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emergent surgery for diverticulitis in the state of Florida
The American Journal of Surgery xxx (xxxx) xxx
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Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida Riccardo Lemini a, Aaron C. Spaulding b, Osayande Osagiede a, Jordan J. Cochuyt b, James M. Naessens c, Marie Crandall d, Robert R. Cima e, Dorin T. Colibaseanu a, * a
Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA Division of Health Care Policy and Research and Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Rochester, MN, USA d Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA e Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 19 July 2019 Received in revised form 22 August 2019 Accepted 8 September 2019
Background: Patients with diverticulitis have a 20% risk of requiring urgent/emergent treatment. Since morbidity and mortality rates differ between elective and urgent/emergent care, understanding associated disparities is critical. We compared factors associated with treatment setting for diverticulitis and evaluated disparities regarding access to Minimally Invasive Surgery (MIS) and development of complications. Methods: The Florida Inpatient Discharge Dataset was queried for patients diagnosed with diverticulitis. Three multivariate models were utilized: 1) elective vs urgent/emergent surgery, 2) MIS vs open and 3) presence of complications. Results: The analysis included 12,654 patients. Factors associated with increased odds of urgent/emergent care included being uninsured or covered by Medicaid, African American, obese, or more comorbid. MIS was associated with reduced odds of complications. Patients treated by high-volume or colorectal surgeons had increased odds of receiving MIS. Conclusions: Patients were more likely to receive MIS if they were treated by a colorectal surgeon, or a high-volume surgeon (colorectal, or general surgeon). Additionally, patients that were older, had increased comorbidities, or did not have health insurance were less likely to receive MIS. © 2019 Elsevier Inc. All rights reserved.
Keywords: Disparities Colorectal surgery Complicated diverticulitis Minimally invasive surgery
Introduction Diverticulitis is responsible for nearly 200,000 new admissions every year in the United States.1 Patients with diverticulosis have 10e25% risk of developing diverticulitis,2 and 20% of these may also present with complications, such as abscess and/or perforation, requiring urgent/emergent treatment.3 The clinical presentation of diverticulitis dictates treatment, and consequently, short- and long-term outcomes. Minimally invasive surgery (MIS) has contributed to a decline in post-operative morbidity for patients undergoing elective surgery.4 However, morbidity and mortality rates remain relatively high for patients
* Corresponding author. Division of Colon and Rectal Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA. E-mail address: [email protected] (D.T. Colibaseanu).
undergoing urgent/emergent surgery, specifically the risk of anastomotic leaks.5 Given this difference in outcomes between elective and urgent/emergent surgery for diverticulitis, it is important to better understand the risk factors responsible for urgent/emergent presentation. While pathophysiology of the disease is undoubtedly the main reason, a delay in timely treatment of what otherwise would be elective, non-operative diverticulitis episodes could result in exacerbation of the disease to the point where urgent/ emergent treatment is necessary (in groups with limited access to care.6e8 In addition to the manner of presentation, there is renewed interest in the use of an MIS approach in the emergent setting.9 Recent studies found that laparoscopic colectomy was safe and was associated with better post-operative outcomes, including reduced blood-loss, post-operative pain, decreased length of stay, and most importantly lower mortality in the elective, urgent and emergent setting.5,10 Therefore, the primary aim of this study was to compare patient
https://doi.org/10.1016/j.amjsurg.2019.09.005 0002-9610/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: Lemini R et al., Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.09.005
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R. Lemini et al. / The American Journal of Surgery xxx (xxxx) xxx
related factors that differ in patients undergoing either elective or urgent/emergent surgery for diverticulitis. A secondary aim was to evaluate the presence of potential disparities with respect to MIS access among patients who received urgent and/or emergent surgeries. Materials and methods This was a retrospective analysis of the Florida Inpatient Discharge Dataset (FIDD) for all patients diagnosed with diverticulitis and undergone surgery between January 2013 and October 2015. Patients were selected using International Classification of Diseases e version 9 (ICD-9) codes identifying a diagnosis of diverticulitis (562.11, 562.13) as well as a related surgical operation resulting in an inpatient stay. We excluded patients who had more than one procedure type thus eliminating patients who might have had a conversion from MIS to open surgery, as the dataset does not allow aligning timing and surgeon characteristics to specific surgical procedure when more than one was performed. Furthermore, only procedures performed by physicians who were classified as either general or colorectal surgeons were included in the analysis. Fig. 1 shows the selection criteria adopted for this study. Since the dataset contains de-identified data and it is publicly available, this research was categorized as exempt by the Institutional Review Board. Dependent variables The key dependent variables for this study include surgical treatment setting (elective vs urgent/emergent), complications, and minimally invasive (MIS) vs open procedure type. Surgical treatment setting is defined within the FIDD and indicates whether the surgical procedure was identified as elective or urgent/emergent. We have limited our dataset to only include patient who had one procedure after admission in order to prevent issues where a patient would be admitted electively and then subsequently need emergency surgery due to complications associated with other
procedures. Surgical complications are identified utilizing the Healthcare Cost and Utilization Project (HCUP) Clinical Classifications Software code 238 which identifies complications of surgical procedures or medical care.11 As complications were not common in the population, this variable was operationalized as presence1 or absence (0) of complications. Finally, MIS vs open was established based upon codes indicating the surgery was conducted laparoscopically or via robotic assistance. If either were indicated as part of the operation the surgery was considered MIS, if neither were present, the surgery was considered open. Independent variables Independent variables include patient and hospital characteristics that may influence disease status, or access to healthcare. As such, for this analysis we adjust for patient age, sex, race, Elixhauser comorbidity score, patient insurance, patient county, patient region and the year in which the procedure occurred. Patient race consists of White, Black or African American, or Hispanic or Latino. The Elixhauser comorbidity score identifies the number of comorbidities an individual has been identified to have and is categories into 0, 1 to 2, 3 to 5 or greater than 5.12 In addition, we have removed obesity (Body Mass Index > 30) from this categorization and included it separately as a binary variable (0 for no indication of obesity and 1 for presence of obesity) as obesity has been shown to be an important patient characteristic that influences surgical outcomes.13,14 Patient insurance is categorized as Commercial, Medicaid, Medicare, Medicaid Managed Care, or Other which includes self-pay or no-insurance. Hospital and physician characteristics include: hospital size and volume, teaching status, facility region, rural setting, physician volume, and physician specialty. Hospital size is based on number of beds and is operationalized as small (fewer than 100 beds), medium (100e299 beds) and large (more than 300 beds). Hospital volume was separated into three categories based upon the distribution of the data including: low (fewer than 10 operations), medium (10e29 operations), and high (30 or more operations). Teaching status is based on indications of a residency program by the Accreditation Council for Graduate Medical Education and is categorized as either teaching or non-teaching. Next, facility region is divided into the 7 regions as defined by the Florida Department of Transportation.15 The National Provider Identifier (NPI) was utilized to identify the specialty of the operating physician of record. Colorectal surgeon was selected if any of the NPI specialty identifiers included colorectal surgery. Similarly, general surgery was selected if any of the identifiers included general surgery and there were no colorectal surgery identifiers present. Finally, Physician volume was defined by the total number of surgical cases that match our inclusion criteria for diverticulitis. Statistical analysis
Fig. 1.
