subject to documentation error of
physicians as well as errors and bias by billing personnel.12 Stud-
ies determining the accuracy of billing codes for AP are limited,
although a previous abstract in a Veterans Administration hospital
setting has indicated a positive predictive value of 62% for ICD-9
coding of inpatient AP as primary diagnosis.13 Another limitation
of this study is the inability to identify patients and measure trends
in patients with severe AP, especially because most mortality and
morbidity in AP occur in severe AP.
Strengths of this study are the sample size and wide geo-
graphic distribution of the NIS database. The conclusions gener-
ated from the data have the potential to be generalizable as data
are derived from across a cross section of population. This con-
trasts with many other epidemiologic studies that include data
from a small geographic area, such as a single state or multicenter
studies where national generalizability is questionable.
There are several favorable trends with regard to mortality,
LOS, and lower cost per hospitalization observed in patients with
AP in the NIS. This is probably a reflection of improvement in the
management of AP. However, the number of hospitalizations re-
lated to AP continues to increase that in turn could contribute to
overall increase in health care spending for this condition. This
study hopefully will create an impetus for further research that
will help reduce hospital costs and disease burden related to AP.
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