title: The value of specialization--is there an outcome difference in the management of fistulas complicating diverticulitis.
abstract: OBJECTIVE
  The value of specialization has frequently been challenged by many health care institutions and providers. This review was conducted to determine whether there were any outcome differences in the management of fistulas complicating diverticulitis.
  
  
  METHODS
  We conducted an historical cohort study using hospital charts of all cases of fistulas complicating diverticulitis that were operated on in four university-affiliated hospitals between 1975 and 1995. There were 122 patients, with 37 under the care of fully trained colorectal surgeons and 85 under the care of general surgeons.
  
  
  RESULTS
  There were no significant differences in patient demographics, preoperative comorbidities, or the number of preoperative diagnostic investigations between the two groups. The colorectal surgeons performed more intraoperative ureteral stenting (Colorectal Surgery 55.5 percent vs. General Surgery 24.4 percent, P = 0.001). The general surgeons performed more initial diverting Hartmann's and colostomy procedures (Colorectal Surgery 5.4 percent vs. General Surgery 27 percent, P = 0.013). The patients in the General Surgery group had longer preoperative lengths of stay (median Colorectal Surgery 3 (range, 1-28) days vs. General Surgery 8 (range, 0-29) days; P < 0.001), longer postoperative lengths of stay (median Colorectal Surgery 11 (range, 5-40) days vs. General Surgery 14 (range, 2-80) days; P = 0.001), and longer total lengths of stay (median Colorectal Surgery 14 (range, 6-62) days vs. General Surgery 24 (range, 6-100) days; P < 0.001). The patients in the General Surgery group experienced a higher rate of wound infections (Colorectal Surgery 5.4 percent vs. General Surgery 12.9 percent), and a larger proportion of them experienced complications (Colorectal Surgery 27 percent vs. General Surgery 41.2 percent).
  
  
  CONCLUSIONS
  We conclude that specialization in colon and rectal surgery contributed to an improved outcome, with a lower rate of diverting procedures, a shorter hospital stay, and a lower rate of complications.
authors.affiliation: Department of Surgery, Lady Davis Institute for Medical Research, SMBD-Jewish General Hospital, Quebec, Canada.
authors.forename: A
authors.initials: A
authors.lastname: Di Carlo
authors.forename: R H
authors.initials: RH
authors.lastname: Andtbacka
authors.forename: I
authors.initials: I
authors.lastname: Shrier
authors.forename: P
authors.initials: P
authors.lastname: Belliveau
authors.forename: J L
authors.initials: JL
authors.lastname: Trudel
authors.forename: B L
authors.initials: BL
authors.lastname: Stein
authors.forename: P H
authors.initials: PH
authors.lastname: Gordon
authors.forename: C A
authors.initials: CA
authors.lastname: Vasilevsky
mesh_terms: D002170:Canada / Q000453:epidemiology; D015331:Cohort Studies; D003107:Colorectal Surgery / Q000592:standards*; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000379:methods; D004238:Diverticulitis / Q000601:surgery*; D013502:General Surgery / Q000592:standards*; D006785:Hospitals, University; D006801:Humans; D007410:Intestinal Diseases / Q000601:surgery*; D007412:Intestinal Fistula / Q000453:epidemiology*; D007902:Length of Stay; D016015:Logistic Models; D008485:Medical Audit; D010043:Outcome and Process Assessment, Health Care; D011183:Postoperative Complications / Q000453:epidemiology*; D013038:Specialization; D013503:Surgery Department, Hospital / Q000592:standards*; D000078329:Workforce