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Patients with uncomplicated diverticulitis often elect to undergo early surgery
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More than half of patients with uncomplicated diverticulitis undergo elective surgery after fewer than three episodes despite recommendations to delay elective colon resection, recent study data found.
“In caring for patients with diverticulitis, surgeons have conventionally offered elective colectomy for patients who recover from a few initial episodes of diverticulitis to prevent recurrence or progression of disease requiring an emergency operation,” Vlad V. Simianu, MD, MPH, from University of Washington, Seattle, and colleagues wrote. However, guidelines have changed in the past decade and now recommend delaying elective surgery until at least three episodes, “or, as of 2014, to not using episode number to determine if resection should be offered. In seeming disconnect with these guidelines, the incidence of elective resection for diverticulitis more than doubled.”
Because previous studies have focused on hospitalized patients, Simianu and colleagues performed a retrospective cohort study using nationwide inpatient, outpatient and antibiotic prescription claims data from 2009 to 2012, aiming to ascertain factors related to earlier or later surgery for uncomplicated diverticulitis.
They identified 87,461 immunocompetent patients aged 18 to 64 years who had at least one claim for incident, uncomplicated diverticulitis, 6.4% of whom underwent a resection. Overall, 3,054 patients who underwent an elective resection were included in the final analysis (55.6% men; mean, 1 ± 0.9 inpatient claims; 1.5 ± 1.5 outpatient claims; 0.5 ± 1.2 related antibiotic prescription claims). Early surgery, defined as occurring after fewer than three diverticulitis episodes, served as the primary endpoint.
Early surgery occurred in 94.9% of inpatient claims, in 80.5% of inpatient plus outpatient claims, and in 56.3% of all three claim types combined.
Analysis of all three types of claims showed patients who had early or delayed surgery both had a mean age of 47.7 years, but patients who had early surgery were less likely to undergo laparoscopy (65.1% vs. 70.8%; P = .001) and had longer durations between the last two episodes before surgery (157 vs. 96 days; P < .001). Patients with HMO or capitated insurance plans underwent early surgery less frequently compared with those who had other types of insurance plans (50.1% vs. 57.4%; P = .01).
“In our nation’s quest to deliver higher-value health care, understanding what constitutes appropriate care for a growing population of patients with diverticulitis and encouraging adherence to appropriateness criteria are critical,” the researchers wrote. “These data suggest that there is a strong need for fundamental research in this setting.”
The research team “hypothesized that patients commonly undergo early … elective resection for diverticulitis, especially when the patient is young and responsible for the cost of operation, which is done laparoscopically, and the preceding episodes have been frequent over a short period [and] concluded that none of these factors influenced the decision to operate and at least 50% of patients had early operations,” James Fleshman, MD, from the department of surgery at Texas A&M Healthsciences, Dallas, and Baylor University Medical Center, Houston, wrote in a related editorial. “As with all interesting studies, there are always more questions than answers at the end of the study. The authors acknowledge that the next step should be a focused prospective approach to answering the number of questions raised from their article.” – by Adam Leitenberger
Disclosure: This study was supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases; also, The Comparative Effectiveness Research Translation Network, a program of the University of Washington, provided research and analytic assistance and was supported by a grant from the Agency for Healthcare Research and Quality.
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