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

 描述（由申请人提供）：60岁以上的美国人中有一半患有结肠憩室病，预计20-25%将发展为急性憩室炎。虽然大多数发作仅用抗生素解决，但10-20%的患者在最初表现时将进行紧急结肠切除术/结肠造口术，所有患者仍有复发发作的终身风险。考虑到复发发作的时间和地点的不确定性以及结肠造口术的潜在风险，外科医生已经接受过培训，建议在2次发作后进行选择性“预防性”结肠切除术，对于< 50岁的患者则更早。因此，憩室炎现在是导致腹泻的主要原因之一。 选择性结肠切除术然而，从憩室炎发作中恢复后的咨询患者是具有挑战性的，因为不到5%的患者将继续需要急诊手术，并且选择性切除术后的主要发病率（5%）和复发率（5-11%）并不小。一些专业协会现在建议推迟选择性切除，并呼吁研究以确定其价值。尽管有这些警告，在过去的十年中，选择性切除术的使用增加了50%以上。随着腹腔镜的广泛应用，选择性切除术的发病率比憩室炎的发病率上升得快得多。鉴于这一意想不到的趋势，重要的是要评估与早期或 延迟切除，决策的驱动因素，以及疾病对选择性切除和不选择性切除的影响。为了解决这些问题，我们提出了3个相关的，但独立的研究，描述治疗模式后，从急性憩室炎，早期和延迟择期手术的相关因素，以及疾病的结果和影响恢复。目的1使用国家索赔数据，对与择期手术前治疗憩室炎发作次数相关的当前护理模式进行人群水平评估。 切除术目的2：比较早期与延迟切除的患者以及年轻与老年患者报告临床和非临床因素作为选择性切除原因的频率。来自这个群体的关于选择性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。为了评估憩室炎对所有憩室炎患者的影响， 目标3涉及全州范围内从确诊憩室炎发作中恢复的所有患者，评估患者出现憩室炎相关症状的频率，患者报告的结局以及疾病随时间的负担。这些研究将共同确定所观察到的憩室炎择期手术使用的急剧增加是否与延迟干预的建议一致，更好地了解与择期手术决策相关的因素，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。这一信息也将是至关重要的结肠切除术和其他治疗憩室炎的比较研究的发展。

 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.