Real life adherence to international guidelines in BD-IPMN management. Clinical and costs impact of divergent strategies in BD-IPMN care. The PACMANS Study

Aims Over the last two decades, there has been a rise in the diagnosis of Branch Duct Intraductal Papillary Mucinous Neoplasms (BD-IPMN), incidental findings posing potential neoplastic risks. Multiple guidelines, notably the International Association of Pancreatology (IAP)' revised in Fukuoka in 2017, have been suggested to optimize risk management. However, the intricate nature of these guidelines makes adherence challenging, raising uncertainties regarding their application in clinical practice. This study aimed to assess adherence to the 2017 IAP guidelines, identify factors associated with non-compliance, and analyze the impact of divergent strategies on clinical outcomes and costs.

Methods Clinical and histopathological data from 2017 to 2023 were retrospectively collected from four tertiary centers in Northern Italy, focusing on patients with suspected BD-IPMN. Multivariate logistic regressions were employed to analyze factors influencing divergent strategies from the IAP guidelines and assess their consequences on clinical outcomes, survival, and costs. Surveillance strategies were considered aggressive if deviating to a narrower surveillance timing or indicating higher-level examinations than recommended by the IAP guidelines. Conservative approach was defined as suggesting extended surveillance timing or indicating lower-level examinations than specified by the IAP.

Results Of the 333 enrolled patients with a total of 1400 visits and a median follow-up of 4 years, 54% received recommendations deviating from the guidelines, predominantly in an aggressive direction (53.7%). Protective factors for deviation were an Age-adjusted Charlson Comorbidity Index (ACCI) above 4 (OR 0.44, 95% CI 0.33-0.58, p<0.001) and larger initial IPMN size (OR 0.22, 95% CI 0.17-0.28, p<0.001), while divergent approach increased by 25% every two years of follow-up (OR 1.25, 95% CI 1.11-1.41, p<0.001). Conservative divergences, occurring in 25% of cases, were associated with the presence of High-Risk Stigmata (HRS) (OR 5.79, 95% CI 1.82-18.50, p=0.003) and female sex (OR 1.55, 95% CI 1.25-2.04, p=0.001). Notably, divergent strategies did not lead to different rates of IPMN-related mortality (2.5% vs 2.4%, p=1). However, they resulted in increased surveillance costs, escalating from 720 [407-1253] to 878 [664-1181] euros per patient over three years (p=0.001).

Conclusions In conclusion, adherence to the IAP guidelines in clinical practice was low, predominantly exhibiting deviations in an aggressive direction. This non-adherence significantly increased costs compared to those projected by following the recommended guidelines.

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Artikel online veröffentlicht:
15. April 2024