Effect of insurance status on patients admitted for acute diverticulitis

Defining diverticular fistula through inpatient admissions: a population study

BACKGROUND

Diverticular fistula, a pathologic connection from the colon to the skin or another organ, is an uncommon sequela of diverticular disease. It is generally considered an indication for surgery. The current literature is limited in terms of defining the epidemiology of this disease process. This analysis defines the demographics of fistulous diverticular disease on a national level.

METHODS

A retrospective review of the 2018 National Inpatient Sample (NIS) was conducted, using ICD-10 codes for diverticular disease, diverticular-associated fistulas, and associated surgeries. Demographic factors were compared between groups, and several sub-group analyses were performed.

RESULTS

A total of 7,105,498 discharges were recorded: 119,115 (1.68%) with non-fistulizing diverticular disease and 3,843 (0.05%) with diverticular fistula. Patients with diverticular fistula were more likely to be younger (64.7 v 68.2 years, p < .0001) and female (57.3% v 55.4%, p = 0.028) than patients with non-fistulizing disease. They were also more likely to undergo surgery (64.9% v 25.7%, p < .0001), to be admitted electively (44.7% v 12.0%, p < .0001), and to have a longer length of stay (LOS) (mean 8.07 v 5.20 days, p < .0001). Diverticular fistula patients that underwent surgery were more likely to be male (44.8% v 39.0%, p = 0.003), to be admitted electively (65.3% v 6.7%, p < .0001), and to have longer LOS (mean 8.74 v 6.81 days, p < .0001) than those who received medical treatment alone.

CONCLUSION

Diverticular fistula is a rare diagnosis, accounting for 0.05% of total admissions and 3.12% of admissions for diverticular disease. However, this is more common than the previously reported rate of < 0.1% of diverticular disease admissions. While surgery is generally indicated for diverticular fistula, only 64.9% of patients underwent surgical treatment. Although this study is limited by its retrospective nature and use of administrative data, our findings elucidate the prevalence and patterns of inpatient admissions for diverticular fistula in the United States.

Association of Insurance Type With Colorectal Surgery Outcomes and Costs at a Safety-Net Hospital: A Retrospective Observational Study

Association of insurance type with colorectal surgical complications, textbook outcomes (TO), and cost in a safety-net hospital (SNH).

Background

SNHs have higher surgical complications and costs compared to low-burden hospitals. How does presentation acuity and insurance type influence colorectal surgical outcomes?

Methods

Retrospective cohort study using single-site National Surgical Quality Improvement Program (2013-2019) with cost data and risk-adjusted by frailty, preoperative serious acute conditions (PASC), case status and open versus laparoscopic to evaluate 30-day reoperations, any complication, Clavien-Dindo IV (CDIV) complications, TO, and hospitalization variable costs.

Results

Cases (Private 252; Medicare 207; Medicaid/Uninsured 619) with patient mean age 55.2 years (SD = 13.4) and 53.1% male. Adjusting for frailty, open abdomen, and urgent/emergent cases, Medicaid/Uninsured patients had higher odds of presenting with PASC (adjusted odds ratio [aOR] = 2.02, 95% confidence interval [CI] = 1.22-3.52, P = 0.009) versus Private. Medicaid/Uninsured (aOR = 1.80, 95% CI = 1.28-2.55, P < 0.001) patients were more likely to undergo urgent/emergent surgeries compared to Private. Medicare patients had increased odds of any and CDIV complications while Medicaid/Uninsured had increased odds of any complication, emergency department or observations stays, and readmissions versus Private. Medicare (aOR = 0.51, 95% CI = 0.33-0.88, P = 0.003) and Medicaid/Uninsured (aOR = 0.43, 95% CI = 0.30-0.60, P < 0.001) patients had lower odds of achieving TO versus Private. Variable cost %change increased in Medicaid/Uninsured patients to 13.94% (P = 0.005) versus Private but was similar after adjusting for case status. Urgent/emergent cases (43.23%, P < 0.001) and any complication (78.34%, P < 0.001) increased %change hospitalization costs.

Conclusions

Decreasing the incidence of urgent/emergent colorectal surgeries, possibly by improving access to care, could have a greater impact on improving clinical outcomes and decreasing costs, especially in Medicaid/Uninsured insurance type patients.

Do Socio-Demographics Play a Role in the Prevalence of Red Flags and Pursuant Colonoscopies in Patients With Irritable Bowel Syndrome?

