National Landscape of Unplanned 30-Day Readmission Rates for Acute Non-hemorrhagic Diverticulitis: Insight from National Readmission Database.

BACKGROUND: Early readmissions are an important indicator of the quality of care. Limited data exist describing hospital readmissions in acute diverticulitis. The study aimed to describe unplanned, 30-day readmissions among adult acute diverticulitis patients and to assess readmission predictors. METHODS: We analyzed the 2013 and 2014 United States National Readmission Database and identified acute diverticulitis admissions using administrative codes in adult patients older than 18 years of age. Our primary outcome was a 30-day, unplanned readmission rate. We used Chi-square tests, t tests, and Wilcoxon rank-sum tests for descriptive analyses and survey logistic regression to calculate adjusted odds ratios (aORs) and 95% confidence intervals for associations with readmissions adjusting for confounders. RESULTS: In the cohort of 364,511 hospitalizations with acute diverticulitis, as the primary diagnosis on index admission, 31,420 (8.6%) had at least one unplanned 30-day readmission. Sixty percent of the readmissions occurred within the first 2 weeks of the index admission. The most common reasons for unplanned 30-day readmission were due to diverticulitis of the colon (41.5%), postoperative infection (4.2%), septicemia (3.6%), intestinal infection due to Clostridium difficile (3%), and other digestive system complications such bleeding or fistula (2.8%). Multivariable analysis showed advance age (> 75 years), discharge against medical advice, comorbidities (renal failure, coronary artery disease, atrial fibrillation, congestive heart failure, hypertension, diabetes, obesity, weight loss, chronic lung disease, malignancy), blood transfusion, Medicare and Medicaid insurance, and increased length of stay (> 3 days) were associated with significantly higher odds for readmission. Patients who have undergone abdominal surgery during index admission were 31% less likely to get readmitted. CONCLUSIONS: On a national level, 1 in 11 hospitalizations for acute diverticulitis was followed by unplanned readmission within 30 days with most admissions occurring in the first 2 weeks. Multiple modifiable and non-modifiable factors influencing readmission rates were noted. Further studies should examine if strategies that address these predictors can decrease readmissions.

Management of Nonoperative Diverticulitis : Is Surgical Admission Always Best?

BACKGROUND: Institutional pathways (IPs) allow efficient utilization of health care resources. Recent literature reports decreased hospital length of stay (LOS), complications, and costs with the admittance of surgical disease to surgical services. Our study aimed to demonstrate that admission to surgery for nonoperative, acute diverticulitis reduces hospital LOS, and cost, with comparable complication rates. METHODS: In January 2017, we defined IPs for diverticulitis, mandating emergency department admission to a surgical service. Patients admitted from October 2015 to June 2016 (pre-protocol, control cohort) were compared with those admitted January 2017-September 2018 (post-protocol, IP cohort). Primary outcomes included hospital LOS, direct cost, indirect cost, total cost, and 30-day readmission. Student's 2-tailed t-test and chi-square analysis were utilized, with statistical significance P < .05. RESULTS: Nonoperative management of acute diverticulitis occurred in 62 (74%) patients in the control cohort. One hundred and eleven patients (85%) were admitted to the IP cohort. Patient characteristics were similar, except for a higher percentage of surgical patients utilizing private insurance and younger in age. Interestingly, no difference in hospital LOS (3.8 vs 4.7 days; P = 0.07), direct cost ($2639.44 vs $3251.52; P = .19), or overall cost ($5968.67 vs $6404.08, P = .61) was found between cohorts. Thirty-day readmission rates were comparable at 8% and 11% (P = .59). CONCLUSION: Institutional policy mandating admissions for patients receiving nonoperative management of diverticulitis to surgical services does not reduce hospital LOS or cost. This argues that admission to medical services may be an acceptable practice. This raises the question, is acute diverticulitis always a surgical issue?

A systematic review and meta-analysis of outpatient treatment for acute diverticulitis.

