Many diverticulitis surgeries performed earlier than recommended

Last Updated: 2016-02-17

By Larry Hand

NEW YORK (Reuters Health) - Early surgeries for uncomplicated diverticulitis - after just one or two episodes - may account for more than half of those procedures being done, according to a new study.

"Despite the shift in professional guidelines to avoid early, elective operations, it seems that over half of surgery for diverticulitis occurs after only a few episodes, hospitalizations or otherwise," Dr. Vlad V. Simianu of the University of Washington, Seattle, told Reuters Health by email. "Almost all of the national surgical societies have recommended avoiding operation on early uncomplicated diverticulitis."

Dr. Simianu and colleagues analyzed nationwide data between 2009 and 2012 in the MarketScan Commercial Claims and Encounters Database, which has information from 100 payers and more than 500 million claims.

Professional surgical organizations have recommended delaying elective surgery until after three episodes or not using the number of episodes in making a decision, the researchers note in an article online February 10 in JAMA Surgery.

They extracted information on inpatient and outpatient claims for individuals 18 to 64 years old with a diagnosis of diverticulitis and a prescription for antibiotics. They excluded individuals who had not been continuously enrolled at least two years and patients who had a diverticulitis diagnosis or colorectal resection in the two years prior to the index claim.

After further excluding patients who had not had a colectomy during the study period, patients who had diagnostic codes associated with immunocompromise, patients who had emergency surgery, and patients who had surgery for complicated diverticulitis, they included data on 3,054 nonimmunocompromised patients who had diverticulitis surgery in their retrospective cohort study.

The researchers found that, based on all types of claims, 56.3% of surgeries occurred among patients with fewer than three episodes of diverticulitis. Based only on inpatient claims, 94.9% of surgeries occurred early, compared to 80.5% of surgeries occurred early based on inpatient and outpatient claims only.

The lowest frequency of early surgeries occurred in patients with capitated services insurance plans (50.0% for health maintenance organizations (HMOs) and 51.4% for capitated point-of-service (POS) plans). Regionally, the highest rate of early surgeries occurred in the South (60.5%).

Although patients having early or delayed surgery were similar in age, patients having early surgery were significantly less likely to have had laparoscopy (65.1% vs. 70.8%).

Independent factors associated with early surgery were male sex, Charlson Comorbity Index of 1, and geographic region.

"The suspected drivers of early elective surgery (younger age, laparoscopy, more frequent episodes, and personal financial risk) were not found to be associated with earlier operations for diverticulitis," the researchers wrote.

Limitations of the study include the lack of data from medium and small insurance companies and self-insured individuals and possibly unreliably coded diagnoses.

The researchers concluded, "In our nation's quest to deliver higher-value health care, understanding what constitutes appropriate care for a growing population of patients with diverticulitis and encouraging adherence to appropriateness criteria are critical. These data suggest that there is a strong need for fundamental research in this setting."

Another message from this study is that "care for diverticulitis has shifted to the outpatient setting. This means that using hospitalizations as the basis for measuring burden of disease (either as a clinician or as a researcher), is missing most episodes of care," Dr. Simianu told Reuters Health.

"Surgeons must consider this growing evidence that does not support operating after one or two episodes, and appropriately weigh the risks of these operations when discussing with patients whether an operation should be considered," he continued.

"Patient factors that should be considered include the burden to the patient's quality of life or anxiety about future episodes, as these may be important in decision making related to early surgery," he noted.

Dr. Simianu added, "Our group's next step will be applying a diverticulitis-specific quality-of-life instrument across a large, statewide cohort to better understand the rationale and impact of both operative and nonoperative treatment of diverticulitis."

Dr. James Fleshman, of Baylor University Medical Center, Houston, Texas, wrote in an accompanying invited commentary, "The concerned, informed, and ethical surgeon will adhere to the recommendations proposed by almost all of the national surgical societies to improve the care for patients with diverticulitis and avoid operation on early uncomplicated diverticulitis."

SOURCE: http://bit.ly/1QW6cmt and http://bit.ly/1Q7LZqG

JAMA Surg 2016.