Highlights
- •Etiology of LBO: 20% colon cancer, 15.6% extracolonic malignancy, 64.7% benign.
- •Prompt intervention (occurring within 2 days of admission) in LBO: 42.6% of cases.
- •Prompt intervention less likely in Blacks with benign LBO and women with malignant LBO.
- •Prompt intervention increased discharge to home and decreased LOS, but not mortality.
Abstract
Background
Methods
Results
Conclusion
Keywords
1. Introduction
2. Methods
3. Results
Total patients N = 31277 Mean (SD) or No. (%) | Obstruction-directed intervention | |||
---|---|---|---|---|
Prompt (≤2days) N = 13323, 42.6% No. (%) | Not prompt (>2days) N = 17954, 57.4% No. (%) | p | ||
Age, years | ||||
Mean age (SD) | 64.6 (16.1) | 64.3 (16.2) | 64.9 (16.1) | 0.001 |
18–44 | 3035 (9.7) | 1372 (10.3) | 1663 (9.3) | <0.0001 |
45-54 | 3724 (11.9) | 1698 (12.7) | 2026 (11.3) | |
55-64 | 5793 (18.5) | 2572 (19.3) | 3221 (17.9) | |
≥65 | 14147 (45.2) | 6148 (46.2) | 7999 (44.6) | |
Missing | 4578 (14.6) | 1533 (11.5) | 3045 (17.0) | |
Sex | ||||
Male | 14309 (45.8) | 6194 (46.5) | 8115 (45.2) | 0.02 |
Female | 16964 (54.2) | 7126 (53.5) | 9838 (54.8) | |
Race | ||||
Black | 3749 (12.8) | 1482 (11.7) | 2267 (13.7) | <0.0001 |
White | 21619 (74.0) | 9424 (74.5) | 12195 (73.6) | |
Other | 3864 (13.2) | 1748 (13.8) | 2116 (12.8) | |
Charlson Index | ||||
0-2 | 18275 (58.5) | 8478 (63.7) | 9797 (54.6) | <0.0001 |
3-6 | 5132 (16.4) | 2031 (15.3) | 3101 (17.3) | |
≥7 | 7828 (25.1) | 2796 (21.0) | 5032 (28.1) | |
Sum of comorbidities | ||||
Median (IQR), Mean | 12 (8–17), 12.5 | 11 (7–16), 11.7 | 13 (8–17), 13.1 | <0.0001 |
Etiology of obstruction | ||||
Colon cancer | 2960 (9.5) | 1181 (8.9) | 1779 (9.9) | <0.0001 |
Metastatic colon cancer | 3204 (10.2) | 1197 (9.0) | 2007 (11.2) | |
Extracolonic malignancy | 4885 (15.6) | 1726 (13.0) | 3159 (17.6) | |
Benign obstruction | 20228 (64.7) | 9219 (69.2) | 11009 (61.3) | |
Transfer status | ||||
Not transferred | 28620 (92.0) | 12169 (91.9) | 16451 (92.1) | 0.52 |
Transferred from other facility | 2487 (8.0) | 1074 (8.1) | 1413 (7.9) | |
Primary payer | ||||
Medicaid | 2555 (9.5) | 1109 (9.4) | 1446 (9.6) | 0.03 |
Private/Medicare/Other | 22857 (85.2) | 10053 (84.9) | 12804 (85.4) | |
Uninsured | 1427 (5.3) | 676 (5.7) | 751 (5.0) | |
Zip code income quartile | ||||
>75th percentile of income | 6916 (22.6) | 3071 (23.6) | 3845 (21.9) | 0.001 |
≤75th percentile of income | 23697 (77.4) | 9969 (76.5) | 13728 (78.1) | |
Hospital location/teaching status | ||||
Urban teaching | 16670 (53.5) | 7050 (53.1) | 9620 (53.8) | <0.0001 |