BACKGROUND: The shift from routine antibiotics towards omitting antibiotics for uncomplicated acute diverticulitis opens up the possibility for outpatient instead of inpatient treatment, potentially reducing the burden of one of the most common gastrointestinal diseases in the Western world. PURPOSE: Assessing the safety and cost savings of outpatient treatment in acute colonic diverticulitis. METHODS: PubMed and EMBASE were searched for studies on outpatient treatment of colonic diverticulitis, confirmed with computed tomography or ultrasound. Outcomes were readmission rate, need for emergency surgery or percutaneous abscess drainage, and healthcare costs. RESULTS: A total of 19 studies with 2303 outpatient treated patients were included. These studies predominantly excluded patients with comorbidity or immunosuppression, inability to tolerate oral intake, or lack of an adequate social network. The pooled incidence rate of readmission for outpatient treatment was 7% (95%CI 6-9%, I2 48%). Only 0.2% (2/1288) of patients underwent emergency surgery, and 0.2% (2/1082) of patients underwent percutaneous abscess drainage. Only two studies compared readmission rates outpatients that had similar characteristics as a control group of inpatients; 4.5% (3/66) and 6.3% (2/32) readmissions in outpatient groups versus 6.1% (4/66) and 0.0% (0/44) readmissions in inpatient groups (p = 0.619 and p = 0.174, respectively). Average healthcare cost savings for outpatient compared with inpatient treatment ranged between 42 and 82%. CONCLUSION: Outpatient treatment of uncomplicated diverticulitis resulted in low readmission rates and very low rates of complications. Furthermore, healthcare cost savings were substantial. Therefore, outpatient treatment of uncomplicated diverticulitis seems to be a safe option for most patients.

Outpatient management of acute uncomplicated diverticulitis results in health-care cost savings.

PURPOSE: Outpatient management without antibiotics has been shown to be safe for selected patients diagnosed with acute uncomplicated diverticulitis (AUD). The aim of this study was to evaluate the impact on admissions, complication rates and health-care costs of the policy of outpatient treatment without using antibiotics. METHODS: The medical records of all patients diagnosed with AUD in the year before (2011) and after (2014) the implementation of outpatient management without antibiotics in Västmanland County were reviewed. Health-care cost analysis was performed using the Swedish cost-per-patient model. RESULTS: In total, 494 episodes of AUD were identified, 254 in 2011 and 240 in 2014. The proportion of patients managed as outpatients was 20% in 2011 compared with 60% in 2014 (p < .001). There were 203 hospital admissions and a total length of stay of 677 days in 2011 compared with 95 admissions and 344 days in 2014 (both p < .001). The total health-care cost was €558,679 in 2011 compared with €370,370 in 2014 (p < .001). Three patients developed complications in 2011 and four in 2014 (p = .469). CONCLUSIONS: The new policy of outpatient management without antibiotics in routine health care almost halved the total health-care cost without an increase in the complication rate.

[Burden of diverticular disease: an observational analysis based on Italian real-world data.] / Valutazione dell'impatto economico delle complicanze della malattia diverticolare con i dati "real life" della Regione Marche.

INTRODUCTION: Diverticular disease (DD) represent a wide variety of conditions associated with the presence of diverticula in the colon. The most serious form is an acute episode of diverticulitis which can lead to hospitalization and surgery with various types of consequences. The main aim of this study was to evaluate, from both cross-sectional and longitudinal perspective, the economic burden of diverticulitis in the real practice. METHOD: A deterministic linkage was performed at individual user level between the different administrative sources of the Marche Region through anonymised ID number for a period of analysis between 1 January 2008 and 31 December 2014. We enrolled all patients with at least one hospitalization for "diverticulitis of the colon without mention of haemorrhage" (ICD-9-CM code 562.11) or "diverticulitis of the colon with haemorrhage" (ICD-9-CM code 562.13) as primary or secondary diagnosis. Cost and outcome were analysed considering transversally (for contemporaneous) and longitudinal (for cohort) perspective. Hospital mortality at one year after discharge was evaluated by mortality rates and Kaplan-Meier curve considering the surgery performed (or not performed) during the index hospitalization. RESULTS: Considering the cross-sectional perspective, 427 patients per year were estimated (about 35 patients per 100,000 adult residents) with an average number of hospitalization equal to 1.14. The direct healthcare costs incurred by the Marche region for episodes of diverticulitis in 2008-2014 amounted to approximately € 11.4 million (€ 1.6 million a year), of which € 10.9 million (95.5%) for the hospitalizations, € 246,000 (2.1%) for pharmaceutical treatment and € 270,000 (2.4%) for specialist outpatient services. The cohort analysis estimates an intra-hospital mortality rate equal to 5.9 per 100 patients' year (5.5 for non-surgery patients and 8.9 for surgery patients - P<0.05). Kaplan-Meier curve demonstrate that there were no differences between intra-hospital mortality due to surgery during index hospitalization. CONCLUSIONS: Our study is the first analysis in Italy to use real-world data to measure the burden of DD with a cross-sectional and longitudinal perspective. This study could be useful for decision maker that could quantify the economic and epidemiological burden of DD in hospital.

