Mortality associated with medical therapy versus elective colectomy in ulcerative colitis: a cohort study

Abstract

Background: Ulcerative colitis (UC) can be treated with surgery or medications. Patients often must choose between long-term immunosuppressant therapy or total colectomy. Whether one of these treatment approaches has a mortality benefit is uncertain.

Objective: To determine whether patients with advanced UC treated with elective colectomy have improved survival compared with those treated with medical therapy.

Design: Retrospective matched cohort study.

Setting: Data from all 50 states for Medicaid beneficiaries (2000 to 2005), Medicare beneficiaries (2006 to 2011), and dual-eligible persons (2000 to 2011).

Patients: 830 patients with UC pursuing elective colectomy and 7541 matched patients with UC pursuing medical therapy.

Measurements: The primary outcome was time to death. Cox proportional hazards models were used to compare the survival of patients with advanced UC treated with elective colectomy or medical therapy. The models controlled for significant comorbid conditions through matched and adjusted analysis.

Results: The mortality rates associated with elective surgery and medical therapy were 34 and 54 deaths per 1000 person-years, respectively. Elective colectomy was associated with improved survival compared with long-term medical therapy (adjusted hazard ratio [HR], 0.67 [95% CI, 0.52 to 0.87]), although this result did not remain statistically significant in all sensitivity analyses. Post hoc analysis by age group showed improved survival with surgery in patients aged 50 years or older with advanced UC (HR, 0.60 [CI, 0.45 to 0.79]; P = 0.032 for age-by-treatment interaction).

Limitations: Retrospective nonrandomized analysis is subject to residual confounding. The source cohort was derived from different databases throughout the study. Sensitivity and secondary analyses had reduced statistical power.

Conclusion: Elective colectomy seemed to be associated with improved survival relative to medical therapy among patients aged 50 years or older with advanced UC.

Primary funding source: National Institutes of Health and Agency for Healthcare Research and Quality.

Figure 1

Identification of elective colectomy surgery patients

Figure 2

Cumulative incidence of death. Cumulative incidence is shown in bold lines; and 95% CI’s are indicated with thin lines. Medical therapy patients are illustrated in black and elective surgery in grey. Data utilized to generate Figure 2 are provided in Table 3.