Addressing the appropriateness of elective colon resection for diverticulitis: a report from the SCOAP CERTAIN collaborative.
Addressing the appropriateness of elective colon resection for diverticulitis: a report from the SCOAP CERTAIN collaborative.
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DOI：
10.1097/sla.0000000000000894
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发表时间：
2014-09
影响因子：
9
通讯作者：
Flum DR
中科院分区：
文献类型：
--
作者：
Simianu VV;Bastawrous AL;Billingham RP;Farrokhi ET;Fichera A;Herzig DO;Johnson E;Steele SR;Thirlby RC;Flum DR
评估憩室炎择期结肠切除术的报告适应症及其与专业指南的一致性。尽管现代专业指南建议将选择性结肠切除术推迟到2次无并发症的憩室炎发作之后，但在过去20年中，选择性结肠切除术的发生率急剧增加。外科医生是否改变了推荐手术干预的阈值尚不清楚。2010年，华盛顿州的外科护理和结果评估计划发起了一项与结肠切除术适应症相关的基准和教育计划。前瞻性队列研究，评价了49家参与医院中1家接受择期结肠切除术的患者的慢性并发症（瘘管、狭窄、出血）或既往接受过治疗的憩室炎发作次数的适应症（2010-2013年）。在2724例患者（58.7 ± 13岁; 46%男性）中，29.4%有慢性并发症适应症（15.6%瘘，7.4%狭窄，3.0%出血，5.8%其他）。对于70.5%具有基于发作的适应症的患者，39.4%有2次或更少发作，56.5%有3 - 10次发作，4.1%有10次以上发作。31%的患者未能满足慢性并发症或3次或3次以上发作的适应症。在4年中，有3次或3次以上发作适应症的患者比例从36.6%增加到52.7%（P < 0.001），而不符合临床或基于发作适应症的患者比例从38.4%下降到26.4%（P < 0.001）。急诊切除的年发生率没有显著增加，从每年5.6到5.9不等（P = 0.81）。坚持基于3次或3次以上的择期结肠切除术的指南，同时增加了基准和对等消息传递倡议。改善遵守与适当护理相关的专业指南至关重要，可以通过质量改进协作来促进。
To assess the reported indications for elective colon resection for diverticulitis and concordance with professional guidelines. Despite modern professional guidelines recommending delay in elective colon resection beyond 2 episodes of uncomplicated diverticulitis, the incidence of elective colectomy has increased dramatically in the last 2 decades. Whether surgeons have changed their threshold for recommending a surgical intervention is unknown. In 2010, Washington State’s Surgical Care and Outcomes Assessment Program initiated a benchmarking and education initiative related to the indications for colon resection. Prospective cohort study evaluating indications from chronic complications (fistula, stricture, bleeding) or the number of previously treated diverticulitis episodes for patients undergoing elective colectomy at 1 of 49 participating hospitals (2010–2013). Among 2724 patients (58.7 ± 13 years; 46% men), 29.4% had a chronic complication indication (15.6% fistula, 7.4% stricture, 3.0% bleeding, 5.8% other). For the 70.5% with an episode-based indication, 39.4% had 2 or fewer episodes, 56.5% had 3 to 10 episodes, and 4.1% had more than 10 episodes. Thirty-one percent of patients failed to meet indications for either a chronic complication or 3 or more episodes. Over the 4 years, the proportion of patients with an indication of 3 or more episodes increased from 36.6% to 52.7% (P < 0.001) whereas the proportion of those who failed to meet either clinical or episode-based indications decreased from 38.4% to 26.4% (P < 0.001). The annual rate of emergency resections did not increase significantly, varying from 5.6 to 5.9 per year (P = 0.81). Adherence to a guideline based on 3 or more episodes for elective colectomy increased concurrently with a benchmarking and peer-to-peer messaging initiative. Improving adherence to professional guidelines related to appropriate care is critical and can be facilitated by quality improvement collaboratives.