Chf and COPD Predict Poor Surgical Outcomes in Older Adults Undergoing Elective Diverticulitis Surgery
Amy Sheer*1,3, Eric B. Schneider1, Albert W. Wu3,2, Jodi B. Segal2, Anne O. Lidor1
1Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; 2Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; 3Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
Background and Aims: Diverticulitis is a common medical condition which disproportionally affects older adults and which accounts for over 300,000 hospitalizations yearly in the United States. This study aims to investigate outcomes among older patients undergoing elective surgery for diverticulitis and to examine subgroups of patients with comorbid congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) to determine whether outcomes in these patients are worse. Methods: Data were derived from the 100% Medicare Provider Analysis and Review (MEDPAR) inpatient files from 2004-2007. We used a retrospective cohort study design to identify patients age 65 years and older with a primary diagnosis of diverticulitis and who underwent elective left colon resection, colostomy, or ileostomy. Patients were then grouped by comorbid CHF and COPD status. The primary outcome variable was in-hospital mortality. Secondary outcome variables included intestinal diversion and predetermined postoperative complication rates. We evaluated preoperative clinical characteristics and performed multivariate analysis, adjusting for CHF, COPD, age, gender, race, and comorbidities as measured by the Charlson Index. Results: A total of 23,765 individuals were eligible for inclusion. Mean age was 73.9 years and 71.7% were female. Among all patients, 17.3% had COPD and 6.2% had CHF. Overall mortality, morbidity and intestinal diversion rate were 1.4%, 21.6% and 12.6%, respectively. Mortality increased with increasing age in both unadjusted and adjusted analysis. On multivariate analysis, patients with CHF had significantly increased odds of in-hospital mortality (OR: 3.5, 95% CI 2.71 - 4.61), intestinal diversion (OR: 1.8, 95% CI 1.58 - 2.07), and all other measured postoperative complications. Patients with COPD did not have increased odds of mortality, but had significantly increased odds of intestinal diversion, wound infections, and pulmonary complications. Conclusions: Our finding of significantly worse outcomes for elective surgical treatment of diverticulitis in older adults, and especially among those with CHF and COPD, suggests that a reappraisal of the proper role of elective surgery in this population may be warranted.
Adjusted odds ratios (95% CI) of outcomes among Medicare beneficiaries undergoing elective diverticulitis surgery
| In-Hospital Death (n=329) | Intestinal diversion (n=3,006 | Hemorrhage (n=470) | Wound (n=1,052 | Pulmonary (n=1,782 | Renal (n=614) | Cardiac (n=594) | Shock/sepsis (n=495) | Thrombo-embolic (n=259 | |
| Age | |||||||||
| 70-74 | * | 1.1 (1.03-1.23) | * | * | * | * | * | * | * |
| 75-79 | 2.5 (1.71-3.71) | 1.4 (1.28-1.60) | 1.4 (1.09-1.81) | * | 1.6 (1.37-1.84) | 1.7 (1.33-2.14) | 1.5 (1.14-1.87) | 1.6 (1.21-2.06) | 1.4 (1.01-1.98) |
| 80-84 | 3.6 (2.38-5.33) | 2.2 (1.92-2.46) | * | 0.72 (0.58-0.911 | 1.9 (1.66-2.29) | 1.7 (1.29-2.22) | 1.8 (1.41-2.41) | 2.1 (1.60-2.85) | * |
| 85+ | 9.7 (6.49-14.45 | 3.7 (3.21-4.33) | * | * | 2.8 (2.32-3.04) | 2.5 (1.81-3.38) | 2.4 (1.73-3.25) | 2.9 (2.11-4.08) | * |
| COPD (n=4,116) | * | 1.1 (1.00-1.22) | * | 1.4 (1.17-1. 63) | 2.1 (1.89-2.42) | * | * | * | * |
| CHF (n=1,486) | 3.5 (2.71-4.61) | 1.8 (1.58-2.07) | 1.4 (1.02-2.07) | 2.0 (1.55-2.42) | 3.9 (3.39-4.54) | 3.8 (3.03-4.69) | 4.2 (3.40-5.23) | 3.3 (2.58-4.28) | 1.7 (1.07-2.46) |
Comparison group age 65-69, * indicates not significant
Unadjusted mortality rates for all diverticulitis patients with and without CHF or COPD stratified by age category, † indicates significance
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