Practice Patterns and Impact of Operative and Non-operative Management of Diverticulitis

 描述(申请人提供)：60岁以上的美国人中有一半患有结肠憩室病，预计有20%-25%的人会发展为急性憩室炎。虽然大多数发作仅用抗生素就能解决，但10%-20%的患者会在首次出现时进行紧急结肠切除术/造口，所有患者仍面临复发的终生风险。考虑到复发的时间和地点的不确定性，以及迫在眉睫的结肠造口风险，外科医生已经接受了培训，建议在两次发作后进行选择性的预防性结肠切除术，并在50年内更早地进行切除。因此，憩室炎现在是导致 择期结肠切除术。然而，在憩室炎发作后对患者进行咨询是具有挑战性的，因为只有不到5%的患者会继续需要紧急手术，而且择期切除后的主要发病率(5%)和复发率(5%-11%)并不是微不足道的。几个专业协会现在建议推迟选择性切除，并呼吁进行研究以确定其价值。尽管有这些警告，在过去的十年中，选择性切除的使用增加了50%以上。随着腹腔镜的广泛应用，选择性切除手术的增加速度远远快于憩室炎的发生率。鉴于这一意想不到的趋势，重要的是评估与早期或 延迟切除，驱动决策的因素，以及疾病对那些进行和没有进行选择性切除的人的影响。为了解决这些问题，我们提出了3项相关但独立的研究，描述了急性憩室炎发作后的治疗模式，与早期和延迟择期手术相关的因素，以及疾病的结果和影响。AIM 1使用国家索赔数据对当前的护理模式进行人口水平的评估，这些模式与选择性治疗前治疗憩室炎的发作次数有关 切除手术。目的比较早期和延迟切除的患者以及年轻和老年患者报告临床和非临床因素作为择期切除的原因的频率。来自这个组织的有关择期切除相关决策的信息可能有助于解释目标1中确定的实践模式。评估憩室炎对所有患有 在此情况下，目标3涉及全州范围内从确诊的憩室炎发作中康复的所有患者的队列，评估患者出现与憩室炎相关的症状的频率、患者报告的结果以及随着时间的推移疾病负担。这些研究将共同确定，所观察到的用于憩室炎的择期手术的急剧增加是否与延迟干预的建议一致，是否有助于更好地了解与择期手术决定相关的因素，并提供有关憩室炎影响的关键信息。这些信息将有助于制定干预措施，旨在更多地以患者为中心和增值护理，并为决策提供信息。这一信息在结肠切除术和其他治疗憩室炎的比较研究的发展中也将是至关重要的。

 DESCRIPTION (provided by applicant): Half of all Americans over the age of 60 have diverticulosis of the colon, and 20-25% are expected to develop acute diverticulitis. While most episodes resolve with antibiotics alone, 10-20% will have an emergency colectomy/colostomy at their initial presentation and all patients remain at lifetime risk for recurrent episodes. Given te uncertainty of when and where a recurrent episode will occur and the looming risk of colostomy, surgeons have been trained to recommend elective, "prophylactic" colectomy after 2 episodes, and earlier for those < 50 years. As a result, diverticulitis is now one of the leading reasons for elective colectomy. However, counseling patients after recovering from an episode of diverticulitis is challenging because less than 5% will go on to need emergency surgery and the major morbidity (5%) and recurrence rate (5-11%) after elective resection is not trivial. Several professional societies have now recommended delaying elective resection and called for research to determine its value. Despite these cautions, over the last decade the use of elective resection has increased more than 50%. Elective resections are rising at a much faster rate than the incidence of diverticulitis, coinciding with the widespread adoption of laparoscopy. Given this unexpected trend, it is important to assess the patterns of practice related to early or delayed resection, factors driving decision making, and the impact of the disease on those who do and do not have an elective resection. To address these issues we propose 3 related, but independent studies that describe treatment patterns after recovery from an episode of acute diverticulitis, the factors associated with early and delayed elective surgery, and outcomes and impact of the disease. Aim 1 uses national claims data for a population-level assessment of current patterns of care related to numbers of episodes of treated diverticulitis prior to elective resection. Aim 2 compare how often patients undergoing early versus delayed resection and young vs old report clinical and non-clinical factors as the reason for elective resection. Information from this group about decision making related to elective resection may help explain practice patterns identified in Aim 1. To assess the impact of diverticulitis on all those with the condition, Aim 3 involves a statewide cohort of all patients who recover from an episode of confirmed diverticulitis, assessing how often patients have symptoms related to diverticulitis, patient-reported outcomes, and the burden of the disease over time. Together these studies will determine if the observed, dramatic increase in the use of elective surgery for diverticulitis is consistent with recommendations about delayed intervention, provide better understanding about the factors associated with decisions for elective surgery and provide critical information about the impact of diverticulitis. This information will be helpful in crafting interventions aime at more patient-centered and value-added care and inform decision making. This information will also be critical in the development of comparative studies of colon resection and other treatments for diverticulitis.