After 2006 Elective Colectomy Guideline Change, Rates of Elective Colectomy Increases Continued

After the 2006 change in elective colectomy guidelines, rates of elective surgery for diverticulitis continued to increase in the United States, doubling among patients age 65 to 79 years.

After the 2006 change in elective colectomy guidelines, rates of elective surgery for diverticulitis continued to increase in the United States, doubling among patients age 65 to 79 years according to a study published in Gastroenterology. Considering the risks of elective colectomy, these findings point to the need for more evidence-based decision making that incorporates both patient preferences and patient-reported outcomes.

Colectomy is one of the most commonly performed procedures in the United States, with diverticulitis being the second most common indication for this elective surgery. New guidelines published in July 2006 and based on evidence that recurrent diverticulitis does not increase the risk of either complicated disease or urgent surgery, recommend that the decision to undergo surgery for uncomplicated diverticulitis be made on a case-by-case basis. This retrospective cohort study was designed to determine if elective and urgent/emergent colectomy trends changed after July 2006. Data for patients ≥20 years old who had elective or urgent/emergent partial colectomy because of diverticulitis were derived from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS), 2000-2016. The NIS is the largest publicly available, all-payer inpatient healthcare database in the United States and when weighted, it represents more than 35 million inpatient hospital stays each year.

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Prior to the 2006 guideline change, the elective colectomy surgery rate per 100,000 adults increased by 0.13 surgeries/year in all age groups except adults age 80 years and older, from 1.8 in 2000 to 2.6 in July 2006. After the guideline change, the increase continued, but at a decreased rate of 0.06 surgeries per 100,000 adults/year, due to a doubled rate of elective colectomy surgeries in patients age 65 to 79. The rate among patients age 20 to 49, 50 to 64 and ≥80 years generally leveled off in this time period.

The rate of urgent/emergent surgery per 100,000 adults increased by 0.06 surgeries/year, from 1.7 in 2000 to 2.1 in July 2006, with rates that remained stable in patients age 65 to 79 years and those 80 years and older, but increased in patients age 20 to 49 and 50 to 64 years. After the guidelines change, urgent/emergent rates of surgery remained stable in patients age 65 to 79 years, but decreased in patients age 20 to 49, 50 to 64, and ≥80 years. Overall, the guideline changes were associated with a similar downward trend deflections for both types of surgery (elective: -0.08; 95% CI, -0.09 to -0.06; urgent/emergent: -0.11; 95% CI, -0.16 to -0.06).

There is evidence that clinicians may be aware of the new guidelines but struggle to implement them, partly because high-quality research on patient-reported outcomes is scarce. Also, there is a lack of options for preventing diverticulitis, so that patients may choose surgery in response to unpredictable and debilitating recurrences.

Limitations to the study include underestimating the incidence of surgery for cases miscoded as colorectal cancer, benign polyps, ibd or missing a diagnosis code as well as overestimating the incidence of surgery for diverticulitis if cases had one of the diagnoses listed above but were miscoded as diverticulitis.

The researchers concluded, “Given the risks associated with elective colectomy, these findings demonstrate the need for a more evidence-based decision-making process, incorporating both patient preferences and patient reported outcomes, for those considering elective colectomy for uncomplicated and some cases of complicated diverticulitis.”

Reference

Strassle PD, Kinlaw AC, Chaumont N, et al. Rates of elective colectomy for diverticulitis continued to increase after 2006 guideline change [published online September 6, 2019]. Gastroenterology. doi: 10.1053/j.gastro.2019.08.045