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Evolving practice patterns in the management of acute colonic diverticulitis: a population-based analysis

Li D, Baxter NN, McLeod RS, Moineddin R, Wilton A, Nathens AB. Dis Colon Rectum. 2014; 57(12):1397-405.

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.

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

Setting — This study was conducted in Ontario, Canada.

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

Main outcome measures — 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).

Limitations — 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.

Keywords: Gastrointestinal disorders Health care delivery Primary care/clinical practice