Urban non-teaching | 11414 (36.6) | 4739 (35.7) | 6675 (37.3) | |
Rural | 3085 (9.9) | 1481 (11.2) | 1604 (9.0) | |
Hospital ownership | ||||
Public, non-federal | 9020 (28.9) | 3594 (27.1) | 5426 (30.3) | <0.0001 |
Private, non-profit | 18566 (59.6) | 8208 (61.9) | 10358 (57.9) | |
Private, for-profit | 3583 (11.5) | 1468 (11.1) | 2115 (11.8) | |
Stent procedure | ||||
Yes | 1686 (5.4) | 561 (4.2) | 1125 (6.3) | <0.0001 |
No | 29591 (94.6) | 12762 (95.8) | 16829 (93.7) | |
Stoma procedure | ||||
Yes | 11954 (38.2) | 4993 (37.5) | 6961 (38.8) | 0.02 |
No | 19323 (61.8) | 8330 (62.5) | 10993 (61.2) | |
Colon resection | ||||
Left-sided resection | 17715 (56.6) | 8114 (60.9) | 9601 (53.5) | <0.0001 |
Right-sided resection | 7514 (24.0) | 2995 (22.5) | 4519 (25.2) | |
No colon resection | 6048 (19.3) | 2214 (16.6) | 3834 (21.4) | |
Discharge disposition | ||||
Died in hospital | 1876 (6.0) | 788 (5.9) | 1088 (6.1) | <0.0001 |
Discharged to home | 21658 (69.3) | 9449 (71.0) | 12209 (68.1) | |
Transfer to other facility | 7723 (24.7) | 3080 (23.1) | 4643 (25.9) | |
Length of stay of patients discharged alive | ||||
Median (IQR), Mean | 10 (7–14), 11.7 | 8 (6–11), 9.8 | 11 (8–15), 13.1 | <0.0001 |
3.1 Interventions
Predictors of prompt intervention | Malignant etiology (n = 10954) | Benign etiology (n = 19999) | ||
---|---|---|---|---|
Adjusted O.R. (95% C.I.) | p | Adjusted O.R. (95% C.I.) | p | |
Stoma procedure | ||||
Yes | 1.3 (1.2–1.4) | <.0001 | 0.83 (0.78–0.88) | <.0001 |
No | 1.0 [Reference] | 1.0 [Reference] | ||
Stent procedure | ||||
Yes | 0.8 (0.7–1.0) | 0.02 | 0.7 (0.6–0.8) | <.0001 |
No | 1.0 [Reference] | 1.0 [Reference] | ||
Age, years | ||||
18-44 | 1.0 [Reference] | 1.0 [Reference] | ||
45-54 | 1.2 (1.0–1.5) | 0.11 | 1.1 (1.0–1.2) | 0.07 |
55-64 | 1.1 (0.9–1.3) | 0.48 | 1.1 (1.0–1.3) | 0.01 |
≥65 | 1.2 (1.0–1.4) | 0.14 | 1.1 (0.9–1.2) | 0.37 |
Missing | 0.8 (0.5–1.3) | 0.8 (0.5–1.1) | 0.17 | |
Sex | ||||
Male | 1.1 (1.0–1.2) | 0.01 | 1.05 (0.99–1.11) | 0.10 |
Female | 1.0 [Reference] | 1.0 [Reference] | ||
Race | ||||
Black | 0.9 (0.8–1.0) | 0.20 | 0.86 (0.79–0.95) | 0.002 |
Other | 1.1 (0.9–1.2) | 0.29 | 1.1 (1.0–1.2) | 0.01 |
Unknown | 0.7 (0.6–0.9) | 0.0002 | 0.6 (0.5–0.7) | <.0001 |
White | 1.0 [Reference] | 1.0 [Reference] | ||
Charlson Comorbidity Index | ||||
≥7 | 0.76 (0.68–0.85) | <.0001 | 0.5 (0.4–0.6) | <.0001 |
3-6 | 0.8 (0.7–0.9) | <.0001 | 0.82 (0.76–0.89) | <.0001 |
0-2 | 1.0 [Reference] | 1.0 [Reference] | ||
Transfer status | ||||
Transferred from other facility | 1.1 (0.9–1.2) | 0.47 | 1.0 (0.9–1.1) | 0.68 |