The study population was described by means and percentages in relation to elective and urgent/emergent admission type. Continuous variables were assessed by Kruskal-Wallis tests and categorical variables by Pearson c2. In order to best understand the association between patient, physician and hospital characteristics, mixed effects model were deployed. These models are used to account for nesting of patients by physician and physician by hospital. Three separate logistic regression models were utilized. The first utilized elective vs urgent/emergent surgery as the dependent variable and included the overall study population; the second and the third included instead only patients who were treated urgently/ emergently and utilized MIS vs open approaches and the presence of complication as dependent variables, respectively. All tests of
Please cite this article as: Lemini R et al., Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.09.005
R. Lemini et al. / The American Journal of Surgery xxx (xxxx) xxx
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Table 1 Descriptive statistics by surgical setting. Elective (N ¼ 5854)
Urgent/Emergent (N ¼ 6800)
Total (N ¼ 12654)
Gender Female Male
3404 (48.1%) 2450 (44.0%)
3677 (51.9%) 3123 (56.0%)
7081 (56.0%) 5573 (44.0%)
Age N Mean (SD) Median Q1, Q3 Range
5854 60.6 (12.8) 61.0 52.0, 70.0 (22.0e99.0)
6800 63.9 (14.7) 65.0 53.0, 75.0 (15.0e100.0)
12654 62.3 (14.0) 63.0 52.0, 73.0 (15.0e100.0)
Race Missing White Black or African American Hispanic or Latino
117 4390 (45.6%) 220 (36.4%) 1127 (52.1%)
138 5242 (54.4%) 385 (63.6%) 1035 (47.9%)
255 9632 (77.7%) 605 (4.9%) 2162 (17.4%)
Elixhauser Score 0 1 to 2 3 to 5 More than 5
1835 (66.9%) 2807 (52.3%) 1104 (29.6%) 108 (13.3%)
908 (33.1%) 2557 (47.7%) 2630 (70.4%) 705 (86.7%)
2743 (21.7%) 5364 (42.4%) 3734 (29.5%) 813 (6.4%)
Length of Stay (Days) N Mean (SD) Median Q1, Q3 Range
5854 5.6 (6.3) 5.0 3.0, 6.0 (1.0e354.0)
6800 12.3 (8.8) 10.0 7.0, 15.0 (0.0e179.0)
12654 9.2 (8.4) 7.0 4.0, 12.0 (0.0e354.0)
Year 2013 2014 2015
2131 (46.7%) 2100 (45.5%) 1623 (46.6%)
2430 (53.3%) 2513 (54.5%) 1857 (53.4%)
4561 (36.0%) 4613 (36.5%) 3480 (27.5%)
Patient Payer Missing Medicare Medicare Managed Care Medicaid Commercial Other
0 1460 (41.0%) 866 (41.8%) 219 (33.5%) 3069 (57.9%) 240 (22.4%)
3 2097 (59.0%) 1204 (58.2%) 434 (66.5%) 2230 (42.1%) 832 (77.6%)
3 3557 (28.1%) 2070 (16.4%) 653 (5.2%) 5299 (41.9%) 1072 (8.5%)
Patient County (Rural vs Urban) Missing Rural Urban
123 250 (45.3%) 5481 (46.9%)
296 302 (54.7%) 6202 (53.1%)
419 552 (4.5%) 11683 (95.5%)
Obesity No Yes
5019 (47.3%) 835 (40.8%)
5586 (52.7%) 1214 (59.2%)
10605 (83.8%) 2049 (16.2%)
Patient Region Missing Southwest Florida Northeast Florida Northwest Florida Southeast Florida Central Florida South Florida West Central Florida
123 887 (43.9%) 598 (56.5%) 410 (55.3%) 1082 (44.8%) 873 (36.9%) 996 (59.6%) 885 (44.9%)
296 1133 (56.1%) 461 (43.5%) 331 (44.7%) 1331 (55.2%) 1490 (63.1%) 674 (40.4%) 1084 (55.1%)
419 2020 (16.5%) 1059 (8.7%) 741 (6.1%) 2413 (19.7%) 2363 (19.3%) 1670 (13.6%) 1969 (16.1%)
Hospital Size Small Medium Large
322 (47.5%) 776 (40.8%) 4756 (47.2%)
356 (52.5%) 1128 (59.2%) 5316 (52.8%)
678 (5.4%) 1904 (15.0%) 10072 (79.6%)
Hospital Teaching Status Missing No Yes
121 2859 (45.2%) 2874 (47.1%)
107 3468 (54.8%) 3225 (52.9%)
228 6327 (50.9%) 6099 (49.1%)
p value <.001a
<.001b
<.001a
<.001a
<.001b
0.450a
<.001a
0.455a
<.001a
<.001a
<.001a
0.031a
(continued on next page)
Please cite this article as: Lemini R et al., Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.09.005
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Table 1 (continued ) Elective (N ¼ 5854)
Urgent/Emergent (N ¼ 6800)
Total (N ¼ 12654)
Hospital Volume Missing Low Medium High
73 375 (32.1%) 2072 (42.1%) 3334 (52.7%)
158 793 (67.9%) 2852 (57.9%) 2997 (47.3%)
231 1168 (9.4%) 4924 (39.6%) 6331 (51.0%)
Nonteaching/Teaching Hospital Status Missing Not Teaching Minor Teaching Major Teaching
122 2859 (45.2%) 2132 (42.5%) 741 (68.9%)
109 3468 (54.8%) 2888 (57.5%) 335 (31.1%)
231 6327 (50.9%) 5020 (40.4%) 1076 (8.7%)
Physician Surgical Count N Mean (SD) Median Q1, Q3 Range
5854 40.2 (50.8) 25.0 14.0, 42.0 (1.0e251.0)
6800 22.3 (23.6) 17.0 9.0, 29.0 (1.0e251.0)
12654 30.6 (39.6) 20.0 12.0, 36.0 (1.0e251.0)
Physician Type Missing General Colorectal
792 3515 (41.6%) 1547 (74.1%)
1324 4934 (58.4%) 542 (25.9%)
2116 8449 (80.2%) 2089 (19.8%)
Facility Region Southwest Florida Northeast Florida Northwest Florida Southeast Florida Central Florida South Florida West Central Florida
866 (42.9%) 658 (57.4%) 429 (54.1%) 1154 (44.6%) 864 (35.5%) 978 (59.8%) 905 (44.4%)
1151 (57.1%) 489 (42.6%) 364 (45.9%) 1434 (55.4%) 1569 (64.5%) 658 (40.2%) 1135 (55.6%)
2017 (15.9%) 1147 (9.1%) 793 (6.3%) 2588 (20.5%) 2433 (19.2%) 1636 (12.9%) 2040 (16.1%)
MIS vs OPEN Open MIS
2188 (29.1%) 3666 (71.4%)
5334 (70.9%) 1466 (28.6%)
7522 (59.4%) 5132 (40.6%)
a b
p value <.001a
<.001a
<.001b
<.001a
<.001a
<.001a
Chi-Square. Kruskal Wallis.
significance were 2-sided, and both parameter estimates (regression coefficients) as well as p-values were reported. The level of statistical significance was set at p-value < 0.05. Analyses were performed using SAS version 9.4 (SAS Institute Inc.). Results A total of 12,654 patients treated at 182 hospitals were identified for the analysis. Table 1 includes the overall patient and hospital characteristics for the entire cohort of patients, summarized for elective vs urgent/emergent surgery. A total of 5854 (46.3%) patients received surgical treatment electively and 6800 (53.7%) urgently/emergently. The median age in the overall cohort was 63 years; 56% of patients were female and 44% male, while the distribution of races was 77.7% White, 4.9% African American, and 17.4% Hispanic. Patients with higher Elixhauser comorbidity scores tended to undergo urgent/emergent surgery, while an opposite trend was found in patients with low scores. Additionally, 16.2% of patients were reported as obese. The majority of patients had commercial insurance (41.9%) followed by Medicare (28.1%). The distribution between general and colorectal surgeons was 80.2% and 19.8% respectively, while the surgical approach was predominantly open (59.4%) over MIS (40.6%). The first multivariate model compared the surgical setting (elective vs urgent/emergent), as presented in Table 2. Patients covered by Medicaid (OR 2.19, 95% CI 1.72e2.79) or uninsured (OR 4.60, 95% CI 3.74e5.66) had greater odds of undergoing urgent/ emergent surgery. Similarly, a higher Elixhauser comorbidity score
(1e2: OR 1.83, 95% CI 1.60e2.10; 3 to 5: OR 5.05, 95% CI 4.30e5.94; >5: OR 13.52, 95% CI 10.10e18.08), being obese (OR 1.25, 95% CI 1.09e1.44) or African American (OR 1.29, 95% CI 1.01e1.64) were associated with increased odds of receiving urgent/emergent care. Compared to Northeast Florida, all regions except the Northwest Florida were significantly associated with increased odds of urgent/ emergent surgery. Female gender was instead associated with increased odds of elective treatment (OR 0.68, 95% CI 0.61e0.76). The second multivariate model evaluated the odds of developing post-operative complications in the urgent/emergent population (Table 3). Patients with a higher Elixhauser comorbidity score had increased odds of developing a complication, and this association became stronger as the score increased (1e2: OR 1.67, 95% CI 1.31e2.13; 3 to 5: OR 1.91, 95% CI 1.48e2.47; >5: OR 2.28, 95% CI 1.66e3.14). Conversely, the use of MIS was associated with reduced odds of developing post-operative complications (OR 0.59, 95% CI 0.49e0.71). Finally, the third multivariate model compared the surgical approach (MIS vs open) for the urgent/emergent population (Table 4). An encouraging finding is represented by the increased use of MIS over the years; being treated in 2015 was associated with increased odds of receiving MIS compared to previous years (OR 1.34, 95% CI 1.09e1.64). Likewise, patients treated by higher volume physician (OR 1.08, 95% CI 1.03e1.14) or colorectal surgeons (OR 2.72, 95% CI 1.89e3.91) had increased odds of receiving MIS. Conversely, older patients (OR 0.79, 95% CI 0.72e0.87) and those with more comorbidities (Elixhauser score 1 to 2: OR 0.69, 95% CI 0.55e0.88; 3 to 5: OR 0.56, 95% CI 0.43e0.73; >5: OR 0.35, 95% CI
Please cite this article as: Lemini R et al., Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.09.005
R. Lemini et al. / The American Journal of Surgery xxx (xxxx) xxx Table 2 Multivariable Logistic Regression on Surgical setting (Reference ¼ Elective Surgery). Variable
OR
Table 3 Multivariable logistic regression on urgent/emergent population for complications.
