Hospitalization for Constipation: A Most Preventable Admission

A poster presentation on October 14, 2013, at the 2013 American College of Gastroenterology Annual Scientific Session by Saurabh Sethi, MD (Beth Israel Deaconess Medical Center, Boston):

Sethi S, Wadhwa V, Lembo C, et al. Inpatient Burden of Constipation in the United States: An Analysis of National Trends From 1997-2010. (P1097)

Saurabh Sethi, MD, and his group at Harvard have pulled together some simple health services research data that should disturb any primary care physician. Health services researchers talk about preventable admissions-those which should never have happened if outpatient care and patient compliance were optimal. Sadly, for many patients, especially elderly ones who are most at risk for severe constipation, communication between home and clinic is poor. Patients become obstipated, and self-treat (or don’t treat), only presenting when they are in pain. Patients presenting with severe and painful constipation can resemble those with complete bowel obstruction or even acute abdomen. In the emergency department, staff may feel that the only way to rule out a severe abdominal process is to admit, treat constipation from below, and observe for return of normal bowel function. This is expensive and wasteful-and in the era of hospital-acquired infections, it’s a dangerous modality for treating a simple condition.

Dr Sethi’s group used data from the National Inpatient Sample (NIS) Database, pulling all subjects from an 8 million hospital-stay database in which constipation (ICD-9 codes 564.0 to 564.09) was the principal diagnosis, in all years from 1997 to 2010. Understand that this means that on discharge, constipation was felt to account for the preponderance of treatment during the hospitalization; it was not simply a comorbidity of a more serious diagnosis.

In 1997, there were 21,190 admissions with a principal diagnosis of constipation; by 2010 this had risen to 48,450 (P < .05). Mean length of stay was statistically unchanged (4.0 days in 2010 vs 3.8 days in 1997; P > .05). However, hospital charges increased 287% ($7406 in 1997 to $21,273 in 2010; P <. 01).

According to the US Administration on Aging’s report, A Profile of Older Americans, 2010, population growth among those over age 65 increased only 12.5% between 1999 and 2009. So even adjusting for the likely increase in elderly population over these 13 years of the study, these data document an increase far in excess of the likely growth in the elderly population-a 129% increase in constipation admissions. The authors do not speculate as to what is causing patients to be admitted more often for constipation. One explanation is the continuing rushed nature of primary care practice, but further study is needed to rule out other factors, including overworked and litigation-fearful emergency physicians, and possible data biases. Are the codes for constipation being used more often when the admission wasn’t justified except for social concerns, such as nursing home placement or respite for caregivers?

But underneath any speculation, primary care physicians should wonder about how to create systems and safety nets so patients’ constipation is treated before they present to emergency departments-once there, they’re at risk for an expensive and unnecessary admission. Satish Rao, MD, presented another lecture at ACG that gives us a framework for a very systematic and thorough approach to chronic constipation.