David A. Etzioni

Diverticulitis in the United States: 1998-2005: changing patterns of disease and treatment.

Objectives:Diverticular disease imposes an impressive clinical burden to the United States population, with over 300,000 admissions and 1.5 million days of inpatient care annually. Consensus regarding the treatment of diverticulitis has evolved over time, with increasing advocacy of primary anastomosis for acute diverticulitis, and nonoperative treatment of recurrent mild/moderate diverticulitis. We analyzed whether these changes are reflected in patterns of practice in a nationally-representative patient cohort. Methods:We used the 1998 to 2005 nationwide inpatient sample to analyze the care received by 267,000 patients admitted with acute diverticulitis, and 33,500 patients operated electively for diverticulitis. Census data were used to calculate population-based incidence rates of disease and surgical treatment. Weighted logistic regression with cluster adjustment at the hospital level was used for hypothesis testing. Results:Overall annual age-adjusted admissions for acute diverticulitis increased from 120,500 in 1998 to 151,900 in 2005 (26% increase). Rates of admission increased more rapidly within patients aged 18 to 44 years (82%) and 45 to 74 years (36%). Elective operations for diverticulitis rose from 16,100 to 22,500 per year during the same time period (29%), also with a more rapid increase (73%) in rates of surgery for individuals aged 18 to 44 years. Multivariate analysis found no evidence that primary anastomosis is becoming more commonly used. Conclusions:We are the first to report dramatic changes in rates of treatment for diverticulitis in the United States. The causes of this emerging disease pattern are unknown, but certainly deserve further investigation. For patients undergoing surgery for acute diverticulitis, there was little change over time in the likelihood of a primary anastomosis.

Patterns of treatment for peripheral arterial disease in the United States: 1996-2005

OBJECTIVE Endovascular procedures are increasingly used in the treatment of peripheral arterial disease (PAD). Whether this new procedural approach translates to clinical outcomes equivalent or superior to open surgical revascularization is a subject of debate. We sought to analyze population-based rates of major amputations for PAD during a time period in which the use of endovascular surgical procedures increased dramatically. METHODS We used the 1996-2005 Nationwide Inpatient Sample (NIS) to analyze rates of amputations and vascular interventions, and also to characterize the treatment of patients admitted acutely for PAD. Vascular interventions were designated based on International Classification of Diseases (ICD) procedure codes as open bypass, endovascular intervention, or major amputation (disarticulation at ankle or higher amputation). Population-based age-adjusted incidence rates of treatment were calculated by combining procedure rates with census data. RESULTS Our analysis included 97,000 acute admissions for PAD, 83,000 major amputations, 77,500 endovascular procedures, and 171,000 open vascular bypass operations. Between 1996 and 2005, population-based rates of acute admissions for PAD decreased by 4.3% per year, open procedures by 6.6% per year, and major amputations by 6.4% per year, whereas endovascular procedures increased by 4.8% per year. Of patients acutely admitted for PAD, the likelihood of undergoing an amputation decreased (30.2% to 21.8%), the likelihood of undergoing an open vascular procedure decreased (34.5% to 26.3%), and the likelihood of undergoing an endovascular operation increased (12.7% to 28.3%). All of these changes were statistically significant at P < .05. CONCLUSION The last decade has seen a significant increase in the use of endovascular procedures and a decrease in rates of major amputation. These trends are seen both for patients admitted with acute PAD, as well as in the population in general. While our study was not designed to demonstrate a causal relationship, our findings suggest an association between increased application of endovascular technology and reduced rates of amputation in patients with PAD.

Treatment of Complex Anal Fistulas with the Collagen Fistula Plug

PurposeAnal fistulas that involve a significant amount of sphincter may be difficult to treat without compromising continence function. In this study, we evaluated our experience with the Surgisis® anal fistula plug, which was recently reported to be successful in >80 percent of patients with complex fistulas.MethodsWe retrospectively collected patient and fistula characteristics, procedure details, and follow-up information for all patients treated with the anal fistula plug at our institution from January 2006 through April 2007. The outcome was considered successful if the external opening was closed and if the patient had no drainage at the last follow-up. Using multivariate statistics, we analyzed the relationship between anal fistula plug success and several key variables.ResultsFrom January 2006 through April 2007, 47 patients with 49 complex anal fistulas underwent 64 anal fistula plug procedures. The median follow-up time for patients who were considered healed was 6.5 (range, 3–11) months. The success rate was 31 percent per procedure and 43 percent per patient. An increased amount of external sphincter involvement was associated with a higher failure rate (P < 0.05).ConclusionsIn our early experience with the anal fistula plug, 43 percent of patients with complex anal fistulas were successfully treated. Patients with less external sphincter involvement were more likely to heal.

Outpatient treatment of acute diverticulitis: rates and predictors of failure.