P-value
Variable
OR
95% CI
P-value
0.97e1.23 0.88e1.14
0.153 0.947
Year 2013 2014 2015
1.00 (ref.) 1.12 1.00
0.96e1.31 0.84e1.18
0.147 0.976
0.78e1.44
0.731
Rural Setting
1.15
0.80e1.65
0.463
1.72e2.79 0.80e1.14 0.80e1.17 3.74e5.66
<.001 0.601 0.736 <.001
Patient Insurance Payer Commercial Medicaid Medicare Medicare Managed Care Other
1.00 (ref.) 1.00 1.28 1.10 1.22
0.74e1.34 1.00e1.63 0.85e1.42 0.97e1.52
0.971 0.047 0.470 0.086
0.61e0.76
<.001
Female
0.98
0.85e1.13
0.782
1.60e2.10 4.30e5.94 10.10e18.08
<.001 <.001 <.001
Elixhauser Score 0 1 to 2 3 to 5 More than 5
1.00 (ref.) 1.67 1.91 2.28
1.31e2.13 1.48e2.47 1.66e3.14
<.001 <.001 <.001
1.09e1.44
0.002
Obese
0.99
0.83e1.18
0.921
0.041 0.140
Race White Black or African American Hispanic or Latino
1.00 (ref.) 0.92 0.81
0.69e1.23 0.64e1.02
0.586 0.069
1.48e4.40 0.65e2.31 1.01e3.49 1.47e4.20 1.31e3.99 1.07e3.17
<.001 0.521 0.045 <.001 0.004 0.026
Facility Region Northeast Florida Central Florida Northwest Florida South Florida Southeast Florida Southwest Florida West Central Florida
1.00 (ref.) 1.12 0.91 1.33 1.45 1.14 1.43
0.76e1.67 0.56e1.47 0.83e2.13 0.99e2.13 0.77e1.71 0.96e2.13
0.561 0.698 0.234 0.058 0.512 0.080
0.912
0.65e1.27
0.586
Teaching Hospital
1.01
0.81e1.26
0.948
Age (10 year increase)
1.119
1.05e1.19
<.001
Age (10 year increase)
0.94
0.87e1.02
0.141
Hospital Size Small Hospital Large Hospital Medium Hospital
Physician Volume
1.00
0.96e1.03
0.054
1.00 (ref.) 0.727 0.957
Hospital Size Small Hospital Large Hospital Medium Hospital
1.00 (ref.) 0.67 0.64
0.44e1.01 0.42e0.99
0.044 0.801
Colorectal Surgeon
1.06
0.81e1.37
0.688
Minimally Invasive Surgery
0.59
0.49e0.71
<.001
Year 2013 2014 2015
1.00 (ref.) 1.090 1.004
Rural Setting
1.055
Patient Insurance Payer Commercial Medicaid Medicare Medicare Managed Care Other
1.00 (ref.) 2.189 0.954 0.968 4.601
Female
0.681
Elixhauser Score 0 1 to 2 3 to 5 More than 5
1.00 (ref.) 1.834 5.051 13.516
Obese
1.251
Race White Black or African American Hispanic or Latino
1.00 (ref.) 1.285 1.144
Facility Region Northeast Florida Central Florida Northwest Florida South Florida Southeast Florida Southwest Florida West Central Florida
1.00 (ref.) 2.553 1.229 1.880 2.481 2.284 1.844
Teaching Hospital
95% CI
5
1.01e1.64 0.96e1.37
0.42e1.27 0.53e1.72
0.261 0.882
CI: Confidence Interval, OR: Odds Ratio.
0.23e0.52) and no insurance (OR 0.66, 95% CI 0.51e0.86) were less likely to receive MIS. Finally, being treated in Southwest Florida is also associated with reduced odds of receiving MIS (OR 0.48, 95% CI 0.24e0.97). Discussion This study seeks to understand the influence of healthcare disparities in presentation and treatment outcomes of patients diagnosed and surgically treated for diverticulitis. In particular, this retrospective analysis focused on factors (besides disease severity) that increase the chances of undergoing urgent/emergent surgery for diverticulitis. Secondarily, the presence of healthcare disparities among urgently/emergently treated patients was evaluated with respect to MIS utilization and development of post-operative complications. The principal findings of this analysis show that multiple factors influence the type of surgical setting and that use of an MIS approach was associated with decreased odds of developing post-operative complications in the urgent/emergent
CI: Confidence Interval, OR: Odds Ratio.
population. Treatment of diverticulitis is most heavily influenced by disease presentation. Uncomplicated cases are usually managed conservatively, even though elective surgery may be beneficial in specific cases.16 In 1978, Hinchey et al. published their classification,17 which has been traditionally used to identify four stages of complicated disease. Several classifications for diverticular disease have been subsequently published, with the modified Hinchey classification being one of the most widely adopted.18,19 Modern imaging techniques have increased the precision in diagnosing the severity of diverticulitis, while percutaneous management techniques have decreased the number of required operative interventions.20,21 Still, in 10e20% of cases an emergency surgery is indicated.3,22
Please cite this article as: Lemini R et al., Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.09.005
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R. Lemini et al. / The American Journal of Surgery xxx (xxxx) xxx
Table 4 Multivariable logistic regression on urgent/emergent population for MIS (Reference ¼ open surgery). Variable
OR
95% CI
P-value
Year 2013 2014 2015
1.00 (ref.) 1.10 1.34
0.91e1.33 1.09e1.64
0.344 0.006
Rural Setting
0.72
0.42e1.22
0.218
Patient Insurance Payer Commercial Medicaid Medicare Medicare Managed Care Other
1.00 (ref.) 0.83 1.17 1.01 0.66
0.59e1.17 0.87e1.56 0.74e1.38 0.51e0.86
0.285 0.304 0.965 0.002
Female
1.15
0.97e1.36
0.101
Elixhauser Score 0 1 to 2 3 to 5 More than 5
1.00 (ref.) 0.69 0.56 0.35
0.55e0.88 0.43e0.73 0.23e0.52
0.003 <.001 <.001
Obese
0.95
0.77e1.17
0.626
Race White Black or African American Hispanic or Latino
1.00 (ref.) 0.92 1.04
0.64e1.31 0.80e1.34
0.641 0.782
Facility Region Northeast Florida Central Florida Northwest Florida South Florida Southeast Florida Southwest Florida West Central Florida
1.00 (ref.) 0.61 0.72 1.30 0.80 0.48 0.68
0.31e1.21 0.31e1.63 0.61e2.78 0.42e1.54 0.24e0.97 0.34e1.34
0.159 0.426 0.502 0.507 0.042 0.2619
Teaching Hospital
1.17
0.78e1.75
0.451
Age (10 year increase)
0.79
0.72e0.87
<.001
Physician Volume
1.08
1.03e1.14
0.002
Hospital Size Small Hospital Large Hospital Medium Hospital
1.00 (ref.) 1.07 1.22
0.50e2.26 0.56e2.67
0.864 0.615
Colorectal Surgeon
2.72
1.89e3.91
<.001
CI: Confidence Interval, OR: Odds Ratio.
