Retrospective Cohort Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Aug 16, 2022; 14(8): 474-486
Published online Aug 16, 2022. doi: 10.4253/wjge.v14.i8.474
Disparities in colonoscopy utilization for lower gastrointestinal bleeding in rural vs urban settings in the United States
Nagapratap Ganta, Mina Aknouk, Dina Alnabwani, Ivan Nikiforov, Veera Jayasree Latha Bommu, Vraj Patel, Pramil Cheriyath, Christopher S Hollenbeak, Alan Hamza
Nagapratap Ganta, Mina Aknouk, Dina Alnabwani, Ivan Nikiforov, Veera Jayasree Latha Bommu, Vraj Patel, Pramil Cheriyath, Department of Internal Medicine, Hackensack Meridian Health Ocean Medical Center, Brick, NJ 08724, United States
Christopher S Hollenbeak, Penn State Milton S. Hershey Medical Center, 500 University Drive, University Park, PA 16802, United States
Alan Hamza, Department of Internal Medicine, Ocala Health, Ocala, FL 34471, United States
Author contributions: Ganta N and Aknouk M contributed equally to this work; Ganta N, Aknouk M, Nikiforov I, Bommu VJL, Patel V, Cheriyath P, Hollenbeak C, and Hamza A, designed the research study; Ganta N, Aknouk M, Alnabwani D, Nikiforov I, Bommu VJL, Patel V, and Hollenbeak C performed the research; Hollenbeak C, Nikiforov I, and Cheriyath P contributed in statistical analysis; Ganta N, Aknouk M, Alnabwani D, Nikiforov I, Bommu VJL, Patel V, and Hollenbeak C analyzed the data and wrote the manuscript.
Conflict-of-interest statement: All authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Pramil Cheriyath, FACP, MBBS, MD, MS, Director, Doctor, Department of Internal Medicine, Hackensack Meridian Health Ocean Medical Center, 1610 NJ-88, Brick, NJ 08724, United States. pramil.cheriyath@hmhn.org
Received: February 15, 2022
Peer-review started: February 15, 2022
First decision: April 12, 2022
Revised: May 14, 2022
Accepted: July 22, 2022
Article in press: July 22, 2022
Published online: August 16, 2022
Abstract
BACKGROUND

Lower gastrointestinal bleeds (LGIB) is a very common inpatient condition in the United States. Gastrointestinal bleeds have a variety of presentations, from minor bleeding to severe hemorrhage and shock. Although previous studies investigated the efficacy of colonoscopy in hospitalized patients with LGIB, there is limited research that discusses disparities in colonoscopy utilization in patients with LGIB in urban and rural settings.

AIM

To investigate the difference in utilization of colonoscopy in lower gastrointestinal bleeding between patients hospitalized in urban and rural hospitals.

METHODS

This is a retrospective cohort study of 157748 patients using National Inpatient Sample data and the Healthcare Cost and Utilization Project provided by the Agency for Healthcare Research and Quality. It includes patients 18 years and older hospitalized with LGIB admitted between 2010 and 2016. This study does not differentiate between acute and chronic LGIB and both are included in this study. The primary outcome measure of this study was the utilization of colonoscopy among patients in rural and urban hospitals admitted for lower gastrointestinal bleeds; the secondary outcome measures were in-hospital mortality, length of stay, and costs involved in those receiving colonoscopy for LGIB. Statistical analyses were all performed using STATA software. Logistic regression was used to analyze the utilization of colonoscopy and mortality, and a generalized linear model was used to analyze the length of stay and cost.

RESULTS

Our study found that 37.9% of LGIB patients at rural hospitals compared to approximately 45.1% at urban hospitals received colonoscopy, (OR = 0.730, 95%CI: 0.705-0.7, P > 0.0001). After controlling for covariates, colonoscopies were found to have a protective association with lower in-hospital mortality (OR = 0.498, 95%CI: 0.446-0.557, P < 0.0001), but a longer length of stay by 0.72 d (95%CI: 0.677-0.759 d, P < 0.0001) and approximately $2199 in increased costs.

CONCLUSION

Although there was a lower percentage of LGIB patients that received colonoscopies in rural hospitals compared to urban hospitals, patients in both urban and rural hospitals with LGIB undergoing colonoscopy had decreased in-hospital mortality. In both settings, benefit came at a cost of extended stay, and higher total costs.

Keywords: Lower gastrointestinal bleeding, Rural-urban disparities, Colonoscopy, Utilization of colonoscopy, Length of stay, Inpatient admission costs

Core Tip: Colonoscopy utilization is lower in rural hospitals than in urban hospitals in the United States for all acute and chronic lower gastrointestinal bleeding. Patients in both rural and urban hospitals who present with lower gastrointestinal bleeds that undergo colonoscopy have decreased in-hospital mortality, an extended length of hospital stay, and higher total costs.