Indications for Elective Colon Resection after Diverticulitis: A Report from the SCOAP Collaborative
Vlad V Simianu*1, Amir L Bastawrous2, Richard P Billingham2, Ellen T Farrokhi3, Alessandro Fichera1, Daniel O Herzig4, Eric Johnson5, Scott R Steele5, Richard C Thirlby6, David R Flum1
1University of Washington, Seattle, WA;2Swedish Medical Center, Seattle, WA;3Surgical Care and Outcomes Assessment Program (SCOAP), Seattle, WA;4Oregon Health & Science University, Portland, OR;5Madigan Army Medical Center, Tacoma, WA;6Virginia Mason Medical Center, Seattle, WA
OBJECTIVE(S): After successful, non-operative initial management of diverticulitis, patients and clinicians must balance the risk of another event and potential emergency colostomy against the risks of elective resection. Delaying resection until after multiple episodes or clinical complications is recommended. To improve adherence to this recommendation, Washington State’s Surgical Care and Outcomes Assessment Program (SCOAP) began surveillance, benchmarking, and education related to the indications for colon resection.
METHODS: Prospective cohort study evaluating clinical indications (fistula, stricture, bleeding) or number of previously treated diverticulitis episodes for elective colectomy from 49 hospitals (2010-2012).
RESULTS: Among 2032 patients (58.8 ±12 years, 46% male) having elective resection for diverticulitis, the proportion with a clinical indication was 23.3% (10.5% fistula, 5.4% stricture, 2.4% bleeding, 4.9% other). For those with an episode-based indication, 50.7% had 2 or fewer episodes, 45.9% had 3-10 episodes, and 3.4% had >10 episodes. The proportion with 3+ episodes increased from 41.8% to 58.0% (p=.007), while those that failed to meet either clinical or episode-based indications decreased from 41.3% to 29.6%, (p=0.02). Data was incomplete or missing in 30.4%. At hospitals performing 10 or more colectomies yearly, the rate of emergency resections per year did not increase significantly (p=.31).
CONCLUSIONS: The proportion of elective resections for diverticulitis not meeting indications decreased by 28.4% while resection for 3+ episodes increased by 38.5%. A learning health care system based on surveillance, benchmarking and peer-to-peer messaging about current clinician-generated standards shows promise in adherence to professional guidelines related to appropriate care.
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