title: Trends in the surgical treatment of ulcerative colitis over time: increased mortality and centralization of care.
abstract: BACKGROUND
  New medical therapies available to ulcerative colitis (UC) patients have influenced operative mortality for patients requiring colectomy. We sought to examine trends in treatment and outcome for UC patients treated surgically.
  
  
  METHODS
  A review of 36,447 UC patients from the Nationwide Inpatient Sample was performed, comparing the pre-monoclonal antibody era (1990-1996) to the present-day era (2000-2006). Patients treated with total colectomy with ileostomy or proctocolectomy with ileal pouch were reviewed for outcome measures and practice setting (rural, urban non-teaching, urban teaching). Our main outcome measures were in-hospital mortality, length of stay, and total charges.
  
  
  RESULTS
  Total colectomy (n = 30,362) was performed five times more often than proctocolectomy (n = 6,085). When comparing the two study periods, mortality after total colectomy increased 3.8% to 4.6% (p = 0.0003). This difference was primarily due to increasing mortality in later years; when 1995-1996 was compared to 2005-2006, mortality increased from 3.6% to 5.6% (p < 0.0001). There were no deaths in the proctocolectomy group (p < 0.0001). The distribution by practice setting shifted over the two study periods, decreasing in rural (7.0% to 4.8%) and urban non-teaching (43.7% to 28.4%) centers, and increasing in urban teaching centers (49.3% to 66.8%). The total inflation-adjusted charges per patient increased significantly ($34,638 vs. $43,621; p < 0.0001).
  
  
  CONCLUSIONS
  The mortality rate after total colectomy is increasing, and the difference is accentuated in the years since widespread use of monoclonal antibody therapy. The care of these patients is being shifted to urban teaching centers and is becoming more expensive.
authors.affiliation: Department of General Surgery, Oregon Health and Science University, Mail Code L619, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
authors.forename: Michelle C
authors.initials: MC
authors.lastname: Ellis
authors.forename: Brian S
authors.initials: BS
authors.lastname: Diggs
authors.forename: John T
authors.initials: JT
authors.lastname: Vetto
authors.forename: Daniel O
authors.initials: DO
authors.lastname: Herzig
mesh_terms: D000367:Age Factors; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D003082:Colectomy / Q000191:economics / Q000401:mortality* / Q000639:trends; D003093:Colitis, Ulcerative / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality* / Q000601:surgery*; D016001:Confidence Intervals; D003362:Cost-Benefit Analysis; D005260:Female; D005500:Follow-Up Studies; D005544:Forecasting; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011183:Postoperative Complications / Q000401:mortality / Q000503:physiopathology; D016737:Proctocolectomy, Restorative / Q000191:economics / Q000401:mortality* / Q000639:trends; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D012737:Sex Factors; D015996:Survival Rate; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult
chemical_list: D000911:Antibodies, Monoclonal