Area Deprivation, Fragmented Care, and Colectomy Case Acuity in the Veterans Health Administration.

Abstract

Background: Colectomy for benign or malignant disease may be elective, urgent, or emergent. Data suggest successively worse outcomes for non-elective colectomy. Few data exist on the contribution of high area deprivation index and care fragmentation to non-elective colectomy.

Objective: Determine the association between area deprivation and non-elective colectomy in the Veterans Health Administration and assess whether accounting for differences in care fragmentation alters the association across indications and for benign and malignant conditions separately.

Design: Retrospective cohort with multivariable multinomial logit models to evaluate associations between high deprivation care fragmentation, and the adjusted odds of non-elective colectomy. We calculated total, direct, and indirect effects to assess whether the association varied by levels of care fragmentation.

Setting: Veterans receiving care in the private sector and Veterans Health Administration.

Patients: Veterans ≥ 65 years undergoing colectomy between 2013 and 2019.

Main outcome/measures: Colectomy case acuity.

Results: We identified 6538 colectomy patients, of which 3006 (46.0%) were for malignancy. The odds of emergent colectomy were higher for patients in high deprivation areas when the indication was for benign pathology (aOR 1.51 95% CI: 1.15, 2.00). For malignant indications, there was no association between high deprivation and non-elective colectomy. More fragmented care was associated with a higher odds of urgent and emergent colectomy for both benign and malignant indications but the association between deprivation and non-elective colectomy did not vary by care fragmentation.

Limitations: Inherent to large administrative retrospective databases.

Conclusions: Veterans living in high deprivation areas are at higher risk for emergent colectomy for benign conditions. Care fragmentation is also associated with a higher risk of emergent colectomy across indications. Efforts to reduce care fragmentation and promote early detection of inflammatory bowel disease and diverticular disease in high deprivation neighborhoods may lower the risk for non-elective colectomy in Veterans. See Video Abstract.