Background

Irritable bowel syndrome (IBS) is a “brain-gut disorder” that lacks laboratory, radiologic, or physical exam findings. Colonoscopies are not routinely performed unless “red flag” symptoms, such as bleeding or abnormal weight loss, are present. Socio-demographics have been implicated as sources of potential disparities in appropriate care.

Aims

We hypothesize that the incidence of red flag symptoms and pursuant colonoscopies differ by socio-demographic status in patients with IBS.

Methods

Patients diagnosed with IBS were extracted from the National Inpatient Sample 2001-2013 using the International Classification of Diseases, Ninth Revision (ICD-9) codes. Gastrointestinal bleed, blood in stool, weight loss, and anemia were pooled into red flag symptoms. Colonoscopies during the admission were identified using ICD-9 procedural codes. Chi-square analysis and binomial logistic regression were used to evaluate potential disparities with α<0.01.

Results

Patients with Medicaid or Medicare or those without insurance had higher odds of presenting with red flag symptoms compared to those with private insurance. Medicaid patients and uninsured patients had higher odds of undergoing colonoscopies. All patients that were not Caucasian had higher odds of presenting with red flags and subsequently undergoing colonoscopies. Older patients had higher odds of presenting with concerning red flag symptoms but lower odds of undergoing colonoscopies.

Conclusions

The incidence of red flag symptoms and performance of colonoscopies differed by socio-demographics in patients with IBS. Patients with non-private or those without insurance were more likely to have red flags and undergo a colonoscopy. Age and race also increased rates of red flag symptoms while having a mixed effect on pursuant colonoscopies. This may represent discrepancies in healthcare utilization in a vulnerable population.

Association of Clostridioides difficile with adverse clinical outcomes in patients with acute diverticulitis: A nationwide study

BACKGROUND AND AIM

Acute diverticulitis (AD) is a common gastrointestinal disease with a significant health care-associated burden. Patients hospitalized with AD have many risk factors for developing Clostridioides difficile infection (CDI). CDI is associated with poor outcomes in many diseases but has yet to be studied in AD.

METHODS

We utilized data from the National Inpatient Sample from January 2012 to October 2015 for patients hospitalized with AD and CDI compared with AD alone. Primary outcomes, which were mortality, length of stay, and hospitalization cost, were compared. Secondary outcomes were complications of diverticulitis and need for surgical interventions. Risk factors for mortality in AD and risk factors associated with CDI in AD patients were analyzed.

RESULTS

Among 767 850 hospitalizations for AD, 8755 also had CDI. A propensity score-matched cohort analysis demonstrated that CDI was associated with increased risk of inpatient mortality (odds ratio [OR] 2.78, 95% confidence interval [CI] 1.30, 5.95), prolonged duration of hospitalization by 4.27 days (P < 0.0001), total hospital cost by $33 271 (P < 0.0001), need for surgery (OR 1.45, 95% CI 1.22, 1.71), and complications of diverticulitis (OR 1.45, 95% CI 1.21, 1.74). Predictors of CDI among patients with AD included female gender (1.12 OR, 95% CI 1.01, 1.24), three or more comorbidities (1.81 OR, 95% CI 1.57, 2.09), and admissions to teaching hospitals (1.44 OR, 95% CI 1.22, 1.70).

CONCLUSIONS

Clostridioides difficile infection in AD is associated with increased mortality, length of stay, and hospital cost. Preventative measures should be made for at-risk patients with AD to decrease infection rate and poor outcomes.

ACCESS TO HEALTHCARE INSURANCE INCREASES THE RATES OF SURGERY FOR DIVERTICULITIS

OBJECTIVE

The goal of this study was to examine the effect of the Affordable Care Act Medicaid expansion on rates of hospitalization and surgery for diverticulitis.

STUDY SETTINGS

Data were obtained from the Healthcare Cost and Utilization Project State Inpatient Databases from 2010 to 2014.

STUDY DESIGN

Retrospective cohort study analyzing adult patients undergoing surgery for diverticulitis in the expansion and nonexpansion states, pre (2010-2013) and post (2014) Medicaid expansion.

FINDINGS

There were a total of 159,419 patients in our cohort analysis. 75,575 (49%) in expansion states and 81,844 (51%) in non-expansion states. In multivariable Poisson regression, the rate of surgical procedures for diverticular disease increased among Medicaid patients (IRR 1.80; p<.01) whereas surgery rates in self-pay patients decreased (IRR 0.67; p<.01) in expansion states compared to non-expansion states.

