Introduction
The Hispanic population is an important and rapidly growing minority group in the USA that is relatively understudied in surgical literature. Hispanics have been found to live longer than non-Hispanics, and in some cases have better health outcomes despite higher risk profiles, a concept known as the Hispanic epidemiologic paradox.1 However, there also is contradicting literature showing worse health outcomes in this ethnic minority group.2 The prevalence of diverticulitis within the Hispanic ethnicity group is comparable to that of non-Hispanic Whites making it important to understand the impact of this common disease on outcomes specific to ethnicity. This study aims to compare the presentation, outcomes, and non-elective surgical management of diverticulitis in Hispanic versus non-Hispanic patients.
Materials and Methods
The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was used to identify adult patients with acute diverticulitis (International Classification of Diseases, 10th revision codes K57.20 and K57.32) who underwent non-elective surgery (Current Procedural Terminology codes 44140–6, 44160, and 44204–8) during the index admission from 2015 to 2019. Ethnicity was defined as either Hispanic or non-Hispanic, consistent with most standard databases including the US Census. Ethnicity refers to the shared culture of a group from a similar region, distinct from race which is ascribed based more on physical characteristics and shared history. Both variables were included in the analysis along with comorbidities and perioperative characteristics. Diverticulitis was defined as either complicated (abscess or perforation) or uncomplicated. Thirty-day outcomes were compared between ethnic groups. This study was approved by the Institutional Review Board.
Results
A total of 13,095 patients were included in the study, of which 46.8% were male with a mean age of 61.3 ± 14.2 years. A small proportion (8.3%) of patients were of Hispanic ethnicity. Hispanic patients were younger (52.9 vs 62.1 years, p < 0.001), had lower rates of several comorbidities (see Table 1), and were significantly less likely to present with complicated disease (83.2% vs 86.4%, p = 0.003) and preoperative sepsis (47.4% vs 51.2%, p = 0.019). In bivariate analysis, 30-day mortality was lower among Hispanic patients (p < 0.001) but there was no difference in overall 30-day morbidity by ethnicity (see Table 2). In multivariate regression analysis, Hispanic ethnicity was independently associated with lower 30-day mortality (OR 0.447, 95% CI 0.210–0.951, p = 0.037) (see Table 3). The Hosmer and Lemeshow test was not significant, confirming the model was a good fit.
Table 1.
Baseline and perioperative characteristics of patients who underwent non-elective surgery for acute diverticulitis by ethnicity
| Characteristic | Non-Hispanic (N = 12,007) |
Hispanic (N = 1088) |
p-value |
|---|---|---|---|
| Age | 62.1 (± 13.7) | 52.9 (± 15.7) | < 0.001 |
| Sex, male | 5520 (46.0%) | 614 (56.4%) | < 0.001 |
| Race | < 0.001 | ||
| White | 10,518 (89.1%) | 773 (97.5%) | – |
| Black | 1033 (8.8%) | 13 (1.6%) | – |
| Asian | 146 (1.2%) | 1 (0.1%) | – |
| American Indian/Alaska Native | 79 (0.7%) | 2 (0.3%) | – |
| Native Hawaiian/Pacific Islander | 24 (0.2%) | 4 (0.5%) | – |