Adherence to clinical guidelines and the potential economic benefits of admission avoidance for acute uncomplicated diverticulitis.

BACKGROUND: The treatment paradigm for acute diverticulitis is changing. There is an increasing trend towards managing patients with uncomplicated diverticulitis in the community. AIMS: The aim of this study was to analyse how acute diverticulitis is managed in our institution and also to analyse national data pertaining to treatment of acute diverticulitis. METHODS: A prospective database of all patients admitted to our institution over a 2-year period (2014-2016) with acute diverticulitis was maintained. Severity of disease, treatment received and average length of stay (LOS) were analysed for all patients. Contemporaneous hospital inpatient enquiry (HIPE) data was interrogated to analyse current management for acute diverticulitis at a national level. RESULTS: One hundred twenty-six patients were admitted to our institution with acute diverticulitis during the study period (inpatient stay = €1277/night). Of patients, 59.5% had uncomplicated diverticulitis while 40.5% had complicated disease. The median LOS was 4 (range 1-34) days and 8 (range 2-51) days in the uncomplicated and complicated group, respectively. Based on HIPE data, there were 11,357 patients with uncomplicated diverticulitis and 526 patients with complicated diverticulitis admitted to Irish hospitals in the year 2015. Nationally, the median LOS for those with uncomplicated diverticulitis was 3 (range 1-142) days and for those with complicated diverticulitis the median LOS was 7 (range 1-308) days. Projected total cost for hospital stay nationally for uncomplicated diverticulitis amounted to €43.5 million for the year 2015. CONCLUSIONS: At present, uncomplicated diverticulitis in Ireland is not being managed as per evidence-based guidelines. Changing practice could result in significant cost savings for surgical departments.

Economic burden of diverticular disease: An observational analysis based on real world data from an Italian region.

INTRODUCTION: Diverticular disease (DD), a herniation of the colonic mucosa through the muscle layer, covers a wide variety of conditions associated with the presence of diverticula in the colon. The most serious form is an acute episode of diverticulitis, which can lead to hospitalization and surgery with various types of consequences. The main aim of this study is to evaluate the economic burden of hospitalizations arising from acute episodes of diverticulitis using data from the administrative databases used in the Marche region in Italy and, as a secondary objective of this real-world data analysis, to study patient outcome variables following initial hospitalization for diverticulitis. METHOD: A deterministic linkage was performed at individual user level between the different administrative sources of the Marche region through anonymous ID number for a period of analysis between 1 January, 2008 and 31 December, 2014. We enrolled all patients with at least one hospitalization for "diverticulitis of the colon without mention of haemorrhage" (ICD-9-CM code 562.11) or "diverticulitis of the colon with haemorrhage" (ICD-9-CM code 562.13) as primary or secondary diagnosis. For each patient we assessed the cost of hospitalization, of medicines and of specialist services considering a time-scale of one year or cohort analysis 365days after first admission. RESULTS: The total number of residents in the Marche region who had at least one hospitalization for diverticulitis in the period 2008-2014 was 2987 (427 patients a year, corresponding to about 35 patients per 100,000 adult residents); the total number of admissions was 3453 (just over 490 a year). The direct healthcare costs incurred by the Marche region for episodes of diverticulitis in 2008-2014 amounted to approximately €11.4 million (€1.6 million a year), of which €10.9 million (95.5%) for the hospitalizations, € 246,000 (2.1%) for pharmaceutical treatment and €270,000 (2.4%) for specialist outpatient services. The average annual cost per patient was €3826, of which €3653 was for hospitalization, while pharmaceutical expenditure and specialist services accounted for €83 and €90, respectively. The cohort of patients undergoing a first admission for diverticulitis between 2010 and 2013 was made up of 1729 people (54.4% women, mean age 68.9 years), of whom 1500 (86.8%) did not undergo surgery while in hospital. Hospital mortality, recorded only for the over-65 age class, averaged 1.2%; for patients not receiving surgery during the initial hospitalization it was 0.5%, reaching 5.2% in patients undergoing surgery. The percentage of patients with one or more readmissions for diverticulitis within a year of the first was on average 7.8% and in 48% of cases this resulted in surgery. CONCLUSIONS: Our study is the first analysis in Italy to use real-world data to measure the financial impact of diverticular disease. Assuming that the diagnostic and therapeutic behaviour identified in the Marche region could be representative of the situation nationwide, the estimated annual number of hospitalizations in Italy for acute episodes of diverticulitis is 19,000. The total amount of economic resources needed to treat patients suffering from acute episodes of diverticulitis is estimated at €63.5 million a year.

