R. A. Tessler1,2, M. Vaughan Sarrazin3,4, Y. Gao3,4, M. A. Jacobs1, C. A. Duncan1, D. E. Hall1,2,5,6 1VA Pittsburgh Healthcare System, Center For Health Equity Research And Promotion, Pittsburgh, PA, USA 2University of Pittsburgh School of Medicine, Department Of Surgery, Pittsburgh, PA, USA 3Iowa City Veterans Affairs Medical Center, Center For Access And Delivery Research And Evaluation, Iowa City, IA, USA 4University of Iowa Carver College of Medicine, Department Of Internal Medicine, Iowa City, IA, USA 5VA Pittsburgh Healthcare System, Geriatric Research Education And Clinical Center, Pittsburgh, PA, USA 6Wolff Center at University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Introduction: Colon pathology requiring surgery may be elective, urgent, or emergent, and applies to both benign and malignant indications. Area deprivation and fragmented care are associated with health inequity leading potentially to urgent or emergent colon resection. Legislation such as the Mission Act has decreased barriers to private sector providers for Veterans but may lead to fragmented care. The extent to which care fragmentation or area deprivation contribute to non-elective colectomy is unknown. We aimed to determine the association between area deprivation and non-elective colectomy in the Veterans Health Administration (VHA) and to assess whether this association is mediated through care fragmentation.
Methods: We analyzed a national retrospective cohort of Veterans ≥ 65 years old undergoing colectomy within the VHA between 2013 and 2019. Multivariable cumulative logit models were used to evaluate associations between area deprivation, care fragmentation, and the adjusted odds of urgent or emergent colectomy overall and separately by benign and malignant indications. Mediation analysis assessed whether care fragmentation mediates the association between area deprivation and colectomy case acuity.
Results: We identified 6538 patients undergoing colectomy of which 3006 (46.0%) were for malignant indications. Over 97% of patients were male. Highly deprived and less deprived areas were similar in terms of patient age, frailty, comorbid conditions, malignant indication, and care fragmentation. Patients from highly deprived areas were more likely to be Black. In adjusted models, the risk of urgent or emergent colectomy was higher for patients in highly deprived areas compared to less deprived areas when the indication was for benign pathology (OR 1.35 95% CI 1.09, 1.68). There was no association between area deprivation and emergency colectomy for malignant indications. More fragmented care was associated with a higher risk of urgent or emergent colectomy (OR 1.06; 95% CI, 1.03-1.08 per 10% increase in fragmented care) across benign and malignant indications but higher fragmentation did not mediate the association between area deprivation and case acuity.
Conclusion: Veterans in highly deprived areas are at higher risk for urgent/emergent colectomy for benign conditions but not for malignancy. Although care fragmentation is associated with a higher risk of urgent/emergent colectomy across indications, fragmentation does not mediate the relationship between area deprivation and case acuity. Greater efforts are needed to minimize fragmented care and counsel Veterans living in highly deprived areas at risk for urgent or emergent colectomy due to colorectal cancer, diverticular disease, or other colorectal pathology.