| BMI | 30.0 (± 7.3) | 31.6 (± 7.6) | < 0.001 |
| Diabetes mellitus | 1314 (10.9%) | 163 (15.0%) | < 0.001 |
| Hypertension | 6142 (51.2%) | 399 (36.7%) | < 0.001 |
| CHF | 240 (2.0%) | 14 (1.3%) | 0.108 |
| COPD | 989 (8.2%) | 24 (2.2%) | < 0.001 |
| Tobacco use | 2908 (25.2%) | 160 (20.4%) | 0.002 |
| Dialysis dependence | 179 (1.5%) | 15 (1.4%) | 0.797 |
| Chronic steroid use | 1328 (11.1%) | 62 (5.7%) | < 0.001 |
| Acute kidney injury | 122 (1.0%) | 11 (1.0%) | 1.000 |
| Bleeding disorder | 1129 (9.4%) | 53 (4.9%) | < 0.001 |
| Metastatic cancer | 305 (2.5%) | 11 (1.0%) | 0.002 |
| Ascites | 94 (0.8%) | 11 (1.0%) | 0.475 |
| Weight loss | 556 (4.6%) | 41 (3.8%) | 0.198 |
| ASA Class 1 or 2 | 3844 (32.0%) | 461 (42.4%) | < 0.001 |
| Preop transfusion | 192 (1.6%) | 20 (1.8%) | 0.615 |
| Preop wound infection | 390 (3.2%) | 17 (1.6%) | 0.003 |
| Preop sepsis | 6145 (51.2%) | 516 (47.4%) | 0.019 |
| Preop ventilator | 115 (1.0%) | 6 (0.6%) | 0.191 |
| Wound class | 0.001 | ||
| Clean | 55 (0.5%) | 7 (0.6%) | – |
| Clean-contaminated | 1729 (14.4%) | 178 (16.4%) | – |
| Contaminated | 1630 (13.6%) | 184 (16.9%) | – |
| Dirty | 8593 (71.6%) | 719 (66.1%) | – |
| Complicated disease | 10,373 (86.4%) | 905 (83.2%) | 0.003 |
Categorical variables presented as N (%). Continuous variables presented as mean (± standard deviation)
ASA, American Society of Anesthesiologists; BMI, body mass index; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease
Table 2.
Bivariate results of short-term post-operative outcomes by ethnicity
| p-value | Odds ratio | 95% C.I | ||
|---|---|---|---|---|
| Lower | Upper | |||
| 30-day mortality | < 0.001 | 0.305 | 0.179 | 0.521 |
| 30-day morbidity | 0.248 | 0.929 | 0.819 | 1.053 |
| SSI (any) | 0.249 | 0.905 | 0.765 | 1.072 |
| Superficial SSI | 0.247 | 1.166 | 0.248 | 0.899 |
| Deep SSI | 0.399 | 1.270 | 0.728 | 2.216 |
| Organ space SSI | 0.042 | 0.808 | 0.657 | 0.993 |
| Wound dehiscence | 0.049 | 0.584 | 0.340 | 1.004 |
| Pneumonia | < 0.001 | 0.450 | 0.298 | 0.680 |
| Reintubation | < 0.001 | 0.336 | 0.193 | 0.586 |
| Pulmonary embolism | 0.715 | 0.892 | 0.481 | 1.653 |
| Prolonged ventilator | 0.005 | 0.642 | 0.470 | 0.875 |
| Renal insufficiency | 0.759 | 0.904 | 0.473 | 1.727 |
| Renal failure | 0.029 | 0.413 | 0.182 | 0.936 |
| Urinary tract infection | 0.979 | 0.994 | 0.619 | 1.596 |
| Stroke | 0.031* | – | – | – |
| Cardiac arrest | 0.007* | 0.255 | 0.081 | 0.801 |
| Myocardial infarction | 0.005* | 0.223 | 0.071 | 0.701 |
| DVT | 0.027 | 0.569 | 0.343 | 0.944 |
| Post-op sepsis | 0.001 | 1.273 | 1.103 | 1.469 |
| Post-op septic shock | < 0.001 | 0.571 | 0.436 | 0.748 |
| Post-op transfusion | < 0.001 | 0.630 | 0.498 | 0.797 |
| Laparoscopic surgery | < 0.001 | 1.500 | 1.305 | 1.725 |
| Ostomy creation | 0.004 | 0.823 | 0.720 | 0.941 |
| Operation duration, min | 0.284 | − 4.931 | − 9.926 | 0.063 |
| LOS, days | 0.008 | 0.814 | 0.335 | 1.293 |
| Reoperation | 0.051 | 0.757 | 0.572 | 1.002 |
| Readmission | 0.840 | 0.978 | 0.801 | 1.194 |
Categorical variables presented as N (%). Continuous variables presented as mean (± standard deviation)
DVT, deep venous thromboembolism; LOS, length of stay; SSI, surgical site infection
* Fisher’s Exact test
Table 3.
