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

Abstract

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.