We found that factors influencing urgent vs elective presentation of diverticulitis include: age, race, insurance status, comorbidities, immunosuppressive therapy, performance status and smoking.23,24 In recent years, the influence of race and insurance status on surgical outcomes has been studied extensively. African American patients have been found to be at higher risk of receiving emergent surgery, and to incur higher morbidity.7,25 We wound that African American patients are similarly exposed to higher risk of undergoing urgent/emergent surgery, though a limitation of the study is that African American represented only 4.9% of the overall cohort, while their ratio among the Florida population is around 15%.26 Regarding insurance status, we found that being uninsured or being covered by Medicaid is strongly associated with urgent/ emergent surgery for diverticulitis. This was more significant than race, especially for uninsured patients. These findings correspond
to the current literature, and are a critical concern since it highlights disparities of the Florida healthcare in a setting that is potentially life threatening, as emergent surgery is associated with higher risk of mortality and complications.5 The second part of our analysis evaluated the likelihood of receiving MIS and developing post-operative complications for patients receiving urgent and emergent surgery for diverticulitis. We found an increased adoption of MIS in 2015 compared to previous years. The advantages of MIS over open surgery have been extensively described for multiple conditions and procedures.5,10,27,28 A significant increase in its use within the urgent/ emergent cohort is promising given the improved outcomes associated with this approach. Patient specific characteristics associated with reduced odds of receiving MIS were higher age and comorbidity score, and uninsured status. As expected, comorbid patients were also more likely to develop post-operative complications. This aspect is particularly true for patients who receive urgent or emergent care, since severity of the disease, setting and available time often do not allow the first choice management of present comorbidities.29,30 Ultimately, MIS was found to be associated with reduced odds of post-operative complications. While this is also well documented in the literature,10,27,28,31,32 our analysis did not adjust for severity of disease due to data limitations, therefore it may be biased towards a stronger association of reduced odds of developing complications. Nevertheless, MIS is associated with a shorter hospital length of stay, improved recovery, lower pain perception, infection rate, and blood loss.28,31 Colorectal surgeons and higher volume centers were more likely to offer MIS. This study has a number of limitations. Despite our aim to evaluate the status of Florida's healthcare, a state level analysis may not be fully generalizable to a national level. Furthermore, The FIDD does not contain information regarding patient readmissions, recurrence or pain levels which may provide more accurate data with respect of the surgical timing and indications. Additionally, the authors acknowledge that the rate of urgent/emergent cases in this study exceeds the national rate. It is unclear whether this rate is a local phenomenon due to health care delivery inefficiencies, or simply a limitation of the database. Furthermore, given the nature of the database we were not able to adjust for disease severity. This may represent a relevant confounding factor since different stages may show different associations with respect of each variable, in particular those related to surgical approach. In clinical practice, surgeons' consideration of timing and approach is primarily dictated by disease severity at the time of presentation. For these reasons, the strength of our results is limited by the lack of ability to adjust for disease severity. Additionally, as already stated above, the proportion of African American patients in the database is lower than the one actually existing in the Florida population; however, a statistically significant association was described, and we would expect it to be stronger if a higher percentage of African American patients were included. Nonetheless, we believe this is a valuable analysis on patient, hospital and treatment specific characteristics associated with surgical setting, access to MIS and risk of postoperative complications for patients undergoing surgery for diverticulitis. In conclusion, besides disease severity, the probability of undergoing elective or urgent/emergent surgery for diverticulitis is influenced by multiple patient-dependent characteristics such as age, comorbidities, gender and obesity, race and insurance status. These two last factors represent high-priority concerns from a healthcare policy perspective in the state of Florida. Lastly, patients without insurance or increased comorbidities were least likely to receive MIS. Further studies addressing disparities in healthcare from different perspectives would be beneficial in understanding
Please cite this article as: Lemini R et al., Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.09.005
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the nature of this phenomenon and filling the gaps that still put patients at risk of non-optimal treatment for their condition. Disclosure The authors declare that there is no conflict of interest. Funding This work was supported by the Robert D. and Patricia E. Kern Center for Science of Health Care Delivery. The funder had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. The authors have no other financial relationships. Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.amjsurg.2019.09.005. References 1. Wheat CL, Strate LL. Trends in Hospitalization for Diverticulitis and Diverticular Bleeding in the United States from 2000 to 2010. Clinical gastroenterology and hepatology : the official clinical practice. J Am Gastroenterol Assoc. 2016;14(1), 96-103.e1. 2. Heise CP. Epidemiology and pathogenesis of diverticular disease. J Gastrointest Surg: Off J Soc Surg Aliment Tract. 2008;12(8):1309e1311. 3. Beyer-Berjot L, Maggiori L, Loiseau D, et al. Emergency Surgery in Acute Diverticulitis: A Systematic Review. Diseases of the colon and rectum; 2019. 4. Papageorge CM, Kennedy GD, Carchman EH. National trends in short-term outcomes following non-emergent surgery for diverticular disease. J Gastrointest Surg : Off J Soc Surg Aliment Tract. 2016;20(7):1376e1387. 5. Moghadamyeghaneh Z, Carmichael JC, Smith BR, et al. A comparison of outcomes of emergent, urgent, and elective surgical treatment of diverticulitis. Am J Surg. 2015;210(5):838e845. 6. Greenwood-Ericksen MB, Havens JM, Ma J, Weissman JS, Schuur JD. Trends in hospital admission and surgical procedures following ED visits for diverticulitis. West J Emerg Med. 2016;17(4):409e417. 7. Lidor AO, Gearhart SL, Wu AW, Chang DC. Effect of race and insurance status on presentation, treatment, and mortality in patients undergoing surgery for diverticulitis. Arch Surg. 2008;143(12):1160e1165. ; discussion 5. 8. Mills AM, Holena DN, Kallan MJ, Carr BG, Reinke CE, Kelz RR. Effect of insurance status on patients admitted for acute diverticulitis. Colorectal Dis: Off J Assoc Coloproctol Great Britain Ireland. 2013;15(5):613e620. 9. Kockerling F. Emergency surgery for acute complicated diverticulitis. Viszeralmedizin. 2015;31(2):107e110. 10. Mahmoud NN, Riddle EW. Minimally invasive surgery for complicated diverticulitis. J Gastrointest Surg : Off J Soc Surg Aliment Tract. 2017;21(4):731e738. 11. CCS H. Healthcare Cost and Utilization Project (HCUP) Rockville, MD. Agency for Healthcare Research and Quality; 2017 [updated March 6, 2017. Available from: https://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp.
7
12. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8e27. 13. Rink AD, Vestweber B, Hahn J, Alfes A, Paul C, Vestweber KH. Single-incision laparoscopic surgery for diverticulitis in overweight patients. Langenbeck's Arch Surg. 2015;400(7):797e804. 14. Tuech JJ, Regenet N, Hennekinne S, Pessaux P, Bergamaschi R, Arnaud JP. Laparoscopic colectomy for sigmoid diverticulitis in obese and nonobese patients: a prospective comparative study. Surg Endosc. 2001;15(12):1427e1430. 15. Health FDo. Rural County List; 2018 [Available from: http://www.floridahealth. gov/programs-and-services/community-health/rural-health/_documents/rualcounties-2000-2010.pdf. 16. Deery SE, Hodin RA. Management of diverticulitis in 2017. J Gastrointest Surg : Off J Soc Surg Aliment Tract. 2017;21(10):1732e1741. 17. Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg. 1978;12:85e109. 18. Wasvary H, Turfah F, Kadro O, Beauregard W. Same hospitalization resection for acute diverticulitis. Am Surg. 1999;65(7):632e635. ; discussion 6. 19. Kaiser AM, Jiang JK, Lake JP, et al. The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol. 2005;100(4): 910e917. 20. Angenete E, Thornell A, Burcharth J, et al. Laparoscopic lavage is feasible and safe for the treatment of perforated diverticulitis with purulent peritonitis: the first results from the randomized controlled trial DILALA. Ann Surg. 2016;263(1):117e122. 21. Thornell A, Angenete E, Bisgaard T, et al. Laparoscopic lavage for perforated diverticulitis with purulent peritonitis: a randomized trial. Ann Intern Med. 2016;164(3):137e145. 22. Biondo S, Lopez Borao J, Millan M, Kreisler E, Jaurrieta E. Current status of the treatment of acute colonic diverticulitis: a systematic review. Colorectal Dis: Off J Assoc Coloproctol Great Britain Ireland. 2012;14(1):e1ee11. 23. Valizadeh N, Suradkar K, Kiran RP. Specific factors predict the risk for urgent and emergent colectomy in patients undergoing surgery for diverticulitis. Am Surg. 2018;84(11):1781e1786. 24. Tan JP, Barazanchi AW, Singh PP, Hill AG, Maccormick AD. Predictors of acute diverticulitis severity: a systematic review. Int J Surg. 2016;26:43e52. 25. Schneider EB, Haider A, Sheer AJ, et al. Differential association of race with treatment and outcomes in Medicare patients undergoing diverticulitis surgery. Arch Surg. 2011;146(11):1272e1276. 26. CensusScope. Florida population by race. http://www.censusscope.org/us/s12/ chart_race.html; 2000. 27. Parker JM, Feldmann TF, Cologne KG. Advances in laparoscopic colorectal surgery. The Surgical clinics of North America. 2017;97(3):547e560. 28. Schwenk W, Haase O, Neudecker J, Muller JM. Short term benefits for laparoscopic colorectal resection. Cochrane Database Syst Rev. 2005;(3). Cd003145. 29. Jeong O, Jung MR, Ryu SY. Impact of various types of comorbidities on the outcomes of laparoscopic total gastrectomy in patients with gastric carcinoma. J Gastr Cancer. 2018;18(3):253e263. 30. Portale G, Valdegamberi A, Cavallin F, Frigo F, Fiscon V. Effect of age and comorbidities on short- and long-term results in patients undergoing laparoscopic curative resection for rectal cancer. J Laparoendosc Adv Surg Tech A. 2019 Mar;29(3):353e359. https://doi.org/10.1089/lap.2018.0340. Epub 2018 Aug 15. PubMed PMID: 30109973. 31. Carr BM, Lyon JA, Romeiser J, Talamini M, Shroyer ALW. Laparoscopic versus Open Surgery: A Systematic Review Evaluating Cochrane Systematic Reviews. Surgical endoscopy; 2018. 32. Moghadamyeghaneh Z, Carmichael JC, Mills S, Pigazzi A, Nguyen NT, Stamos MJ. Variations in laparoscopic colectomy utilization in the United States. Dis Colon Rectum. 2015;58(10):950e956.
