title: Addressing the appropriateness of elective colon resection for diverticulitis: a report from the SCOAP CERTAIN collaborative.
abstract: OBJECTIVE
  To assess the reported indications for elective colon resection for diverticulitis and concordance with professional guidelines.
  
  
  BACKGROUND
  Despite modern professional guidelines recommending delay in elective colon resection beyond 2 episodes of uncomplicated diverticulitis, the incidence of elective colectomy has increased dramatically in the last 2 decades. Whether surgeons have changed their threshold for recommending a surgical intervention is unknown. In 2010, Washington State's Surgical Care and Outcomes Assessment Program initiated a benchmarking and education initiative related to the indications for colon resection.
  
  
  METHODS
  Prospective cohort study evaluating indications from chronic complications (fistula, stricture, bleeding) or the number of previously treated diverticulitis episodes for patients undergoing elective colectomy at 1 of 49 participating hospitals (2010-2013).
  
  
  RESULTS
  Among 2724 patients (58.7 ± 13 years; 46% men), 29.4% had a chronic complication indication (15.6% fistula, 7.4% stricture, 3.0% bleeding, 5.8% other). For the 70.5% with an episode-based indication, 39.4% had 2 or fewer episodes, 56.5% had 3 to 10 episodes, and 4.1% had more than 10 episodes. Thirty-one percent of patients failed to meet indications for either a chronic complication or 3 or more episodes. Over the 4 years, the proportion of patients with an indication of 3 or more episodes increased from 36.6% to 52.7% (P < 0.001) whereas the proportion of those who failed to meet either clinical or episode-based indications decreased from 38.4% to 26.4% (P < 0.001). The annual rate of emergency resections did not increase significantly, varying from 5.6 to 5.9 per year (P = 0.81).
  
  
  CONCLUSIONS
  Adherence to a guideline based on 3 or more episodes for elective colectomy increased concurrently with a benchmarking and peer-to-peer messaging initiative. Improving adherence to professional guidelines related to appropriate care is critical and can be facilitated by quality improvement collaboratives.
authors.affiliation: *Department of Surgery, University of Washington, Seattle †Department of Surgery, Swedish Medical Center, Seattle, WA ‡Surgical Care and Outcomes Assessment Program (SCOAP), Seattle, WA §Department of Surgery, Oregon Health & Science University, Portland ¶Department of Surgery, Madigan Army Medical Center, Tacoma, WA ‖Department of Surgery, Virginia Mason Medical Center, Seattle, WA.
authors.forename: Vlad V
authors.initials: VV
authors.lastname: Simianu
authors.forename: Amir L
authors.initials: AL
authors.lastname: Bastawrous
authors.forename: Richard P
authors.initials: RP
authors.lastname: Billingham
authors.forename: Ellen T
authors.initials: ET
authors.lastname: Farrokhi
authors.forename: Alessandro
authors.initials: A
authors.lastname: Fichera
authors.forename: Daniel O
authors.initials: DO
authors.lastname: Herzig
authors.forename: Eric
authors.initials: E
authors.lastname: Johnson
authors.forename: Scott R
authors.initials: SR
authors.lastname: Steele
authors.forename: Richard C
authors.initials: RC
authors.lastname: Thirlby
authors.forename: David R
authors.initials: DR
authors.lastname: Flum
mesh_terms: D000328:Adult; D000368:Aged; D019985:Benchmarking; D003082:Colectomy / Q000706:statistics & numerical data*; D004239:Diverticulitis, Colonic / Q000601:surgery*; D017558:Elective Surgical Procedures; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012042:Registries