Evolving practice patterns in the management of acute colonic diverticulitis: a population-based analysis.
BACKGROUND
There is increasing evidence to support the use of percutaneous abscess drainage, laparoscopy, and primary anastomosis in managing acute diverticulitis.


OBJECTIVE
The aim of this study was to evaluate how practices have evolved and to determine the effects on clinical outcomes.


METHODS
This is a population-based retrospective cohort study using administrative discharge data.


METHODS
This study was conducted in Ontario, Canada.


METHODS
All patients had been hospitalized for a first episode of acute diverticulitis (2002-2012).


METHODS
Temporal changes in treatment strategies and outcomes were evaluated by using the Cochran-Armitage test for trends. Multivariable logistic regression with generalized estimating equations was used to test for trends while adjusting for patient characteristics.


RESULTS
There were 18,543 patients hospitalized with a first episode of diverticulitis, median age 60 years (interquartile range, 48-74). From 2002 to 2012, there was an increase in the proportion of patients admitted with complicated disease (abscess, perforation), 32% to 38%, yet a smaller proportion underwent urgent operation, 28% to 16% (all p < 0.001). The use of percutaneous drainage increased from 1.9% of admissions in 2002 to 3.3% in 2012 (p < 0.001). After adjusting for changes in patient and disease characteristics over time, the odds of urgent operation decreased by 0.87 per annum (95% CI, 0.85-0.89). In those undergoing urgent surgery (n = 3873), the use of laparoscopy increased (9% to 18%, p <0.001), whereas the use of the Hartmann procedure remained unchanged (64%). During this time, in-hospital mortality decreased (2.7% to 1.9%), as did the median length of stay (5 days, interquartile range, 3-9; to 3 days, interquartile range, 2-6; p <0.001).


CONCLUSIONS
There is the potential for residual confounding, because clinical parameters available for risk adjustment were limited to fields existing within administrative data.


CONCLUSIONS
There has been an increase in the use of nonoperative and minimally invasive strategies in treating patients with a first episode of acute diverticulitis. However, the Hartmann procedure remains the most frequently used urgent operative approach. Mortality and length of stay have improved during this time.
1Department of Surgery, University of Toronto, Toronto, Ontario, Canada 2Department of Surgery and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada 3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada 4Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada 5Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada 6Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada 7Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada 8Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
Debbie
D
Li
Nancy N
NN
Baxter
Robin S
RS
McLeod
Rahim
R
Moineddin
Andrew S
AS
Wilton
Avery B
AB
Nathens
D000038:Abscess / Q000209:etiology / Q000601:surgery; D000208:Acute Disease; D000714:Anastomosis, Surgical / Q000379:methods / Q000706:statistics & numerical data; D002170:Canada / Q000453:epidemiology; D003082:Colectomy / Q000379:methods / Q000706:statistics & numerical data; D003106:Colon / Q000473:pathology; D019468:Disease Management; D004239:Diverticulitis, Colonic / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery; D004322:Drainage / Q000379:methods / Q000706:statistics & numerical data; D017050:Episode of Care; D005260:Female; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007416:Intestinal Perforation / Q000209:etiology / Q000601:surgery; D010535:Laparoscopy / Q000379:methods / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D018579:Patient Selection; D010818:Practice Patterns, Physicians'; D012189:Retrospective Studies; D020379:Risk Adjustment