Please cite this article as: Lemini R et al., Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.09.005
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Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida Riccardo Lemini a, Aaron C. Spaulding b, Osayande Osagiede a, Jordan J. Cochuyt b, James M. Naessens c, Marie Crandall d, Robert R. Cima e, Dorin T. Colibaseanu a, * a
Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, FL, USA Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA Division of Health Care Policy and Research and Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Rochester, MN, USA d Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA e Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 19 July 2019 Received in revised form 22 August 2019 Accepted 8 September 2019
Background: Patients with diverticulitis have a 20% risk of requiring urgent/emergent treatment. Since morbidity and mortality rates differ between elective and urgent/emergent care, understanding associated disparities is critical. We compared factors associated with treatment setting for diverticulitis and evaluated disparities regarding access to Minimally Invasive Surgery (MIS) and development of complications. Methods: The Florida Inpatient Discharge Dataset was queried for patients diagnosed with diverticulitis. Three multivariate models were utilized: 1) elective vs urgent/emergent surgery, 2) MIS vs open and 3) presence of complications. Results: The analysis included 12,654 patients. Factors associated with increased odds of urgent/emergent care included being uninsured or covered by Medicaid, African American, obese, or more comorbid. MIS was associated with reduced odds of complications. Patients treated by high-volume or colorectal surgeons had increased odds of receiving MIS. Conclusions: Patients were more likely to receive MIS if they were treated by a colorectal surgeon, or a high-volume surgeon (colorectal, or general surgeon). Additionally, patients that were older, had increased comorbidities, or did not have health insurance were less likely to receive MIS. © 2019 Elsevier Inc. All rights reserved.
Keywords: Disparities Colorectal surgery Complicated diverticulitis Minimally invasive surgery
Introduction Diverticulitis is responsible for nearly 200,000 new admissions every year in the United States.1 Patients with diverticulosis have 10e25% risk of developing diverticulitis,2 and 20% of these may also present with complications, such as abscess and/or perforation, requiring urgent/emergent treatment.3 The clinical presentation of diverticulitis dictates treatment, and consequently, short- and long-term outcomes. Minimally invasive surgery (MIS) has contributed to a decline in post-operative morbidity for patients undergoing elective surgery.4 However, morbidity and mortality rates remain relatively high for patients
* Corresponding author. Division of Colon and Rectal Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA. E-mail address: [email protected] (D.T. Colibaseanu).
undergoing urgent/emergent surgery, specifically the risk of anastomotic leaks.5 Given this difference in outcomes between elective and urgent/emergent surgery for diverticulitis, it is important to better understand the risk factors responsible for urgent/emergent presentation. While pathophysiology of the disease is undoubtedly the main reason, a delay in timely treatment of what otherwise would be elective, non-operative diverticulitis episodes could result in exacerbation of the disease to the point where urgent/ emergent treatment is necessary (in groups with limited access to care.6e8 In addition to the manner of presentation, there is renewed interest in the use of an MIS approach in the emergent setting.9 Recent studies found that laparoscopic colectomy was safe and was associated with better post-operative outcomes, including reduced blood-loss, post-operative pain, decreased length of stay, and most importantly lower mortality in the elective, urgent and emergent setting.5,10 Therefore, the primary aim of this study was to compare patient
https://doi.org/10.1016/j.amjsurg.2019.09.005 0002-9610/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: Lemini R et al., Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.09.005
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related factors that differ in patients undergoing either elective or urgent/emergent surgery for diverticulitis. A secondary aim was to evaluate the presence of potential disparities with respect to MIS access among patients who received urgent and/or emergent surgeries. Materials and methods This was a retrospective analysis of the Florida Inpatient Discharge Dataset (FIDD) for all patients diagnosed with diverticulitis and undergone surgery between January 2013 and October 2015. Patients were selected using International Classification of Diseases e version 9 (ICD-9) codes identifying a diagnosis of diverticulitis (562.11, 562.13) as well as a related surgical operation resulting in an inpatient stay. We excluded patients who had more than one procedure type thus eliminating patients who might have had a conversion from MIS to open surgery, as the dataset does not allow aligning timing and surgeon characteristics to specific surgical procedure when more than one was performed. Furthermore, only procedures performed by physicians who were classified as either general or colorectal surgeons were included in the analysis. Fig. 1 shows the selection criteria adopted for this study. Since the dataset contains de-identified data and it is publicly available, this research was categorized as exempt by the Institutional Review Board. Dependent variables The key dependent variables for this study include surgical treatment setting (elective vs urgent/emergent), complications, and minimally invasive (MIS) vs open procedure type. Surgical treatment setting is defined within the FIDD and indicates whether the surgical procedure was identified as elective or urgent/emergent. We have limited our dataset to only include patient who had one procedure after admission in order to prevent issues where a patient would be admitted electively and then subsequently need emergency surgery due to complications associated with other
procedures. Surgical complications are identified utilizing the Healthcare Cost and Utilization Project (HCUP) Clinical Classifications Software code 238 which identifies complications of surgical procedures or medical care.11 As complications were not common in the population, this variable was operationalized as presence1 or absence (0) of complications. Finally, MIS vs open was established based upon codes indicating the surgery was conducted laparoscopically or via robotic assistance. If either were indicated as part of the operation the surgery was considered MIS, if neither were present, the surgery was considered open. Independent variables Independent variables include patient and hospital characteristics that may influence disease status, or access to healthcare. As such, for this analysis we adjust for patient age, sex, race, Elixhauser comorbidity score, patient insurance, patient county, patient region and the year in which the procedure occurred. Patient race consists of White, Black or African American, or Hispanic or Latino. The Elixhauser comorbidity score identifies the number of comorbidities an individual has been identified to have and is categories into 0, 1 to 2, 3 to 5 or greater than 5.12 In addition, we have removed obesity (Body Mass Index > 30) from this categorization and included it separately as a binary variable (0 for no indication of obesity and 1 for presence of obesity) as obesity has been shown to be an important patient characteristic that influences surgical outcomes.13,14 Patient insurance is categorized as Commercial, Medicaid, Medicare, Medicaid Managed Care, or Other which includes self-pay or no-insurance. Hospital and physician characteristics include: hospital size and volume, teaching status, facility region, rural setting, physician volume, and physician specialty. Hospital size is based on number of beds and is operationalized as small (fewer than 100 beds), medium (100e299 beds) and large (more than 300 beds). Hospital volume was separated into three categories based upon the distribution of the data including: low (fewer than 10 operations), medium (10e29 operations), and high (30 or more operations). Teaching status is based on indications of a residency program by the Accreditation Council for Graduate Medical Education and is categorized as either teaching or non-teaching. Next, facility region is divided into the 7 regions as defined by the Florida Department of Transportation.15 The National Provider Identifier (NPI) was utilized to identify the specialty of the operating physician of record. Colorectal surgeon was selected if any of the NPI specialty identifiers included colorectal surgery. Similarly, general surgery was selected if any of the identifiers included general surgery and there were no colorectal surgery identifiers present. Finally, Physician volume was defined by the total number of surgical cases that match our inclusion criteria for diverticulitis. Statistical analysis
Fig. 1.
