Retrospective Study
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Nov 6, 2018; 6(13): 624-631
Published online Nov 6, 2018. doi: 10.12998/wjcc.v6.i13.624
Effect of a region-wide incorporation of an algorithm based on the 2012 international consensus guideline on the practice pattern for the management of pancreatic cystic neoplasms in an integrated health system
Andrew Khoi Nguyen, Agathon Girgis, Timnit Tekeste, Karen Chang, Mopelola Adeyemo, Armen Eskandari, Emilio Alonso, Priyanka Yaramada, Charles Chaya, Albert Ko, Edmund Burke, Isaiah Roggow, Rebecca Butler, Aniket Kawatkar, Brian S Lim
Andrew Khoi Nguyen, Agathon Girgis, Timnit Tekeste, Karen Chang, Mopelola Adeyemo, Armen Eskandari, Emilio Alonso, Priyanka Yaramada, Isaiah Roggow, Brian S Lim, School of Medicine, University of California, Riverside, CA 92521, United States
Charles Chaya, Brian S Lim, Department of Gastroenterology, Kaiser Permanente Riverside Medical Center, Riverside, CA 92521, United States
Albert Ko, Edmund Burke, Department of Surgery, Kaiser Permanente Riverside Medical Center, Riverside, CA 92521, United States
Rebecca Butler, Aniket Kawatkar, Department of Research and Evaluation, Southern California Permanente Medical Group, Pasadena, CA 92521, United States
Author contributions: Nguyen AK, Girgis A, and Tekeste T performed research, analysed data, and wrote the paper; Chang K, Adeyemo M, Alonso E, Yaramada P, and Roggow I performed research and reviewed manuscript; Eskandari A, Chaya C, and Burke E performed research, analysed data, and reviewed manuscript; Ko A, Butler R, and Kawatkar A analysed data and reviewed manuscript; Lim B designed research, performed research, analysed data, wrote the paper, and reviewed manuscript.
Institutional review board statement: This study was approved by the Institutional Review Board of KPSC.
Conflict-of-interest statement: No conflict of interest exists.
Data sharing statement: No additional data are available.
Open-Access: This is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Andrew Khoi Nguyen, MD, Doctor, School of Medicine, University of California, 900 University Ave, Riverside, CA 92521, United States.
Telephone: +1-714-9025641
Received: July 16, 2018
Peer-review started: July 16, 2018
First decision: September 10, 2018
Revised: September 16, 2018
Accepted: October 11, 2018
Article in press: October 11, 2018
Published online: November 6, 2018

To examine the practice pattern in Kaiser Permanente Southern California (KPSC), i.e., gastroenterology (GI)/surgery referrals and endoscopic ultrasound (EUS), for pancreatic cystic neoplasms (PCNs) after the region-wide dissemination of the PCN management algorithm.


Retrospective review was performed; patients with PCN diagnosis given between April 2012 and April 2015 (18 mo before and after the publication of the algorithm) in KPSC (integrated health system with 15 hospitals and 202 medical offices in Southern California) were identified.


2558 (1157 pre- and 1401 post-algorithm) received a new diagnosis of PCN in the study period. There was no difference in the mean cyst size (pre- 19.1 mm vs post- 18.5 mm, P = 0.119). A smaller percentage of PCNs resulted in EUS after the implementation of the algorithm (pre- 45.5% vs post- 34.8%, P < 0.001). A smaller proportion of patients were referred for GI (pre- 65.2% vs post- 53.3%, P < 0.001) and surgery consultations (pre- 24.8% vs post- 16%, P < 0.001) for PCN after the implementation. There was no significant change in operations for PCNs. Cost of diagnostic care was reduced after the implementation by 24%, 18%, and 36% for EUS, GI, and surgery consultations, respectively, with total cost saving of 24%.


In the current healthcare climate, there is increased need to optimize resource utilization. Dissemination of an algorithm for PCN management in an integrated health system resulted in fewer EUS and GI/surgery referrals, likely by aiding the physicians ordering imaging studies in the decision making for the management of PCNs. This translated to cost saving of 24%, 18%, and 36% for EUS, GI, and surgical consultations, respectively, with total diagnostic cost saving of 24%.

Keywords: Pancreatic cyst, Algorithm incorporation, Pancreas, Optimization of resource utilization, Fukuoka criteria, Sendai criteria, Pancreatic cancer, Intraductal papillary mucinous neoplasm, Practice management, Algorithm

Core tip: There are ever-increasing numbers of detected incidental, asymptomatic pancreatic cystic neoplasms. This increasing detection has led to work up and treatment guidelines that have been a challenging clinical entity for primary care physicians, gastroenterologists, radiologists and surgeons alike. Our retrospective study included over 2500 patients spanning multiple large hospital centers within an integrative health system. This research demonstrated that the dissemination of an algorithm for pancreatic cyst management in an integrated health system increased the threshold for referrals for intervention and workup, resulting in significant cost savings on the order of up to millions of dollars, without compromising patient care.