Number of Diverticulitis Episodes Before Resection and Factors Associated With Earlier Interventions
Authors: Vlad V. Simianu, Alessandro Fichera, Amir L. Bastawrous, Giana H. Davidson, Michael G. Florence, Richard C. Thirlby, David R. Flum
Journal: JAMA Surgery (2016)

<h3>Importance</h3> Despite professional recommendations to delay elective colon resection for patients with uncomplicated diverticulitis, early surgery (after &lt;3 preceding episodes) appears to be common. Several factors have been suggested to contribute to early surgery, including increasing numbers of younger patients, a lower threshold to operate laparoscopically, and growing recognition of "smoldering" (or nonrecovering) diverticulitis episodes. However, the relevance of these factors in early surgery has not been well tested, and most prior studies have focused on hospitalizations, missing outpatient events and making it difficult to assess guideline adherence in earlier interventions. <h3>Objective</h3> To describe patterns of episodes of diverticulitis before surgery and factors associated with earlier interventions using inpatient, outpatient, and antibiotic prescription claims. <h3>Design, Setting, and Participants</h3> This investigation was a nationwide retrospective cohort study from January 1, 2009, to December 31, 2012. The dates of the analysis were July 2014 to May 2015. Participants were immunocompetent adult patients (age range, 18-64 years) with incident, uncomplicated diverticulitis. <h3>Exposure</h3> Elective colectomy for diverticulitis. <h3>Main Outcomes and Measures</h3> Inpatient, outpatient, and antibiotic prescription claims for diverticulitis captured in the MarketScan (Truven Health Analytics) databases. <h3>Results</h3> Of 87 461 immunocompetent patients having at least 1 claim for diverticulitis, 6.4% (n = 5604) underwent a resection. The final study cohort comprised 3054 nonimmunocompromised patients who underwent elective resection for uncomplicated diverticulitis, of whom 55.6% (n = 1699) were male. Before elective surgery, they had a mean (SD) of 1.0 (0.9) inpatient claims, 1.5 (1.5) outpatient claims, and 0.5 (1.2) antibiotic prescription claims related to diverticulitis. Resection occurred after fewer than 3 episodes in 94.9% (2897 of 3054) of patients if counting inpatient claims only, in 80.5% (2459 of 3054) if counting inpatient and outpatient claims only, and in 56.3% (1720 of 3054) if counting all types of claims. Based on all types of claims, patients having surgery after fewer than 3 episodes were of similar mean age compared with patients having delayed surgery (both 47.7 years,<i>P</i> = .91), were less likely to undergo laparoscopy (65.1% [1120 of 1720] vs 70.8% [944 of 1334],<i>P</i> = .001), and had more time between the last 2 episodes preceding surgery (157 vs 96 days,<i>P</i> &lt; .001). Patients with health maintenance organization or capitated insurance plans had lower rates of early surgery (50.1% [247 of 493] vs 57.4% [1429 of 2490],<i>P</i> = .01) than those with other insurance plan types. <h3>Conclusions and Relevance</h3> After considering all types of diverticulitis claims, 56.3% (1720 of 3054) of elective resections for uncomplicated diverticulitis occurred after fewer than 3 episodes. Earlier surgery was not explained by younger age, laparoscopy, time between the last 2 episodes preceding surgery, or financial risk-bearing for patients. In delivering value-added surgical care, factors driving early, elective resection for diverticulitis need to be determined.