The study population was described by means and percentages in relation to elective and urgent/emergent admission type. Continuous variables were assessed by Kruskal-Wallis tests and categorical variables by Pearson c2. In order to best understand the association between patient, physician and hospital characteristics, mixed effects model were deployed. These models are used to account for nesting of patients by physician and physician by hospital. Three separate logistic regression models were utilized. The first utilized elective vs urgent/emergent surgery as the dependent variable and included the overall study population; the second and the third included instead only patients who were treated urgently/ emergently and utilized MIS vs open approaches and the presence of complication as dependent variables, respectively. All tests of
Please cite this article as: Lemini R et al., Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.09.005
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Table 1 Descriptive statistics by surgical setting. Elective (N ¼ 5854)
Urgent/Emergent (N ¼ 6800)
Total (N ¼ 12654)
Gender Female Male
3404 (48.1%) 2450 (44.0%)
3677 (51.9%) 3123 (56.0%)
7081 (56.0%) 5573 (44.0%)
Age N Mean (SD) Median Q1, Q3 Range
5854 60.6 (12.8) 61.0 52.0, 70.0 (22.0e99.0)
6800 63.9 (14.7) 65.0 53.0, 75.0 (15.0e100.0)
12654 62.3 (14.0) 63.0 52.0, 73.0 (15.0e100.0)
Race Missing White Black or African American Hispanic or Latino
117 4390 (45.6%) 220 (36.4%) 1127 (52.1%)
138 5242 (54.4%) 385 (63.6%) 1035 (47.9%)
255 9632 (77.7%) 605 (4.9%) 2162 (17.4%)
Elixhauser Score 0 1 to 2 3 to 5 More than 5
1835 (66.9%) 2807 (52.3%) 1104 (29.6%) 108 (13.3%)
908 (33.1%) 2557 (47.7%) 2630 (70.4%) 705 (86.7%)
2743 (21.7%) 5364 (42.4%) 3734 (29.5%) 813 (6.4%)
Length of Stay (Days) N Mean (SD) Median Q1, Q3 Range
5854 5.6 (6.3) 5.0 3.0, 6.0 (1.0e354.0)
6800 12.3 (8.8) 10.0 7.0, 15.0 (0.0e179.0)
12654 9.2 (8.4) 7.0 4.0, 12.0 (0.0e354.0)
Year 2013 2014 2015
2131 (46.7%) 2100 (45.5%) 1623 (46.6%)
2430 (53.3%) 2513 (54.5%) 1857 (53.4%)
4561 (36.0%) 4613 (36.5%) 3480 (27.5%)
Patient Payer Missing Medicare Medicare Managed Care Medicaid Commercial Other
0 1460 (41.0%) 866 (41.8%) 219 (33.5%) 3069 (57.9%) 240 (22.4%)
3 2097 (59.0%) 1204 (58.2%) 434 (66.5%) 2230 (42.1%) 832 (77.6%)
3 3557 (28.1%) 2070 (16.4%) 653 (5.2%) 5299 (41.9%) 1072 (8.5%)
Patient County (Rural vs Urban) Missing Rural Urban
123 250 (45.3%) 5481 (46.9%)
296 302 (54.7%) 6202 (53.1%)
419 552 (4.5%) 11683 (95.5%)
Obesity No Yes
5019 (47.3%) 835 (40.8%)
5586 (52.7%) 1214 (59.2%)
10605 (83.8%) 2049 (16.2%)
Patient Region Missing Southwest Florida Northeast Florida Northwest Florida Southeast Florida Central Florida South Florida West Central Florida
123 887 (43.9%) 598 (56.5%) 410 (55.3%) 1082 (44.8%) 873 (36.9%) 996 (59.6%) 885 (44.9%)
296 1133 (56.1%) 461 (43.5%) 331 (44.7%) 1331 (55.2%) 1490 (63.1%) 674 (40.4%) 1084 (55.1%)
419 2020 (16.5%) 1059 (8.7%) 741 (6.1%) 2413 (19.7%) 2363 (19.3%) 1670 (13.6%) 1969 (16.1%)
Hospital Size Small Medium Large
322 (47.5%) 776 (40.8%) 4756 (47.2%)
356 (52.5%) 1128 (59.2%) 5316 (52.8%)
678 (5.4%) 1904 (15.0%) 10072 (79.6%)
Hospital Teaching Status Missing No Yes
121 2859 (45.2%) 2874 (47.1%)
107 3468 (54.8%) 3225 (52.9%)
228 6327 (50.9%) 6099 (49.1%)
p value <.001a
<.001b
<.001a
<.001a
<.001b
0.450a
<.001a
0.455a
<.001a
<.001a
<.001a
0.031a
(continued on next page)
Please cite this article as: Lemini R et al., Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.09.005
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Table 1 (continued ) Elective (N ¼ 5854)
Urgent/Emergent (N ¼ 6800)
Total (N ¼ 12654)
Hospital Volume Missing Low Medium High
73 375 (32.1%) 2072 (42.1%) 3334 (52.7%)
158 793 (67.9%) 2852 (57.9%) 2997 (47.3%)
231 1168 (9.4%) 4924 (39.6%) 6331 (51.0%)
Nonteaching/Teaching Hospital Status Missing Not Teaching Minor Teaching Major Teaching
122 2859 (45.2%) 2132 (42.5%) 741 (68.9%)
109 3468 (54.8%) 2888 (57.5%) 335 (31.1%)
231 6327 (50.9%) 5020 (40.4%) 1076 (8.7%)
Physician Surgical Count N Mean (SD) Median Q1, Q3 Range
5854 40.2 (50.8) 25.0 14.0, 42.0 (1.0e251.0)
6800 22.3 (23.6) 17.0 9.0, 29.0 (1.0e251.0)
12654 30.6 (39.6) 20.0 12.0, 36.0 (1.0e251.0)
Physician Type Missing General Colorectal
792 3515 (41.6%) 1547 (74.1%)
1324 4934 (58.4%) 542 (25.9%)
2116 8449 (80.2%) 2089 (19.8%)
Facility Region Southwest Florida Northeast Florida Northwest Florida Southeast Florida Central Florida South Florida West Central Florida
866 (42.9%) 658 (57.4%) 429 (54.1%) 1154 (44.6%) 864 (35.5%) 978 (59.8%) 905 (44.4%)
1151 (57.1%) 489 (42.6%) 364 (45.9%) 1434 (55.4%) 1569 (64.5%) 658 (40.2%) 1135 (55.6%)
2017 (15.9%) 1147 (9.1%) 793 (6.3%) 2588 (20.5%) 2433 (19.2%) 1636 (12.9%) 2040 (16.1%)
MIS vs OPEN Open MIS
2188 (29.1%) 3666 (71.4%)
5334 (70.9%) 1466 (28.6%)
7522 (59.4%) 5132 (40.6%)
a b
p value <.001a
<.001a
<.001b
<.001a
<.001a
<.001a
Chi-Square. Kruskal Wallis.
significance were 2-sided, and both parameter estimates (regression coefficients) as well as p-values were reported. The level of statistical significance was set at p-value < 0.05. Analyses were performed using SAS version 9.4 (SAS Institute Inc.). Results A total of 12,654 patients treated at 182 hospitals were identified for the analysis. Table 1 includes the overall patient and hospital characteristics for the entire cohort of patients, summarized for elective vs urgent/emergent surgery. A total of 5854 (46.3%) patients received surgical treatment electively and 6800 (53.7%) urgently/emergently. The median age in the overall cohort was 63 years; 56% of patients were female and 44% male, while the distribution of races was 77.7% White, 4.9% African American, and 17.4% Hispanic. Patients with higher Elixhauser comorbidity scores tended to undergo urgent/emergent surgery, while an opposite trend was found in patients with low scores. Additionally, 16.2% of patients were reported as obese. The majority of patients had commercial insurance (41.9%) followed by Medicare (28.1%). The distribution between general and colorectal surgeons was 80.2% and 19.8% respectively, while the surgical approach was predominantly open (59.4%) over MIS (40.6%). The first multivariate model compared the surgical setting (elective vs urgent/emergent), as presented in Table 2. Patients covered by Medicaid (OR 2.19, 95% CI 1.72e2.79) or uninsured (OR 4.60, 95% CI 3.74e5.66) had greater odds of undergoing urgent/ emergent surgery. Similarly, a higher Elixhauser comorbidity score
(1e2: OR 1.83, 95% CI 1.60e2.10; 3 to 5: OR 5.05, 95% CI 4.30e5.94; >5: OR 13.52, 95% CI 10.10e18.08), being obese (OR 1.25, 95% CI 1.09e1.44) or African American (OR 1.29, 95% CI 1.01e1.64) were associated with increased odds of receiving urgent/emergent care. Compared to Northeast Florida, all regions except the Northwest Florida were significantly associated with increased odds of urgent/ emergent surgery. Female gender was instead associated with increased odds of elective treatment (OR 0.68, 95% CI 0.61e0.76). The second multivariate model evaluated the odds of developing post-operative complications in the urgent/emergent population (Table 3). Patients with a higher Elixhauser comorbidity score had increased odds of developing a complication, and this association became stronger as the score increased (1e2: OR 1.67, 95% CI 1.31e2.13; 3 to 5: OR 1.91, 95% CI 1.48e2.47; >5: OR 2.28, 95% CI 1.66e3.14). Conversely, the use of MIS was associated with reduced odds of developing post-operative complications (OR 0.59, 95% CI 0.49e0.71). Finally, the third multivariate model compared the surgical approach (MIS vs open) for the urgent/emergent population (Table 4). An encouraging finding is represented by the increased use of MIS over the years; being treated in 2015 was associated with increased odds of receiving MIS compared to previous years (OR 1.34, 95% CI 1.09e1.64). Likewise, patients treated by higher volume physician (OR 1.08, 95% CI 1.03e1.14) or colorectal surgeons (OR 2.72, 95% CI 1.89e3.91) had increased odds of receiving MIS. Conversely, older patients (OR 0.79, 95% CI 0.72e0.87) and those with more comorbidities (Elixhauser score 1 to 2: OR 0.69, 95% CI 0.55e0.88; 3 to 5: OR 0.56, 95% CI 0.43e0.73; >5: OR 0.35, 95% CI
Please cite this article as: Lemini R et al., Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.09.005
R. Lemini et al. / The American Journal of Surgery xxx (xxxx) xxx Table 2 Multivariable Logistic Regression on Surgical setting (Reference ¼ Elective Surgery). Variable
OR
Table 3 Multivariable logistic regression on urgent/emergent population for complications.
