Area Deprivation, Fragmented Care, and Colectomy Case Acuity in the Veterans Health Administration

Abstract

BACKGROUND: Colectomy for benign or malignant disease may be elective, urgent, or emergent. Data suggest successively worse outcomes for nonelective colectomy. Limited data exist regarding the contribution of high area deprivation index and care fragmentation to nonelective colectomy. OBJECTIVE: Determine the association between area deprivation and nonelective colectomy in the Veterans Health Administration and assess whether accounting for differences in care fragmentation alters the association across indications and for benign and malignant conditions separately. DESIGN: Retrospective cohort with multivariable multinomial logit models to evaluate associations between high-deprivation care fragmentation and the adjusted odds of nonelective colectomy. We calculated total, direct, and indirect effects to assess whether the association varied by levels of care fragmentation. SETTING: Veterans receiving care in the private sector and Veterans Health Administration. PATIENTS: Veterans aged 65 years or older undergoing colectomy between 2013 and 2019 were included. MAIN OUTCOME MEASURES: Colectomy case acuity. RESULTS: We identified 6538 colectomy patients, of whom 3006 (46.0%) were identified for malignancy. The odds of emergent colectomy were higher for patients in high-deprivation areas when the indication was for benign pathology (adjusted OR 1.51; 95% CI, 1.15–2.00). For malignant indications, there was no association between high deprivation and nonelective colectomy. More fragmented care was associated with higher odds of urgent and emergent colectomy for both benign and malignant indications, but the association between deprivation and nonelective colectomy did not vary by care fragmentation. LIMITATIONS: Inherent to large administrative retrospective databases. CONCLUSIONS: Veterans living in high-deprivation areas are at higher risk for emergent colectomy for benign conditions. Care fragmentation is also associated with a higher risk of emergent colectomy across indications. Efforts to reduce care fragmentation and promote early detection of IBD and diverticular disease in high-deprivation neighborhoods may lower the risk for nonelective colectomy in veterans.