PURPOSE: Many patients with acute diverticulitis can be managed as outpatients, but the success rate of this approach has not been thoroughly studied. We analyzed a large cohort of patients treated on an outpatient basis for an initial episode of acute diverticulitis to test our hypothesis that outpatient treatment of acute diverticulitis is highly effective. METHODS: We analyzed patients within the Kaiser Permanente Southern California system (from 2006 to 2007) who were diagnosed with an initial episode of diverticulitis during an emergency room visit and subsequently discharged home. Each patient underwent a computed tomography (CT) scan for diagnosis or for confirmation of a diagnosis, and each radiologic report was evaluated regarding the presence of free fluid, phlegmon, perforation, and abscess. Treatment failure was defined as a return to the emergency room or an admission for diverticulitis within 60 days of the initial evaluation. RESULTS: Our study included 693 patients, of whom 54% were women, the average age was 58.5 years, and 6% failed treatment. In multivariate analysis, women (odds ratio, 3.08 [95% CI, 1.31-7.28]) and patients with free fluid on CT scan (odds ratio, 3.19 [95% CI, 1.45-7.05]) were at significantly higher risk for treatment failure. Age, white blood cell count, Charlson score, and duration of antibiotics were not significant predictive factors. CONCLUSIONS: In a retrospective analysis, among a cohort of patients who were referred for outpatient treatment, we found that such treatment was effective for the vast majority (94%) of patients. Women and those with free fluid on CT scan appear to be at higher risk for treatment failure.

Impact of the Aging Population on the Demand for Colorectal Procedures

PURPOSE: With the baby boomers entering retirement age, the United States population is seeing a dramatic increase in the number of elderly individuals. We hypothesized that as a result, during the next 20 years, the demand for colorectal procedures will grow rapidly. METHODS: We used the 2005 Nationwide Inpatient Sample and the Florida State Ambulatory Surgery Database as source data. From these two data sources, we identified commonly performed inpatient and outpatient colorectal procedures, as well as associated diagnoses. These data were combined with census projections to generate projected volumes for the selected procedures and diagnoses. RESULTS: Between 2005 and 2025, the United States population is expected to grow by 18 percent, with disproportionate growth in individuals aged 65 to 74 years (92 percent) and those aged 75+ years (54 percent). We forecast that growth in outpatient procedures and inpatient procedures will be 21.3 percent and 40.6 percent, respectively. Inpatient operations for colon cancer and rectal cancer show the greatest growth. CONCLUSIONS: During the next two decades, demographic changes in the United States population will lead to a marked increase in the use of colorectal surgical services, especially inpatient and oncologic procedures. The ability of the surgical workforce to meet this projected growth in demand should be assessed.

Racial and ethnic differences in patterns of treatment for acute peripheral arterial disease in the United States, 1998-2006.

OBJECTIVE Prior studies have documented racial and ethnic disparities in rates of amputations for peripheral arterial disease (PAD) in the United States. We analyze whether there are underlying differences in the types of treatment provided to patients who are acutely hospitalized for PAD. METHODS The 1998-2006 Nationwide Inpatient Sample was used to examine patterns of treatment. We considered a hospitalization an acute admission for PAD if (1) the primary diagnosis was PAD, and (2) the patient was admitted urgently or emergently or through an emergency department. Vascular interventions were designated as open bypass, endovascular intervention, or major amputation, defined as disarticulation at the ankle or higher amputation. RESULTS From 1998 through 2006, the likelihood of an endovascular procedure being performed during an acute hospitalization for PAD increased from 11.5% to 35.3%, and open vascular procedures decreased from 34.9% to 25.4%. The likelihood of a major amputation during an acute hospitalization for PAD decreased from 29.7% to 20.3%. Black and Hispanic patients were more likely than white patients to undergo amputation and were less likely to have an endovascular or open revascularization. CONCLUSION Use of endovascular procedures has increased and use of open vascular bypass has decreased in the inpatient treatment of acute PAD. Although the overall likelihood of amputation has decreased, racial and ethnic differences persist, with black and Hispanic patients experiencing a higher likelihood of amputation.

Getting the science right on the surgeon workforce issue.

In this article we summarize the perspectives given by a range of health policy researchers as presented at the fifth annual meeting of the Surgical Outcomes Club at the annual meeting of the American College of Surgeons in Chicago, Illinois, on October 11, 2009. During that session, the participants reviewed 3 main areas that are summarized here: history of physician/surgeon workforce policy, current beliefs, recent policy activity, and issues related to forecasting/planning the future surgical workforce.

Colorectal procedures: What proportion is performed by American board of Colon and rectal surgery-certified surgeons?

PURPOSE: The surgical workforce within the United States is moving rapidly toward increasing subspecialization. We hypothesized that over time an increasing proportion of colorectal procedures is performed by subspecialty-trained colorectal surgeons. METHODS: We used data from the Surveillance, Epidemiology, and End Results–Medicare program to examine the treatment of patients who underwent a colorectal surgical procedure between 1992 and 2002. We established whether the surgeon responsible for the patients initial care was a board-certified colorectal surgeon based on a linkage with 2 overlapping data sources: 1) historical data from the American Board of Colon and Rectal Surgery and 2) the American Medical Association Physician Masterfile. RESULTS: We examined a total of 104,636 procedures; overall, 30.6% of anorectal procedures, 22.0% of proctectomies, 14.0% of ostomy-related procedures, and 11.5% of colectomies were performed by board-certified colorectal surgeons. Procedures in regions with lower population density or during urgent/emergent hospitalizations were more likely to be performed by a noncolorectal surgeon. Operations for cancer and those performed on an elective basis were more likely to be performed by a board-certified colorectal surgeon. Over time, the proportion of each of these types of cases performed by a colorectal surgeon increased. This increase was fastest for anorectal procedures. CONCLUSIONS: During the 11-year period of our study, there was a significant increase in the proportion of colorectal surgical procedures performed by board-certified colorectal surgeons.