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Half of diverticulitis patients diagnosed in ER can avoid hospital admission
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Patients diagnosed with uncomplicated diverticulitis in the emergency department who were discharged home with a prescription for oral antibiotics had a very low risk for returning to the hospital, according to new research published online in the Journal of the American College of Surgeons.
These patients “can be safely discharged home on oral antibiotics, as long as CT findings are included in the decision-making process,” Mary R. Kwaan, MD, MPH, FACS, assistant professor of surgery in the division of colon and rectal surgery, department of surgery, University of Minnesota, and colleagues wrote. However, “patients with complicated diverticulitis on CT scan ... should be admitted to the hospital with surgical consultation.”
Avoiding hospitalization of patients without complicated findings on CT scan — about half of whom were still admitted to the hospital in this study — would result in significant cost savings to both the health care system and the patient, the investigators concluded.
Although these findings “may not seem surprising to most surgeons, it is a poorly studied topic in the United States, and gathering some data on this occurrence is important to clarify in terms of whether there are even more people seen in the emergency room who could be safely managed at home,” Kwaan said in a press release.
Diverticulitis accounts for about 150,000 hospital admissions per year in the U.S., but only 15% of patients require surgery during the same admission, Kwaan and colleagues wrote. Additionally, ED visits for diverticulitis have increased by 21% between 2006 and 2011.
To compare outcomes between patients diagnosed with diverticulitis in the ED who were discharged home or hospitalized, the researchers reviewed data on 240 patients diagnosed by CT scan in five emergency departments within the Fairview Health System in Minneapolis, Minn., from 2010 through 2012 (55% women; mean age, 59.1 years; median follow-up, 36.5 months).
“The CT scan provides us with a surrogate for determining the severity of perforation one has suffered,” Kwaan noted in the press release.
Overall, 60% of the patients were admitted to the hospital and 40% were discharged home on oral antibiotics. Those admitted to the hospital were more likely to be older than 65 years (P = .0007), have a Charlson comorbidity score of at least 2 (P = .0025), be receiving steroids or immunosuppressants (P = .0019) and have CT scan results showing extraluminal air or diverticular abscess (P < .0001 for both).
Further, just 12.5% of patients who were discharged home returned to the ED or were admitted to the hospital within 30 days, and only one patient required emergency surgery after 20 months.
“That [finding] didn’t seem to be a high rate,” Kwaan said in the press release; in comparison, the hospital readmission rate among patients who were initially hospitalized was only slightly higher and statistically comparable at 15%.
Kwaan and colleagues concluded that 53% of the patients who were admitted to the hospital met previously defined criteria for having low-risk diverticulitis, “and could be safely discharged home,” according to the press release. However, they noted in the study report that half of these admissions were due to CT scan results showing complicated diverticulitis, highlighting the importance of CT scan results for diagnosis.
In addition, they found that high fever and high white blood cell counts predicted the severity of diverticulitis. In low-risk patients “we found that few patients had high fevers and most patients had normal or mildly elevated white blood cell counts,” Kwaan said in the press release.
These findings could be used to develop protocols to better treat diverticulitis in EDs, Kwaan added.
“As a result of this study, a checklist approach to patient and CT characteristics can prompt a protocol that allows an emergency room doctor to quickly sort out whether or not the patient needs a surgical consult or whether they need to be admitted to the hospital, and then whether they can be safely discharged home,” she said in the release. “Diverticulitis is quite a common disease, and there is a general movement among hospitals toward being more strategic with their resources. Unnecessary hospital admissions cost the system and potentially expose patients to hospital-acquired infections.” – by Adam Leitenberger
Disclosures: The researchers report no relevant financial disclosures.
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