L. Cournoyer1, A. H. Steven1, S. Chao2, D. S. Heffernan1 2Weill Cornell Medical College, Surgery, New York, NY, USA 1Brown University School Of Medicine, Department Of Surgery, Providence, RI, USA
Background: Diverse factors influence management options for surgical diseases between urban teaching(UT) and rural non-teaching(RNT) hospitals. Perforated diverticulitis remains a surgical emergency. Operative versus non-operative approaches to managing perforated diverticulitis have evolved and remain controversial. However, there is a paucity of data pertaining to differences in management of patients with perforated diverticulitis between UT and RNT hospitals.
Methods: Retrospective 3-year review of National In-Patient Sample (NIS) patients aged >/=18 years and older, with acute, perforated diverticulitis. Demographics, medical comorbidities and hospital course were reviewed. The Charlson Comorbidity Index (CCI) was calculated. Institutions were divided into Urban Teaching (UT) hospitals versus Rural Non-Teaching (RNT) hospitals. The primary management was categorized as involving Operative Intervention versus Interventional Radiology drainage (IR) versus antibiotics alone. Outcomes included length of stay, mortality and failure of initial non-operative management requiring delayed operative intervention during the index hospitalization.
Results: Among 40,454 patients, 35,433 patients) were treated at UT and 5,021 were treated at RNT hospitals. There was no difference in age(58.1+/-0.08 vs 58.5+/-0.002;p=0.1), but RNT patients were more likely male (50.8% vs 49.2%;p=0.03), White (88.6% vs 74.3%;p<0.0001) and presented on a weekend (22.4% vs 20.5%;p=0.002), but less likely to have private health insurance (44.1% vs 48.3%;p<0.001). There was no difference in hypertension (50.4% vs 49.2%;p=0.14), dementia (2.0% vs 1.9%;p=0.9) or diabetes (11.6% vs 12.4%;p=0.08), but RNT patients less likely had renal disease (9.9% vs 11.4%;p=0.002) or obesity (19.1% vs 20.1%;p=0.008) and more likely to have COPD (12.1% vs 9.9%;p<0.001). There was no difference in CCI (2.8+/-0.001 vs 2.8+/-0.03;p=0.48). Overall, RNT patients were less likely to undergo operative intervention (32.2% vs 34.7%;p=0.0006), or IR drainage (8.6% vs 13.0%;p<0.0001) and were more likely to be managed with antibiotics alone (59.2% vs 52.3%;p<0.0001). Adjusting for demographics, socioeconomic factors, comorbidities and CCI, RNT patients were less likely to undergo operation (OR=0.86;95%CI=0.81-0.92). There was no difference in length of stay (5.5 vs 5.8 days) or mortality (0.6% vs 0.56%;p=0.64). Further, among patients who were initially managed non-operatively (either IR or antibiotics alone) there was no difference in failure rate of initial non-operative management.
Conclusion: Within RNT hospitals, patients with perforated diverticulitis were significantly more likely to be managed with antibiotics alone. Although primary surgical management plans differ between UT and RNT hospitals, outcomes were not affected by hospital type. We believe that this lack of differences in outcomes likely reflects sound surgical principles and judgement despite differing hospital resources.