CONCLUSIONS

In states that expanded Medicaid coverage under the Affordable Care Act, the rate of surgery for diverticular disease in Medicaid patients increased. Therefore, legislation that increases healthcare access may increase the utilization of surgical care for diverticular disease.

Hospital admission for complicated diverticulitis is increasing in Italy, especially in younger patients: a national database study

BACKGROUND

Epidemiological studies show an increasing trend of hospitalization for acute diverticulitis (AD), but data regarding the trend in hospitalization for complicated AD in Italy are scarce. The aim of this study was to analyze the Italian trend in hospitalization for complicated AD, from 2008 to 2015.

METHODS

Using the Italian Hospital Information System, we identified all patients with complicated colonic AD as a discharge diagnosis. Age- and sex-specific rates for AD as well as type of hospital admission (emergency/elective), type of complication (peritonitis, obstruction, bleeding, abscess, fistula, perforation, sepsis) and type of treatment (medical/surgical), were analyzed.

RESULTS

A total of 41,622 patients with a discharge diagnosis of complicated AD were identified. Over the study period the admission rate grew from 8.8 to 11.8 per 100,000 inhabitants. The hospitalization rate was highest for patients ≥ 70 years, but the increase in the admission rate was higher among patients aged ≤ 60 years. There were more males in the group < 60 years and more females in the group ≥ 60 years old. The rate of emergency admissions associated with surgery showed a significant mean annual increase (+ 3.9% per year) in the rate of emergency admissions associated with surgery, whereas elective admissions for surgery remained stable. Peritonitis was the most frequent complication (35.5%). The rate of surgery increased in AD complicated by peritonitis (+ 5.1% per year), abscess (+ 5.8% per year) and decreased for obstruction (- 1.8% per year).

CONCLUSIONS

From 2008 to 2015, we documented an increasing rate of hospitalization for complicated AD, especially for younger patients, with an increase in surgery for peritonitis and abscess. Further studies are needed to clearly assess the risk factors for complications and risk of surgery.

Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida

BACKGROUND

Patients with diverticulitis have a 20% risk of requiring urgent/emergent treatment. Since morbidity and mortality rates differ between elective and urgent/emergent care, understanding associated disparities is critical. We compared factors associated with treatment setting for diverticulitis and evaluated disparities regarding access to Minimally Invasive Surgery (MIS) and development of complications.

METHODS

The Florida Inpatient Discharge Dataset was queried for patients diagnosed with diverticulitis. Three multivariate models were utilized: 1) elective vs urgent/emergent surgery, 2) MIS vs open and 3) presence of complications.

RESULTS

The analysis included 12,654 patients. Factors associated with increased odds of urgent/emergent care included being uninsured or covered by Medicaid, African American, obese, or more comorbid. MIS was associated with reduced odds of complications. Patients treated by high-volume or colorectal surgeons had increased odds of receiving MIS.

CONCLUSIONS

Patients were more likely to receive MIS if they were treated by a colorectal surgeon, or a high-volume surgeon (colorectal, or general surgeon). Additionally, patients that were older, had increased comorbidities, or did not have health insurance were less likely to receive MIS.

Disparities in elective surgery for diverticulitis: Identifying the gap in care

BACKGROUND

Minimally invasive surgery (MIS) in patients with diverticulitis is advantageous relative to open surgery. We aimed to determine disparities associated with MIS access for diverticulitis and post-operative complications.

METHODS

The Florida Inpatient Discharge Dataset was retrospectively queried for patients with diverticulitis undergoing elective surgery between 2013 and 2015. Associations of patient, physician, and hospital characteristics with surgical approach (MIS vs open) and development of complications were calculated in two separate mixed effects logistic regression models.

RESULTS

Of the 5857 patients in the analysis, older, sicker patients, residing in rural areas or with Medicaid insurance had decreased odds of receiving MIS. Being treated by high volume or colorectal surgeons increased the odds of MIS. Decreased complications were present with MIS, in younger, healthier patients, treated by high volume surgeons.

CONCLUSIONS

Disparities in Florida are present in patients undergoing elective diverticulitis surgery. MIS access and complications rates are not equal, and MIS is associated with significantly reduced odds of post-operative complications. Improved access to MIS-trained surgeons is a critical step towards improving surgical outcomes for Floridians.