Emergency Department Burden of Diverticulitis in the USA, 2006-2013.

GOALS: The aim of this study was to analyze recent trends in emergency department (ED) visits for diverticulitis between 2006 and 2013. BACKGROUND: Acute diverticulitis is a serious medical condition that frequently leads to ED visits, hospitalizations, and surgeries resulting in a significant health care burden. METHODS: Data were obtained from the National Emergency Department Sample (NEDS) records in which diverticulitis (ICD-9-CM codes 562.11 and 562.13) was the primary diagnosis in the ED between 2006 and 2013. The NEDS collects data from more than 25 million visits in over 950 hospital emergency departments and is weighted to provide national estimates. Our findings reflected patient and hospital characteristics such as demographics, geographical region, and total charges for ED and inpatient stays. RESULTS: Between 2006 and 2013, the rate of diverticulitis-related ED visits increased by 26.8% from 89.8 to 113.9 visits per 100,000 population. The aggregate national cost of diverticulitis-related ED visits increased by 105%, from approximately $822 million in 2006 to over $1.6 billion in 2013. Cost data were adjusted for inflation and reported in 2015 dollars. The percentage of individuals admitted to the same hospital from the ED decreased from 58.0 to 47.1% from 2006 to 2013, respectively, while the rate of bowel surgeries per 100,000 ED visits for diverticulitis decreased by 33.7% from 2006 to 2013. CONCLUSIONS: The number of ED visits due to diverticulitis and associated costs continued to rise between 2006 and 2013, while the rate of bowel surgeries and inpatient admissions through the ED for diverticulitis decreased.

Out-Patient Management of Mild or Uncomplicated Diverticulitis: A Systematic Review.

BACKGROUND: Management of diverticular disease has undergone a paradigm shift, with movement towards a less invasive management strategy. In keeping with this, outpatient management of uncomplicated diverticulitis (UD) has been advocated in several studies, but concerns still remain regarding the safety of this practice. AIM: To assess outcomes of out-patient management of acute UD. METHODS: A comprehensive search for published studies using the search terms 'uncomplicated diverticulitis', 'mild diverticulitis' and 'out-patient' was performed. The primary outcomes were failure of medical treatment. Secondary outcomes were recurrence rate at follow up and medical cost savings. RESULTS: The search yielded 192 publications. Of these, 10 studies met the inclusion criteria including 1 randomized controlled trial, 6 clinical controlled trials and 3 case series. There was no difference in failure rates of medical treatment (6.5 vs. 4.6%, p = 0.32) or in recurrence rates (13.0 vs. 12.1%, p = 0.81) between those receiving ambulatory care and in-patient care for UD. Ambulatory treatment is associated with an estimated daily cost savings of between 600 and 1,900 euros per patient treated. Meta-analysis of data was not possible due to heterogeneity in study designs and inclusion criteria. CONCLUSION: Ambulatory management of acute UD is reasonable in selected patients.

Surgeon Volume Correlates with Reduced Mortality and Improved Quality in the Surgical Management of Diverticulitis.