Multivariate regression of factors significantly associated with 30-day mortality
| p-value | Odds ratio | 95% C.I. for odds ratio | ||
|---|---|---|---|---|
| Lower | Upper | |||
| Age | < 0.001 | 1.085 | 1.073 | 1.097 |
| Hispanic ethnicity | 0.032 | 0.438 | 0.206 | 0.933 |
| Native Hawaiian/Pacific Islander race | 0.026 | 4.954 | 1.209 | 20.302 |
| Diabetes mellitus | 0.012 | 1.405 | 1.079 | 1.829 |
| COPD | < 0.001 | 2.232 | 1.732 | 2.878 |
| Ascites | < 0.001 | 3.699 | 1.938 | 7.059 |
| CHF | < 0.001 | 2.325 | 1.571 | 3.441 |
| Preop ventilator dependence | < 0.001 | 4.139 | 2.535 | 6.758 |
| Dialysis dependence | < 0.001 | 2.654 | 1.539 | 4.272 |
| Metastatic cancer | < 0.001 | 5.085 | 3.598 | 7.188 |
| Chronic steroid use | < 0.001 | 1.571 | 1.234 | 2.001 |
| Bleeding disorder | < 0.001 | 1.850 | 1.455 | 2.351 |
| Preoperative transfusion | 0.040 | 1.699 | 1.025 | 2.816 |
| Preoperative wound infection | 0.001 | 1.892 | 1.281 | 2.794 |
| Preoperative sepsis | < 0.001 | 2.728 | 2.115 | 3.517 |
| Emergent surgery | 0.001 | 1.509 | 1.195 | 1.904 |
| Wound classification | 0.049 | 1.210 | 1.001 | 1.463 |
| Laparoscopic surgery | 0.046 | 0.696 | 0.487 | 0.994 |
CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease
Discussion
This study found no difference in overall 30-day morbidity among Hispanic versus non-Hispanic patients who underwent surgery for acute diverticulitis, whereas 30-day mortality was lower among Hispanic patients compared to non-Hispanic patients. In addition, Hispanic patients had other favorable outcomes including shorter lengths of stay, higher rates of minimally invasive surgery, and fewer ostomy creations.
These results were surprising given the inequities in access to care and socioeconomic status of Hispanics in the USA. Hispanic patients in this dataset did have some favorable baseline features including fewer comorbidities, less complicated disease, and less preoperative sepsis which could explain higher rates of laparoscopy and lower stoma creation in this group. Prior studies using NSQIP data have found similar outcomes among Hispanic patients,3,4 the largest of which included 3.5 million patients, and found that Hispanic patients had lower 30-day post-operative morbidity and mortality.5 Another consideration to support these findings is the Hispanic epidemiological paradox, driven by factors that are not fully understood.5 Additionally, Hispanic ethnicity itself is a widely diverse group.6
This study suggests that Hispanic patients actually fare better compared to non-Hispanic patients undergoing non-elective surgery for acute diverticulitis. Future research should investigate the specific factors driving these differences in outcomes and the surgical outcomes for subgroups within the Hispanic population.
Acknowledgements
The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the sources of the data used herein; they have not been verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.
Author Contribution
Braschi—study design, data interpretation, manuscript writing and editing.
Liu—manuscript writing and editing.
Moazzez—study design, data analysis and interpretation, manuscript writing and editing.
Petrie—supervision, study design, manuscript writing and editing.
Data Availability
These data are avaialble by request from the American College of Surgeons National Surgical Quality Improvement Program.
Declarations
Conflict of Interest
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
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Associated Data
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Data Availability Statement
These data are avaialble by request from the American College of Surgeons National Surgical Quality Improvement Program.