International Variation in Emergency Operation Rates for Acute Diverticulitis: Insights into Healthcare Value

BACKGROUND

International comparison of outcomes of surgical diseases has become a global focus because of widespread concern over surgical quality, rising costs and the value of healthcare. Acute diverticulitis is a common disease potentially amenable to optimization of strategies for operative intervention. The aim was to compare the emergency operative intervention rates for acute diverticulitis in USA, England and Australia.

METHODS

Unplanned admissions for acute diverticulitis were found from an international administrative dataset between 2008 and 2014 for hospitals in USA, England and Australia. The primary outcome measured was emergency operative intervention rate. Secondary outcomes included inpatient mortality and percutaneous drainage rate. Multivariable analysis was performed after development of a weighted comorbidity scoring system.

RESULTS

There were 15,150 unplanned admissions for acute diverticulitis. The emergency operative intervention rates were 16, 13 and 10% for USA, England and Australia. The percutaneous drainage rate was highest in USA at 10%, while the mortality rate was highest in England at 2.8%. The propensity for emergency operative intervention was higher in USA (OR 1.45, p < 0.001) and England (OR 1.49, p < 0.001) than in Australia. The risk of 7-day mortality was higher in England than in Australia (OR 2.79, p < 0.001). Percutaneous drainage was associated with reduced 7-day mortality risk.

CONCLUSION

Australia has a lower propensity for emergency operative intervention, while England has a greater risk of mortality for acute diverticulitis. International variations raise the issue of healthcare value in terms of differing resource use and outcomes.

A systematic review and meta-analysis of outpatient treatment for acute diverticulitis

BACKGROUND

The shift from routine antibiotics towards omitting antibiotics for uncomplicated acute diverticulitis opens up the possibility for outpatient instead of inpatient treatment, potentially reducing the burden of one of the most common gastrointestinal diseases in the Western world.

PURPOSE

Assessing the safety and cost savings of outpatient treatment in acute colonic diverticulitis.

METHODS

PubMed and EMBASE were searched for studies on outpatient treatment of colonic diverticulitis, confirmed with computed tomography or ultrasound. Outcomes were readmission rate, need for emergency surgery or percutaneous abscess drainage, and healthcare costs.

RESULTS

A total of 19 studies with 2303 outpatient treated patients were included. These studies predominantly excluded patients with comorbidity or immunosuppression, inability to tolerate oral intake, or lack of an adequate social network. The pooled incidence rate of readmission for outpatient treatment was 7% (95%CI 6-9%, I² 48%). Only 0.2% (2/1288) of patients underwent emergency surgery, and 0.2% (2/1082) of patients underwent percutaneous abscess drainage. Only two studies compared readmission rates outpatients that had similar characteristics as a control group of inpatients; 4.5% (3/66) and 6.3% (2/32) readmissions in outpatient groups versus 6.1% (4/66) and 0.0% (0/44) readmissions in inpatient groups (p = 0.619 and p = 0.174, respectively). Average healthcare cost savings for outpatient compared with inpatient treatment ranged between 42 and 82%.

CONCLUSION

Outpatient treatment of uncomplicated diverticulitis resulted in low readmission rates and very low rates of complications. Furthermore, healthcare cost savings were substantial. Therefore, outpatient treatment of uncomplicated diverticulitis seems to be a safe option for most patients.

Management of Acute Uncomplicated Diverticulitis May Exclude Antibiotic Therapy

Diverticulitis is a common ailment that is prevalent in the developed world. As such, the management of diverticulitis places a substantial economic burden on healthcare. Research is ongoing to further elucidate both the pathogenesis of the disease, as well as ways to reduce associated expenditures. One of these emerging areas of research calls into question the use of antibiotics during treatment of acute uncomplicated diverticulitis. Current guidelines are largely based on expert opinion, with little evidence supporting the standard practice of antibiotic therapy. In this literature review, we have compiled and analyzed the latest collection of evidence in managing acute uncomplicated diverticulitis. There have been two randomized controlled trials (RCTs) performed that assessed the possibility of treating acute uncomplicated diverticulitis without antibiotics. Both the Antibiotika Vid Okomplicerad Divertikulit (AVOD) study and Daniels, et al. have found that an observational approach to acute uncomplicated diverticulitis is not inferior to antibiotic treatment and does not result in increased complication or recurrence rates. We also reviewed a single-center cohort study, a prospective observational study, and two retrospective case-controlled studies comparing observational management versus antibiotic treatment in patients with acute uncomplicated diverticulitis. We found the results were comparable; there was no difference in complication rates or recurrence in any study. The consensus among the studies reviewed challenges the current practice guidelines issued by the American Gastroenterological Association. However, given the geographical difference in diverticular disease and inherent bias found in these studies, we cannot recommend a modification of the guidelines. Based on this literature review, we feel compelled to suggest, and strongly recommend, further research be conducted in the United States in order to bolster the already significant evidence against antibiotic therapy in acute uncomplicated diverticulitis.