P-value
Variable
OR
95% CI
P-value
0.97e1.23 0.88e1.14
0.153 0.947
Year 2013 2014 2015
1.00 (ref.) 1.12 1.00
0.96e1.31 0.84e1.18
0.147 0.976
0.78e1.44
0.731
Rural Setting
1.15
0.80e1.65
0.463
1.72e2.79 0.80e1.14 0.80e1.17 3.74e5.66
<.001 0.601 0.736 <.001
Patient Insurance Payer Commercial Medicaid Medicare Medicare Managed Care Other
1.00 (ref.) 1.00 1.28 1.10 1.22
0.74e1.34 1.00e1.63 0.85e1.42 0.97e1.52
0.971 0.047 0.470 0.086
0.61e0.76
<.001
Female
0.98
0.85e1.13
0.782
1.60e2.10 4.30e5.94 10.10e18.08
<.001 <.001 <.001
Elixhauser Score 0 1 to 2 3 to 5 More than 5
1.00 (ref.) 1.67 1.91 2.28
1.31e2.13 1.48e2.47 1.66e3.14
<.001 <.001 <.001
1.09e1.44
0.002
Obese
0.99
0.83e1.18
0.921
0.041 0.140
Race White Black or African American Hispanic or Latino
1.00 (ref.) 0.92 0.81
0.69e1.23 0.64e1.02
0.586 0.069
1.48e4.40 0.65e2.31 1.01e3.49 1.47e4.20 1.31e3.99 1.07e3.17
<.001 0.521 0.045 <.001 0.004 0.026
Facility Region Northeast Florida Central Florida Northwest Florida South Florida Southeast Florida Southwest Florida West Central Florida
1.00 (ref.) 1.12 0.91 1.33 1.45 1.14 1.43
0.76e1.67 0.56e1.47 0.83e2.13 0.99e2.13 0.77e1.71 0.96e2.13
0.561 0.698 0.234 0.058 0.512 0.080
0.912
0.65e1.27
0.586
Teaching Hospital
1.01
0.81e1.26
0.948
Age (10 year increase)
1.119
1.05e1.19
<.001
Age (10 year increase)
0.94
0.87e1.02
0.141
Hospital Size Small Hospital Large Hospital Medium Hospital
Physician Volume
1.00
0.96e1.03
0.054
1.00 (ref.) 0.727 0.957
Hospital Size Small Hospital Large Hospital Medium Hospital
1.00 (ref.) 0.67 0.64
0.44e1.01 0.42e0.99
0.044 0.801
Colorectal Surgeon
1.06
0.81e1.37
0.688
Minimally Invasive Surgery
0.59
0.49e0.71
<.001
Year 2013 2014 2015
1.00 (ref.) 1.090 1.004
Rural Setting
1.055
Patient Insurance Payer Commercial Medicaid Medicare Medicare Managed Care Other
1.00 (ref.) 2.189 0.954 0.968 4.601
Female
0.681
Elixhauser Score 0 1 to 2 3 to 5 More than 5
1.00 (ref.) 1.834 5.051 13.516
Obese
1.251
Race White Black or African American Hispanic or Latino
1.00 (ref.) 1.285 1.144
Facility Region Northeast Florida Central Florida Northwest Florida South Florida Southeast Florida Southwest Florida West Central Florida
1.00 (ref.) 2.553 1.229 1.880 2.481 2.284 1.844
Teaching Hospital
95% CI
5
1.01e1.64 0.96e1.37
0.42e1.27 0.53e1.72
0.261 0.882
CI: Confidence Interval, OR: Odds Ratio.
0.23e0.52) and no insurance (OR 0.66, 95% CI 0.51e0.86) were less likely to receive MIS. Finally, being treated in Southwest Florida is also associated with reduced odds of receiving MIS (OR 0.48, 95% CI 0.24e0.97). Discussion This study seeks to understand the influence of healthcare disparities in presentation and treatment outcomes of patients diagnosed and surgically treated for diverticulitis. In particular, this retrospective analysis focused on factors (besides disease severity) that increase the chances of undergoing urgent/emergent surgery for diverticulitis. Secondarily, the presence of healthcare disparities among urgently/emergently treated patients was evaluated with respect to MIS utilization and development of post-operative complications. The principal findings of this analysis show that multiple factors influence the type of surgical setting and that use of an MIS approach was associated with decreased odds of developing post-operative complications in the urgent/emergent
CI: Confidence Interval, OR: Odds Ratio.
population. Treatment of diverticulitis is most heavily influenced by disease presentation. Uncomplicated cases are usually managed conservatively, even though elective surgery may be beneficial in specific cases.16 In 1978, Hinchey et al. published their classification,17 which has been traditionally used to identify four stages of complicated disease. Several classifications for diverticular disease have been subsequently published, with the modified Hinchey classification being one of the most widely adopted.18,19 Modern imaging techniques have increased the precision in diagnosing the severity of diverticulitis, while percutaneous management techniques have decreased the number of required operative interventions.20,21 Still, in 10e20% of cases an emergency surgery is indicated.3,22
Please cite this article as: Lemini R et al., Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.09.005
6
R. Lemini et al. / The American Journal of Surgery xxx (xxxx) xxx
Table 4 Multivariable logistic regression on urgent/emergent population for MIS (Reference ¼ open surgery). Variable
OR
95% CI
P-value
Year 2013 2014 2015
1.00 (ref.) 1.10 1.34
0.91e1.33 1.09e1.64
0.344 0.006
Rural Setting
0.72
0.42e1.22
0.218
Patient Insurance Payer Commercial Medicaid Medicare Medicare Managed Care Other
1.00 (ref.) 0.83 1.17 1.01 0.66
0.59e1.17 0.87e1.56 0.74e1.38 0.51e0.86
0.285 0.304 0.965 0.002
Female
1.15
0.97e1.36
0.101
Elixhauser Score 0 1 to 2 3 to 5 More than 5
1.00 (ref.) 0.69 0.56 0.35
0.55e0.88 0.43e0.73 0.23e0.52
0.003 <.001 <.001
Obese
0.95
0.77e1.17
0.626
Race White Black or African American Hispanic or Latino
1.00 (ref.) 0.92 1.04
0.64e1.31 0.80e1.34
0.641 0.782
Facility Region Northeast Florida Central Florida Northwest Florida South Florida Southeast Florida Southwest Florida West Central Florida
1.00 (ref.) 0.61 0.72 1.30 0.80 0.48 0.68
0.31e1.21 0.31e1.63 0.61e2.78 0.42e1.54 0.24e0.97 0.34e1.34
0.159 0.426 0.502 0.507 0.042 0.2619
Teaching Hospital
1.17
0.78e1.75
0.451
Age (10 year increase)
0.79
0.72e0.87
<.001
Physician Volume
1.08
1.03e1.14
0.002
Hospital Size Small Hospital Large Hospital Medium Hospital
1.00 (ref.) 1.07 1.22
0.50e2.26 0.56e2.67
0.864 0.615
Colorectal Surgeon
2.72
1.89e3.91
<.001
CI: Confidence Interval, OR: Odds Ratio.