BACKGROUND: Volume has been shown to be an important determinant of quality and cost outcomes. METHODS: We performed a retrospective study of patients who underwent surgery for diverticulitis using the University HealthSystem Consortium database from 2008­2012. Outcomes evaluated included minimally invasive approach, stoma creation, intensive-care admission, post-operative complications, length of stay, and total direct hospital costs by surgeon volume. Surgeon volume was categorized into four categories by mean annual volumes: very-high (VHVS) (>31), high (HVS) (13­31), medium (MVS) (6­12), and low (LVS) (≤5). RESULTS: A total of 19,212 patients with a mean age of 59 years, 54 % female makeup, and 55 % rate of private insurance were included. Similar to the unadjusted analysis, multivariable analysis revealed decreasing odds of stoma creation, complications, ICU admission, reoperation, readmission, and inpatient mortality with increasing surgeon volume. Additionally, compared with LVS, a higher surgeon volume was associated with higher rates of the minimally invasive approach. Median length of stay and costs were also notably lower with increasing surgeon volume. CONCLUSION: Quality and the use of minimally invasive technique are tightly associated with surgeon volume. Further studies are necessary to validate the direct association of volume with outcomes in surgery for diverticulitis.

[Are antibiotics necessary in the treatment of uncomplicated diverticulitis?]. / Jsou nutná antibiotika v lécbe nekomplikované divertikulitidy?

INTRODUCTION: This paper deals with the results of recently published studies on the importance of the use of antibiotics in the treatment of uncomplicated diverticulitis. It is based on the articles available in the Medline database. CONCLUSION: The prevalence of diverticulosis in the developed countries of the Western world is increasing and, along with it, the costs of treatment of diverticulitis. The use of antibiotics in the treatment of uncomplicated diverticulitis does not reduce the incidence of complications or shorten the treatment, nor does it reduce the risk of recurrence.

[Outpatient treatment of uncomplicated acute diverticulitis: Impact on healthcare costs]. / Tratamiento ambulatorio de la diverticulitis aguda no complicada: impacto sobre los costes sanitarios.

BACKGROUND: Outpatient treatment of uncomplicated acute diverticulitis is safe and effective. The aim of this study was to determine the impact of outpatient treatment on the reduction of healthcare costs. PATIENTS AND METHODS: A retrospective cohort study comparing 2 groups was performed. In the outpatient treatment group, patients diagnosed with uncomplicated acute diverticulitis were treated with oral antibiotics at home. In the hospital treatment group, patients met the criteria for outpatient treatment but were admitted to hospital and received intravenous antibiotic therapy. Cost estimates have been made using the hospital cost accounting system based on total costs, the sum of all variable costs (direct costs) plus overhead expenses divided by activity (indirect costs). RESULTS: A total of 136 patients were included, 90 in the outpatient treatment group and 46 in the hospital group. There were no differences in the characteristics of the patients in both groups. There were also no differences in the treatment failure rate in both groups (5.5% vs. 4.3%; P=.7). The total cost per episode was significantly lower in the outpatient treatment group (882 ± 462 vs. 2.376 ± 830 euros; P=.0001). CONCLUSIONS: Outpatient treatment of acute diverticulitis is not only safe and effective but also reduces healthcare costs by more than 60%.

Outcomes and costs of elective surgery for diverticular disease: a comparison with other diseases requiring colectomy.

OBJECTIVE: To compare outcomes and costs of elective surgery for diverticular disease (DD) with those of other diseases commonly requiring colectomy. DESIGN: Multivariable analyses using the Nationwide Inpatient Sample to compare outcomes across primary diagnosis while adjusting for age, sex, race, year of admission, and comorbid disease. SETTING: A sample of US hospital admissions from 2003-2009. PATIENTS: All adult patients (≥18 years) undergoing elective resection of the descending colon or subtotal colectomy who had a primary diagnosis of DD, colon cancer (CC), or inflammatory bowel disease (IBD). MAIN OUTCOME MEASURES: In-hospital mortality, postoperative complications, ostomy placement, length of stay, and hospital charges. RESULTS: Of the 74,879 patients, 50.52% had DD, 43.48% had CC, and 6.00% had IBD. After adjusting for other variables, patients with DD were significantly more likely than patients with CC to experience in-hospital mortality (adjusted odds ratio, 1.90; 95% CI, 1.37-2.63; P < .001), develop a postoperative infection (1.67; 1.48-1.89; P < .001), and have an ostomy placed (1.87; 1.65-2.11; P < .001). The adjusted total hospital charges for patients with DD were $6678.78 higher (95% CI, $5722.12-$7635.43; P < .001) and length of stay was 1 day longer (95% CI, 0.86-1.14; P < .001) compared with patients with CC. Patients with IBD had the highest in-hospital mortality, highest rates of complications and ostomy placement, longest length of stay, and highest hospital charges. CONCLUSIONS: Despite undergoing the same procedure, patients with DD have significantly worse and more costly outcomes after elective colectomy compared with patients with CC but better than patients with IBD. These relatively poor outcomes should be recognized when considering routine elective colectomy after successful nonoperative management of acute diverticulitis.