Total Joint Arthroplasty: A Granular Analysis of Outcomes in the Economically Disadvantaged Patient

BACKGROUND

Poor patients experience more serious complications and worse outcomes after surgery than higher-income patients. Our objective was to study detailed patient sociodemographic characteristics and preoperative/postoperative patient-oriented outcomes in economically disadvantaged and non-economically disadvantaged primary total joint arthroplasty patients.

METHODS

From a consecutive series, 213 economically disadvantaged patients and 1940 non-economically-disadvantaged patients were statistically analyzed. Baseline sociodemographic characteristics and pain visual analog scale, Quality of Well-Being Index 7, Short Form 36, and Western Ontario and McMaster Universities Arthritis Index scores recorded before and after surgery were compared between both groups controlling for baseline differences. Minimum follow-up was 1 year.

RESULTS

Economically disadvantaged patients were significantly younger, more likely to be disabled, and had worse preoperative and postoperative scores.

CONCLUSION

When compared with non-economically disadvantaged patients, economically disadvantaged patients consistently had lower function and worse quality of life before and after total joint arthroplasty.

Outpatient, non-antibiotic management in acute uncomplicated diverticulitis: a prospective study

PURPOSE

The aim of this study was to evaluate outpatient, non-antibiotic management in acute uncomplicated diverticulitis with regard to admissions, complications, and recurrences, within a 3-month follow-up period.

METHODS

A prospective, observational study in which patients with computer tomography-verified acute uncomplicated diverticulitis were managed as outpatients without antibiotics. The patients kept a personal journal, were contacted daily by a nurse, and then followed up by a surgeon at 1 week and 3 months.

RESULTS

In total, 155 patients were included, of which 54 were men; the mean age of the patients was 57.4 years. At the time of diagnosis, the mean C-reactive protein and white blood cell count were 73 mg/l and 10.5 × 10(9), respectively, and normalized in the vast majority of patients within the first week. The majority of the patients (97.4%) were managed successfully as outpatients without antibiotics, admissions, or complications. In only four (2.6%) patients, the management failed because of complications in three and deterioration in one. These patients were all treated successfully as inpatients without surgery. Five patients had recurrences and were treated as outpatients without antibiotics. Follow-up colonic investigations revealed cancer in two patients and polyps in 13 patients.

CONCLUSION

Previous results of low complication rates with the non-antibiotic policy were confirmed. The new policy of outpatient management without antibiotics in acute uncomplicated diverticulitis is now shown to be feasible, well functioning, and safe.

Insurance status is associated with treatment allocation and outcomes after subarachnoid hemorrhage

OBJECTIVE

Subarachnoid hemorrhage (SAH) is a particularly devastating type of stroke which is responsible for one third of all stroke-related years of potential life lost before age 65. Surgical treatment has been shown to decrease both morbidity and mortality after subarachnoid hemorrhage. We hypothesized that payer status other than private insurance is associated with lower allocation to surgical treatment for patients with SAH and worse outcomes.

DESIGN

We examined the association between insurance type and surgical treatment allocation and outcomes for patients with SAH while adjusting for a wide range of patient and hospital factors. We analyzed the Nationwide Inpatient Sample hospital discharge database using survey procedures to produce weighted estimates representative of the United States population.

PATIENTS

We studied 21047 discharges, representing a weighted estimate of 102595 patients age 18 and above with a discharge diagnosis of SAH between 2003 and 2008.

MEASUREMENTS

Multivariable logistic and generalized linear regression analyses were used to assess for any associations between insurance status and surgery allocation and outcomes.

MAIN RESULTS

Despite the benefits of surgery 66% of SAH patients did not undergo surgical treatment to prevent rebleeding. Mortality was more than twice as likely for patients with no surgical treatment compared to those who received surgery. Medicare patients were significantly less likely to receive surgical treatment.

CONCLUSIONS

Nearly two thirds of patients with SAH don't receive operative care, and Medicare patients were significantly less likely to receive surgical treatment than other patients. Bias against the elderly and those with chronic illness and disability may play a part in these findings. A system of regionalized care for patients presenting with SAH may reduce disparities and improve appropriate allocation to surgical care and deserves prospective study.