We found that factors influencing urgent vs elective presentation of diverticulitis include: age, race, insurance status, comorbidities, immunosuppressive therapy, performance status and smoking.23,24 In recent years, the influence of race and insurance status on surgical outcomes has been studied extensively. African American patients have been found to be at higher risk of receiving emergent surgery, and to incur higher morbidity.7,25 We wound that African American patients are similarly exposed to higher risk of undergoing urgent/emergent surgery, though a limitation of the study is that African American represented only 4.9% of the overall cohort, while their ratio among the Florida population is around 15%.26 Regarding insurance status, we found that being uninsured or being covered by Medicaid is strongly associated with urgent/ emergent surgery for diverticulitis. This was more significant than race, especially for uninsured patients. These findings correspond
to the current literature, and are a critical concern since it highlights disparities of the Florida healthcare in a setting that is potentially life threatening, as emergent surgery is associated with higher risk of mortality and complications.5 The second part of our analysis evaluated the likelihood of receiving MIS and developing post-operative complications for patients receiving urgent and emergent surgery for diverticulitis. We found an increased adoption of MIS in 2015 compared to previous years. The advantages of MIS over open surgery have been extensively described for multiple conditions and procedures.5,10,27,28 A significant increase in its use within the urgent/ emergent cohort is promising given the improved outcomes associated with this approach. Patient specific characteristics associated with reduced odds of receiving MIS were higher age and comorbidity score, and uninsured status. As expected, comorbid patients were also more likely to develop post-operative complications. This aspect is particularly true for patients who receive urgent or emergent care, since severity of the disease, setting and available time often do not allow the first choice management of present comorbidities.29,30 Ultimately, MIS was found to be associated with reduced odds of post-operative complications. While this is also well documented in the literature,10,27,28,31,32 our analysis did not adjust for severity of disease due to data limitations, therefore it may be biased towards a stronger association of reduced odds of developing complications. Nevertheless, MIS is associated with a shorter hospital length of stay, improved recovery, lower pain perception, infection rate, and blood loss.28,31 Colorectal surgeons and higher volume centers were more likely to offer MIS. This study has a number of limitations. Despite our aim to evaluate the status of Florida's healthcare, a state level analysis may not be fully generalizable to a national level. Furthermore, The FIDD does not contain information regarding patient readmissions, recurrence or pain levels which may provide more accurate data with respect of the surgical timing and indications. Additionally, the authors acknowledge that the rate of urgent/emergent cases in this study exceeds the national rate. It is unclear whether this rate is a local phenomenon due to health care delivery inefficiencies, or simply a limitation of the database. Furthermore, given the nature of the database we were not able to adjust for disease severity. This may represent a relevant confounding factor since different stages may show different associations with respect of each variable, in particular those related to surgical approach. In clinical practice, surgeons' consideration of timing and approach is primarily dictated by disease severity at the time of presentation. For these reasons, the strength of our results is limited by the lack of ability to adjust for disease severity. Additionally, as already stated above, the proportion of African American patients in the database is lower than the one actually existing in the Florida population; however, a statistically significant association was described, and we would expect it to be stronger if a higher percentage of African American patients were included. Nonetheless, we believe this is a valuable analysis on patient, hospital and treatment specific characteristics associated with surgical setting, access to MIS and risk of postoperative complications for patients undergoing surgery for diverticulitis. In conclusion, besides disease severity, the probability of undergoing elective or urgent/emergent surgery for diverticulitis is influenced by multiple patient-dependent characteristics such as age, comorbidities, gender and obesity, race and insurance status. These two last factors represent high-priority concerns from a healthcare policy perspective in the state of Florida. Lastly, patients without insurance or increased comorbidities were least likely to receive MIS. Further studies addressing disparities in healthcare from different perspectives would be beneficial in understanding
Please cite this article as: Lemini R et al., Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.09.005
R. Lemini et al. / The American Journal of Surgery xxx (xxxx) xxx
the nature of this phenomenon and filling the gaps that still put patients at risk of non-optimal treatment for their condition. Disclosure The authors declare that there is no conflict of interest. Funding This work was supported by the Robert D. and Patricia E. Kern Center for Science of Health Care Delivery. The funder had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. The authors have no other financial relationships. Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.amjsurg.2019.09.005. References 1. Wheat CL, Strate LL. Trends in Hospitalization for Diverticulitis and Diverticular Bleeding in the United States from 2000 to 2010. Clinical gastroenterology and hepatology : the official clinical practice. J Am Gastroenterol Assoc. 2016;14(1), 96-103.e1. 2. Heise CP. Epidemiology and pathogenesis of diverticular disease. J Gastrointest Surg: Off J Soc Surg Aliment Tract. 2008;12(8):1309e1311. 3. Beyer-Berjot L, Maggiori L, Loiseau D, et al. Emergency Surgery in Acute Diverticulitis: A Systematic Review. Diseases of the colon and rectum; 2019. 4. Papageorge CM, Kennedy GD, Carchman EH. National trends in short-term outcomes following non-emergent surgery for diverticular disease. J Gastrointest Surg : Off J Soc Surg Aliment Tract. 2016;20(7):1376e1387. 5. Moghadamyeghaneh Z, Carmichael JC, Smith BR, et al. A comparison of outcomes of emergent, urgent, and elective surgical treatment of diverticulitis. Am J Surg. 2015;210(5):838e845. 6. Greenwood-Ericksen MB, Havens JM, Ma J, Weissman JS, Schuur JD. Trends in hospital admission and surgical procedures following ED visits for diverticulitis. West J Emerg Med. 2016;17(4):409e417. 7. Lidor AO, Gearhart SL, Wu AW, Chang DC. Effect of race and insurance status on presentation, treatment, and mortality in patients undergoing surgery for diverticulitis. Arch Surg. 2008;143(12):1160e1165. ; discussion 5. 8. Mills AM, Holena DN, Kallan MJ, Carr BG, Reinke CE, Kelz RR. Effect of insurance status on patients admitted for acute diverticulitis. Colorectal Dis: Off J Assoc Coloproctol Great Britain Ireland. 2013;15(5):613e620. 9. Kockerling F. Emergency surgery for acute complicated diverticulitis. Viszeralmedizin. 2015;31(2):107e110. 10. Mahmoud NN, Riddle EW. Minimally invasive surgery for complicated diverticulitis. J Gastrointest Surg : Off J Soc Surg Aliment Tract. 2017;21(4):731e738. 11. CCS H. Healthcare Cost and Utilization Project (HCUP) Rockville, MD. Agency for Healthcare Research and Quality; 2017 [updated March 6, 2017. Available from: https://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp.
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12. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8e27. 13. Rink AD, Vestweber B, Hahn J, Alfes A, Paul C, Vestweber KH. Single-incision laparoscopic surgery for diverticulitis in overweight patients. Langenbeck's Arch Surg. 2015;400(7):797e804. 14. Tuech JJ, Regenet N, Hennekinne S, Pessaux P, Bergamaschi R, Arnaud JP. Laparoscopic colectomy for sigmoid diverticulitis in obese and nonobese patients: a prospective comparative study. Surg Endosc. 2001;15(12):1427e1430. 15. Health FDo. Rural County List; 2018 [Available from: http://www.floridahealth. gov/programs-and-services/community-health/rural-health/_documents/rualcounties-2000-2010.pdf. 16. Deery SE, Hodin RA. Management of diverticulitis in 2017. J Gastrointest Surg : Off J Soc Surg Aliment Tract. 2017;21(10):1732e1741. 17. Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg. 1978;12:85e109. 18. Wasvary H, Turfah F, Kadro O, Beauregard W. Same hospitalization resection for acute diverticulitis. Am Surg. 1999;65(7):632e635. ; discussion 6. 19. Kaiser AM, Jiang JK, Lake JP, et al. The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol. 2005;100(4): 910e917. 20. Angenete E, Thornell A, Burcharth J, et al. Laparoscopic lavage is feasible and safe for the treatment of perforated diverticulitis with purulent peritonitis: the first results from the randomized controlled trial DILALA. Ann Surg. 2016;263(1):117e122. 21. Thornell A, Angenete E, Bisgaard T, et al. Laparoscopic lavage for perforated diverticulitis with purulent peritonitis: a randomized trial. Ann Intern Med. 2016;164(3):137e145. 22. Biondo S, Lopez Borao J, Millan M, Kreisler E, Jaurrieta E. Current status of the treatment of acute colonic diverticulitis: a systematic review. Colorectal Dis: Off J Assoc Coloproctol Great Britain Ireland. 2012;14(1):e1ee11. 23. Valizadeh N, Suradkar K, Kiran RP. Specific factors predict the risk for urgent and emergent colectomy in patients undergoing surgery for diverticulitis. Am Surg. 2018;84(11):1781e1786. 24. Tan JP, Barazanchi AW, Singh PP, Hill AG, Maccormick AD. Predictors of acute diverticulitis severity: a systematic review. Int J Surg. 2016;26:43e52. 25. Schneider EB, Haider A, Sheer AJ, et al. Differential association of race with treatment and outcomes in Medicare patients undergoing diverticulitis surgery. Arch Surg. 2011;146(11):1272e1276. 26. CensusScope. Florida population by race. http://www.censusscope.org/us/s12/ chart_race.html; 2000. 27. Parker JM, Feldmann TF, Cologne KG. Advances in laparoscopic colorectal surgery. The Surgical clinics of North America. 2017;97(3):547e560. 28. Schwenk W, Haase O, Neudecker J, Muller JM. Short term benefits for laparoscopic colorectal resection. Cochrane Database Syst Rev. 2005;(3). Cd003145. 29. Jeong O, Jung MR, Ryu SY. Impact of various types of comorbidities on the outcomes of laparoscopic total gastrectomy in patients with gastric carcinoma. J Gastr Cancer. 2018;18(3):253e263. 30. Portale G, Valdegamberi A, Cavallin F, Frigo F, Fiscon V. Effect of age and comorbidities on short- and long-term results in patients undergoing laparoscopic curative resection for rectal cancer. J Laparoendosc Adv Surg Tech A. 2019 Mar;29(3):353e359. https://doi.org/10.1089/lap.2018.0340. Epub 2018 Aug 15. PubMed PMID: 30109973. 31. Carr BM, Lyon JA, Romeiser J, Talamini M, Shroyer ALW. Laparoscopic versus Open Surgery: A Systematic Review Evaluating Cochrane Systematic Reviews. Surgical endoscopy; 2018. 32. Moghadamyeghaneh Z, Carmichael JC, Mills S, Pigazzi A, Nguyen NT, Stamos MJ. Variations in laparoscopic colectomy utilization in the United States. Dis Colon Rectum. 2015;58(10):950e956.
Please cite this article as: Lemini R et al., Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.09.005