Insurance but not race is associated with diverticulitis mortality in a statewide database.

OBJECTIVES: Racial identity and health insurance have been associated with differential health care outcomes for many diseases, but not for diverticulitis. We examined the association of racial identity and insurance with admission, treatment, and mortality for patients admitted to inpatient care for acute diverticulitis. METHODS: Data on adult inpatients with nonelective diverticulitis admissions between 1985 and 2006 were extracted from the New York Statewide Planning and Cooperative Systems Database. Race categories were white non-Hispanic, black non-Hispanic, Hispanic, Asian, other race, and unknown race. A multivariable logistic regression model adjusted for insurance, year, patient factors, community factors, and hospital factors was used to examine the association of racial identity and insurance with presentation, treatment, and mortality. Five outcomes were considered: 1) admission via the emergency department, 2) complicated disease presentation, 3) surgical intervention, 4) colostomy creation, and 5) mortality. White race and private insurance were reference groups. RESULTS: We identified 253,655 admissions. Race distribution included 77.7% white, 8.1% black, and 7.2% Hispanic. Medicare was the most commonly held insurance (52.7%), and 73.7% of patients were admitted through the emergency department. Of 36,190 surgeries, 20,650 (57.1%) included colostomies, and 3.0% of all patients died. Race other than white and Medicaid insurance were the strongest predictors of admission via the emergency department (OR 1.34, 95% CI 1.12-1.60; OR 1.60, 95% CI 1.44-1.78). Patients categorized as black, Hispanic, Asian, or other were less likely to have complicated disease, surgery, and colostomy creation (OR 0.81, 95% CI 0.76-0.85; OR 0.87, 95% CI 0.81-0.94; and OR 0.67, 95% CI 0.61-0.74). Insurance was associated with higher rates of mortality; having Medicaid or no insurance were the strongest predictors (OR 1.61, 95% CI 1.36-1.89; OR 1.34, 95% CI 1.06-1.69). CONCLUSIONS: In acute diverticulitis, race and insurance were associated with differential admission patterns, and patients categorized as black, Hispanic, Asian, or other were less likely to receive surgical treatment or colostomy. Insurance status, but not race, was associated with mortality. Future research is needed to further explore these differences in admission, treatment, and mortality.

A multicenter randomized clinical trial investigating the cost-effectiveness of treatment strategies with or without antibiotics for uncomplicated acute diverticulitis (DIABOLO trial).

BACKGROUND: Conservative treatment of uncomplicated or mild diverticulitis usually includes antibiotic therapy. It is, however, uncertain whether patients with acute diverticulitis indeed benefit from antibiotics. In most guidelines issued by professional organizations antibiotics are considered mandatory in the treatment of mild diverticulitis. This advice lacks evidence and is merely based on experts' opinion. Adverse effects of the use of antibiotics are well known, including allergic reactions, development of bacterial resistance to antibiotics and other side-effects. METHODS: A randomized multicenter pragmatic clinical trial comparing two treatment strategies for uncomplicated acute diverticulitis. I) A conservative strategy with antibiotics: hospital admission, supportive measures and at least 48 hours of intravenous antibiotics which subsequently are switched to oral, if tolerated (for a total duration of antibiotic treatment of 10 days). II) A liberal strategy without antibiotics: admission only if needed on clinical grounds, supportive measures only. Patients are eligible for inclusion if they have a diagnosis of acute uncomplicated diverticulitis as demonstrated by radiological imaging. Only patients with stages 1a and 1b according to Hinchey's classification or "mild" diverticulitis according to the Ambrosetti criteria are included. The primary endpoint is time-to-full recovery within a 6-month follow-up period. Full recovery is defined as being discharged from the hospital, with a return to pre-illness activities, and VAS score below 4 without the use of daily pain medication. Secondary endpoints are proportion of patients who develop complicated diverticulitis requiring surgery or non-surgical intervention, morbidity, costs, health-related quality of life, readmission rate and acute diverticulitis recurrence rate. In a non-inferiority design 264 patients are needed in each study arm to detect a difference in time-to-full recovery of 5 days or more with a power of 85% and a confidence level of 95%. With an estimated one percent of patients lost to follow up, a total of 533 patients will be included. CONCLUSION: A clinically relevant difference of more than 5 days in time-to-full recovery between the two treatment strategies is not expected. The liberal strategy without antibiotics and without the strict requirement for hospital admission is anticipated to be more a more cost-effective approach. TRIAL REGISTRATION NUMBER: NCT01111253.