Not transferred | 1.0 [Reference] | 1.0 [Reference] | ||
Primary payer | ||||
Medicaid | 1.0 (0.8–1.3) | 0.91 | 0.9 (0.7–1.0) | 0.06 |
Private/Medicare/Other | 0.9 (0.8–1.2) | 0.60 | 0.9 (0.8–1.0) | 0.11 |
Unknown | 1.0 (0.6–1.7) | 0.93 | 0.8 (0.5–1.2) | 0.23 |
Uninsured | 1.0 [Reference] | 1.0 [Reference] | ||
Zip code income quartile | ||||
>75th percentile of income | 1.1 (1.0–1.2) | 0.05 | 1.14 (1.06–1.22) | 0.003 |
Unknown | 1.1 (0.8–1.4) | 0.64 | 1.0 (0.8–1.2) | 0.82 |
≤75th percentile of income | 1.0 [Reference] | 1.0 [Reference] | ||
Hospital ownership | ||||
Public, non-federal | 1.3 (1.1–1.5) | 0.002 | 1.0 (0.9–1.1) | 0.66 |
Private, non-profit | 1.3 (1.2–1.5) | <.0001 | 1.1 (1.0–1.2) | 0.05 |
Private, for-profit | 1.0 [Reference] | 1.0 [Reference] | ||
Hospital location/teaching status | ||||
Urban teaching | 0.7 (0.6–0.8) | <.0001 | 0.85 (0.77–0.93) | 0.001 |
Urban non-teaching | 0.7 (0.6–0.8) | <.0001 | 0.8 (0.7–0.9) | <.0001 |
Rural | 1.0 [Reference] | 1.0 [Reference] |
3.2 Patient, procedure, and hospital factors associated with prompt intervention
3.3 Outcomes
Predictors of inpatient death | Malignant etiology (n = 10952) | Benign etiology (n = 19994) | ||
---|---|---|---|---|
Adjusted O.R. (95% C.I.) | p | Adjusted O.R. (95% C.I.) | p | |
Prompt intervention | ||||
Yes | 1.0 (0.8–1.2) | 0.92 | 1.0 (0.9–1.2) | 0.74 |
No | 1.0 [Reference] | 1.0 [Reference] | <.0001 | |
Age, years | ||||
18-44 | 1.0 [Reference] | 1.0 [Reference] | ||
45-54 | 1.0 (0.6–1.9) | 0.90 | 1.3 (0.8–2.1) | 0.25 |
55-64 | 1.1 (0.7–1.9) | 0.66 | 2.2 (1.5–3.4) | 0.0002 |
≥65 | 2.1 (1.3–3.5) | 0.01 | 5.6 (3.7–8.4) | <.0001 |
Missing | 2.2 (0.7–6.8) | 0.17 | 7.8 (3.4–17.9) | <.0001 |
Sex | ||||
Male | 1.0 (0.9–1.2) | 0.68 | 1.0 (0.9–1.1) | 0.74 |
Female | 1.0 [Reference] | 1.0 [Reference] | ||
Race | ||||
Black | 0.9 (0.7–1.2) | 0.42 | 1.3 (1.1–1.6) | 0.01 |
Other | 0.8 (0.6–1.0) | 0.10 | 1.1 (0.9–1.3) | 0.47 |
Unknown | 0.9 (0.6–1.3) | 0.55 | 1.2 (0.9–1.5) | 0.20 |
White | 1.0 [Reference] | 1.0 [Reference] | ||
Charlson Comorbidity Index | ||||
≥7 | 1.5 (1.1–2.1) | 0.01 | 2.0 (1.4–2.6) | <.0001 |
3-6 | 1.4 (1.0–1.9) | 0.09 | 1.6 (1.3–1.8) | <.0001 |
0-2 | 1.0 [Reference] | 1.0 [Reference] | ||
Sum of Comorbidities | 1.09 (1.07–1.10) | <.0001 | 1.10 (1.09–1.11) | <.0001 |
Perforation/peritonitis secondary diagnosis | ||||
Yes | 5.4 (4.5–6.5) | <.0001 | 5.3 (4.6–6.1) | <.0001 |
No | 1.0 [Reference] | 1.0 [Reference] | ||
Stoma procedure | ||||
Yes | 1.3 (1.1–1.5) | 0.003 | 1.1 (1.0–1.2) | 0.24 |
No | 1.0 [Reference] | 1.0 [Reference] | ||
Transfer status | ||||
