GS2 - The Impact of Social Determinants of Health on Ostomy Reversal in Diverticulitis

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Purpose/Background: Colectomy with temporary ostomy remains the most prevalent surgical management of diverticulitis. Many of these temporary ostomies, unfortunately, are never reversed. Several factors affect the rate of ostomy reversal (OR) after surgery for diverticulitis. The purpose of this study was to evaluate the impact of social determinants of health on time to and rate of OR.

Methods/Interventions: This was an institutional review board approved retrospective study of patients who underwent ostomy creation for diverticulitis from January 2018 to December 2022 and were followed until December 2023. Patients with inflammatory bowel disease, planned permanent ostomy, and mortality within 1 year of index operation were excluded. The primary aim was to determine the effect of social determinants of health on time to and rate of OR. Chart review of patient demographics, medical/surgical history, procedure performed (Hartmann’s (HP), or primary anastomosis with diverting ostomy (PA+)), reversal information, and patient outcomes was performed. Patient’s home zip code was used to assign a distressed community index (DCI) to each patient. DCI uses the latest census data to classify patients into one of five different quintiles of economic well-being: prosperous, comfortable, mid-tier, at risk, and distressed. Data were assessed with Mann-Whitney U-tests (continuous variables), Chi-square tests (categorical variables), and logistic regression models. Logistic regression was used to identify predictors of failure of ostomy reversal and timing of reversal.

Results/Outcomes: One hundred and nine patients underwent ostomy creation, either HP or PA+, and were included in the final analysis. Mean age of the cohort was 59 years. The majority were female (53%) and white (82%). Most of the procedures were urgent (73%) and 55% of patients underwent HP. Almost 90% of the study population went on to have an ostomy reversal. The most common reason for non-reversal was loss to follow up. Patients who did not undergo ostomy reversal were more likely to be older (p=0.029), non-white (p=0.004), live in at risk neighborhoods (p=0.004), unhoused (p < 0.001), widowed (p < 0.001), and have a HP as their index procedure (p=0.007).They were also more likely to have a longer hospital length of stay (HLOS) (p=0.002) and less likely to be discharged home (p < 0.001) after the index procedure. Patients who had delayed reversal (> 6 months after index procedure) were more likely to be female (p=0.02), have undergone a HP (p = 0.003), experience a complication (p=0.004), have a longer HLOS (p=0.04), and be discharged to a skilled nursing facility (p=0.03) after index procedure. We found female sex (p=0.003), living in at risk neighborhoods (p=0.026), complication after index surgery (p=0.005), and HP (p=0.007) to be independent predictors of delayed ostomy reversal. Insurance status, employment status, and religious preference were not significantly associated with OR.

Conclusion/Discussion: Our data suggests that patients from distressed communities that underwent a HP for diverticulitis were more likely to have delayed reversal, if at all. Patients with several social determinants of health challenges requiring surgical management for diverticulitis should be strongly considered for PA over HP. These same social determinants should also be used to identify patients at high risk for non-reversal and thus closer follow up in the post operative period.