[Safety and efficiency of ambulatory treatment of acute diverticulitis]. / Eficiencia y seguridad del tratamiento ambulatorio de la diverticulitis aguda.

INTRODUCTION: The treatment of acute diverticulitis is currently being modified, showing a tendency to limit surgical treatment and favor conservative management. OBJECTIVE: To analyze the safety and efficiency of ambulatory treatment of acute diverticulitis in a selected group of patients. METHODS: We performed a prospective study of domiciliary oral antibiotic therapy for acute diverticulitis in a cohort of patients in the Emergency Surgery Section of our hospital. Seventy-four patients (44 men and 30 women) were included between 2000 and 2006. Patients with Hinchey stage 1 diverticulitis and those with Hinchey stage 2 diverticulitis and abscesses of less than 3cm, who were clinically and biochemically stable, were selected. The patients were treated with oral ciprofloxacin and metronidazole for 7-10 days. Follow-up was performed in the outpatients unit with clinical evaluation at 10 days and an imaging test at 1 month. RESULTS: The mean age of the patients was 55 years. The most frequent clinical presentation was spontaneous abdominal pain associated with leukocytosis. The mean duration of treatment was 8.8 days. Four patients (5.4%) required subsequent hospital admission for intravenous antibiotic administration and 70 (94.6%) completed treatment without complications. During follow-up, two cases of colonic adenocarcinoma and six cases of polyposis were diagnosed. Only 13 patients underwent elective surgery. CONCLUSIONS: In most of the patients studied, ambulatory conservative management was safe and effective in the treatment of uncomplicated acute diverticulitis. Moreover, this approach reduces length of hospital stay and lowers costs.

Hartmann's colectomy and reversal in diverticulitis: a population-level assessment.

PURPOSE: This study was designed to assess the costs and outcomes of colostomy and colostomy reversal in patients with diverticulitis and examine the impact of such procedures on the health care system. METHODS: We employed a retrospective design and used a Washington State administrative database to identify patients undergoing operations with colostomy (1987-2002) who were followed over time. Descriptive and comparative analysis was performed, focusing on patients with diverticulitis. RESULTS: There were 16,556 patients who underwent colostomy and 5,420 (32.7 percent) were for diverticulitis and its related complications (mean age, 64.8 +/- 15.1 years; 53.2 percent female). In patients with diverticulitis, the rate of colostomy reversal was 56.3 percent (80 percent in patients less than 50 years, and 30 percent in patients over 77 years). The in-hospital mortality rate after colostomy reversal was 0.36 percent, and was 2.6 percent in those over 77 years of age. After colostomy reversal a second stoma was used in 3.4 percent, reoperation was required for bleeding complications in 0.6 percent, and infectious complications were noted in 2 percent. The length of time from colostomy to its reversal was approximately five months (138.1 +/- 164 days; interquartile range, 72-156). The relationship between the length of time from colostomy to reversal was evaluated and the adjusted odds of a second stoma being used at the time of colostomy reversal were 45 percent higher (odds ratio, 1.45; 95 percent confidence interval, 1.22, 1.73) for each increase in time interval (<3, 6-9, 9-12, >12 months). CONCLUSIONS: One-third of all colostomies were related to diverticulitis and only 56 percent were reversed. We identified a higher than expected mortality rate among older patients undergoing colostomy reversal. The impact of colostomy and reversal operations on both patients and the health care system is significant.