Transferred from other facility | 1.3 (1.0–1.8) | 0.07 | 1.1 (0.9–1.4) | 0.20 |
Not transferred | 1.0 [Reference] | 1.0 [Reference] | ||
Primary payer | ||||
Medicaid | 0.9 (0.5–1.6) | 0.71 | 1.1 (0.6–1.8) | 0.78 |
Private/Medicare/Other | 0.8 (0.5–1.3) | 0.37 | 0.9 (0.6–1.4) | 0.59 |
Unknown | 0.5 (0.2–1.6) | 0.25 | 0.4 (0.2–1.1) | 0.07 |
Uninsured | 1.0 [Reference] | 1.0 [Reference] | ||
Zip code income quartile | ||||
>75th percentile of income | 1.1 (0.9–1.3) | 0.53 | 0.9 (0.7–1.0) | 0.05 |
Unknown | 1.1 (0.6–2.0) | 0.72 | 1.0 (0.7–1.6) | 0.88 |
≤75th percentile of income | 1.0 [Reference] | 1.0 [Reference] | ||
Hospital ownership | ||||
Public, non-federal | 1.2 (0.9–1.7) | 0.20 | 1.0 (0.8–1.3) | 0.68 |
Private, non-profit | 0.8 (0.6–1.0) | 0.07 | 0.8 (0.7–1.0) | 0.02 |
Private, for-profit | 1.0 [Reference] | 1.0 [Reference] | ||
Hospital location/teaching status | ||||
Urban teaching | 0.7 (0.5–0.9) | 0.01 | 0.8 (0.7–1.0) | 0.05 |
Urban non-teaching | 0.8 (0.6–1.1) | 0.16 | 0.9 (0.7–1.1) | 0.20 |
Rural | 1.0 [Reference] | 1.0 [Reference] |
3.4 Demographic subgroups of interest
All patients N = 31277 | Race | Sex | Zip code income quartile | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
White 21595 (74.0%) | Black 3742 (12.8%) | Other 3856 (13.2%) | p | Female 16942 (54.3%) | Male 14289 (45.8%) | p | >75th percentile | ≤75th percentile | p | ||
Mean (SD) age in years | 64.6 (16.1) | 66.1 (15.7) | 60.5 (15.9) | 60.6 (17.0) | * | 66.4 (16.0) | 62.5 (16.1) | * | 65.0 (16.6) | 64.6 (16.0) | @ |
Charlson Comorbidity index | |||||||||||
0-2 | 58.4% | 59.1% | 54.9% | 58.3% | * | 60.0% | 56.6% | * | 58.5% | 58.5% | @ |
3-6 | 16.5% | 16.6% | 17.2% | 15.1% | 15.9% | 17.0% | 15.6% | 16.8% | |||
≥7 | 25.1% | 24.3% | 27.9% | 26.7% | 24.0% | 26.3% | 26.0% | 24.8% | |||
Obstruction etiology | |||||||||||
Colon cancer | 9.5% | 9.1% | 10.0% | 11.0% | * | 8.7% | 10.4% | * | 9.2% | 9.5% | * |
Metastatic colon cancer | 10.3% | 9.7% | 12.2% | 11.5% | 8.7% | 12.1% | 10.6% | 10.2% | |||
Extracolonic malignancy | 15.6% | 15.6% | 15.2% | 15.9% | 17.1% | 13.8% | 17.3% | 15.2% | |||
Benign obstruction | 64.7% | 65.6% | 62.6% | 61.6% | 65.5% | 63.7% | 62.9% | 65.2% |
4. Discussion
National Bowel Cancer Audit Methodology Supplemental Document 2019. January vol. 9, 2020. http://www.nboca.org.uk/content/uploads/2018/12/Methodology-Supplement-PDF.pdf. Accessed November 6, 2021.
5. Conclusions
Funding
Declaration of competing interest
Appendix A. Supplementary data
- Multimedia component 1
- Multimedia component 2
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