Effect of race and insurance status on presentation, treatment, and mortality in patients undergoing surgery for diverticulitis

Objective: To determine the effect of race and insurance status on patient presentation, treatment, and mortality in individuals who underwent surgery for diverticulitis. Design: Retrospective analysis of the Nationwide Inpatient Sample file from 1999 to 2003. Setting: A 20% representative sample of all hospitals in 37 states in the United States. Patients: Patients admitted with a primary diagnosis of diverticulitis who subsequently underwent either colectomy and/or colostomy (n = 45 528). Main Outcome Measures: Odds ratios (ORs) for association of race (black vs white) and insurance status (Medicaid or self-pay [inadequate insurance] vs other insurance) with (1) complicated presentation, (2) colostomy, and (3) in-hospital mortality. Results: On multivariate analysis, black race was significantly associated with complicated presentation (OR, 1.16; 95% confidence interval [CI], 1.04-1.30) and mortality (OR, 1.41; 95% CI, 1.06-1.86) but not with receiving a colostomy. In contrast, insurance status was significantly associated with complicated presentation (OR, 1.21; 95% CI, 1.08-1.36), receiving a colostomy (OR, 2.10; 95% CI, 1.89-2.32), and mortality (OR, 2.64; 95% CI, 1.82-3.82). Conclusions: Black patients were no more likely than white patients to undergo colostomy; however, race was a significant variable on patient presentation. Therefore, racial differences in outcome can be attributed to differences in patient presentation and not to differences in treatment received. Lack of adequate health insurance is a more powerful predictor of disease severity, suboptimal surgical treatment, and mortality.