Study examines association of race, insurance status with diverticulitis presentation and treatment

December 15, 2008

Among patients undergoing surgery for diverticulitis, race was associated with a complicated presentation and in-hospital mortality, but not with receiving a colostomy, whereas insurance status was associated with complicated presentation, in-hospital mortality and receiving a colostomy, according to a report in the December issue of Archives of Surgery, one of the JAMA/Archives journals. The results suggest that racial disparities in outcomes may be related to the patients' initial condition rather than differences in treatment.

Diverticulitis refers to inflammation and infection involving small outpouchings of the colon (known as diverticula) that can result in perforations (holes or breaks) in colon walls, according to background information in the article. The disease accounts for more than 200,000 hospitalizations and more than $300 million in health care costs each year. Diverticulitis is considered complicated if it is accompanied by bowel obstruction, hemorrhage, perforation or abscess formation.

"Complicated diverticulitis is managed by hospital admission, bowel rest, intravenous antibiotics, and, depending on the patient's condition, either emergency surgery or conservative management," the authors write. Surgical interventions involve removing the diseased portion of the colon and reattaching the healthy sections. This can be done in one procedure or in a two-staged operation involving a colostomy (surgical opening through the abdominal wall to allow for waste removal). "The need for a colostomy usually relates to higher disease severity at presentation and is difficult for patients from a functional as well as emotional standpoint," the authors write.

Anne O. Lidor, M.D., M.P.H., and colleagues at Johns Hopkins University, Baltimore, analyzed the records of 45,528 patients with diverticulitis who were admitted to hospitals nationwide between 1999 and 2003. Of these, 85.3 percent were white, 5.3 percent were black and 6.7 percent were underinsured.

"In our study, we found that race did not affect the type of surgical treatment received for diverticulitis, notwithstanding that black patients were more likely than white patients to present with more complicated cases," the authors write. "In contrast, insurance status did correlate with the type of treatment provided. Uninsured and underinsured patients were more likely to receive a colostomy, even after adjusting for a higher rate of complicated diverticulitis in those patients than their insured counterparts."

The results suggest that a lack of adequate health insurance is a more powerful predictor of treatment patterns for patients with diverticulitis, the authors note. "This, to some degree, questions the conventional wisdom that race is the primary determinant of suboptimal outcomes in health care delivery and has obvious prescriptive implications for future health care policy decisions," they conclude. "To the extent to which these findings can be generalized to a variety of other medical conditions, a new paradigm of health care resource allocation may be in order, one based more on socioeconomic than racial distinctions. Future research should assess the means by which barriers to equal access to adequate health care can be reduced or eliminated by negating socioeconomic factors rather than emphasizing race-based distinctions."
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(Arch Surg. 2008;143[12]:1160-1165. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

The JAMA Network Journals

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