Efficacy and safety of an early discharge protocol in low-risk patients with upper gastrointestinal bleeding

Initial assessment and management of patients with nonvariceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is a substantial clinical and economic burden, with an estimated mortality rate between 3% and 15%. The initial management starts with hemodynamic assessment and resuscitation. Blood transfusions may be needed in patients with low hemoglobin levels or massive bleeding, and patients who are anticoagulated may require administration of fresh frozen plasma. Patients with significant bleeding should be started on a proton-pump inhibitor infusion, and if there is concern for variceal bleeding, an octreotide infusion. Patients with UGIB should be stratified into low-risk and high-risk categories using validated risk scores. The use of these risk scores can aid in separating low-risk patients who are suitable for outpatient management or early discharge following endoscopy from patients who are at increased risk for needing endoscopic intervention, rebleeding, and death. Upper endoscopy after adequate resuscitation is required for most patients and should be performed within 24 hours of presentation. Key to improving outcomes is appropriate initial management of patients presenting with UGIB.

State of the art: emergency department observation units

Hospitals and emergency departments face the challenges of escalating healthcare costs, mismatched resource utilization, concern over avoidable admissions, and hospital and emergency department overcrowding. One approach that has been used by hospitals to address these issues is the use of emergency department observation units. Research in this setting has increased in recent years, leading to a better understanding of the role of these units and their unique benefits. These benefits have been proven for health systems as a whole and for several acute conditions including chest pain, asthma, syncope, transient ischemic attack, atrial fibrillation, heart failure, abdominal pain, and more. Benefits include a decrease in diagnostic uncertainty, lower cost and resource utilization, improved patient satisfaction, and clinical outcomes that are comparable to admitted patients. As more hospitals begin to use observation units, there is a need for further education and research in how to optimize the use of emergency department observation units. The purpose of this article is to provide a general overview of observation units, including advancements and research in this field.

Comparing the Blatchford and pre-endoscopic Rockall score in predicting the need for endoscopic therapy in patients with upper GI hemorrhage

BACKGROUND

The need for therapeutic endoscopy in patients with upper GI hemorrhage is important in determining the risk and disposition of these patients. Pre-endoscopic risk scores may be helpful in predicting this need.

OBJECTIVE

To test the Blatchford and pre-endoscopic Rockall scores with the need for therapeutic endoscopy as the primary outcome.

DESIGN

Prospective validation study.

SETTING

Tertiary-care university-affiliated hospital.

PATIENTS AND INTERVENTIONS

Between January 1, 2006 and February 28, 2007, 1087 patients with upper GI hemorrhage who had undergone an inpatient EGD within 24 hours were entered in the study.

MAIN OUTCOME MEASUREMENTS

Blatchford and pre-endoscopic Rockall scores were prospectively calculated for all patients, and the need for therapeutic endoscopy was determined during the EGD.

RESULTS

Of the 1087 patients, 297 (27.3%) needed therapeutic endoscopy. The mean Blatchford score for those who needed therapeutic endoscopy was significantly higher (mean [standard deviation]: 10.3 [3.5] vs 7.0 [4.4], P < .001). The area under a receiver-operating characteristic curve was 0.72 (95% CI, 0.68-0.75). A threshold of 0 (low risk) predicted the need for therapeutic endoscopy with 100% sensitivity and 6.3% specificity. Fifty (4.6%) patients were identified as low risk. The pre-endoscopic Rockall score was unable to predict this need.

LIMITATIONS

The decision to perform therapeutic endoscopy is a subjective one, although endoscopists are trained to follow international consensus guidelines.

CONCLUSIONS

The Blatchford score is more useful for predicting low-risk patients who do not need therapeutic endoscopy and who may be suitable for outpatient management. A threshold of 0 for low risk should be used. The Rockall score is not helpful in predicting the presence of low-risk lesions.

[Guidelines of treatment for bleeding peptic ulcer disease]

Peptic ulcer (PU) bleeding is the main cause of non-variceal gastrointestinal bleeding. Negative outcomes include re-bleeding and death, and many of the deaths are associated with decompensation of coexisting medical conditions precipitated by acute bleeding event. Accurate analysis of risk for clinical features can help physician to decide treatment modality. Endoscopy can detect bleeding stigmata and perform therapeutic hemostasis. Proton pump inhibitor (PPI) compared with placebo or H2RA reduces mortality following PU bleeding among patients with high-risk endoscopic findings, and reduces re-bleeding rates and surgical intervention. PPI treatment initiated prior to endoscopy in upper gastrointestinal (UGI) bleeding significantly reduces the proportion of patients with stigmata of recent hemorrhage (SRH) at index endoscopy but does not reduce mortality, re-bleeding or the need for surgery. The strategy of giving oral PPI before and after endoscopy, with endoscopic hemostasis for those with major SRH, is likely to be the most cost-effective. The treatment of H. pylori infection was found to be more effective than anti-secretory therapy in preventing recurrent bleeding from PU. H. pylori eradication alone and eradication followed by misoprostol (with switch to PPI, if misoprostol is not tolerated) are the two most cost-effective strategies to prevent ulcer bleeding among H. pylori-infected NSAID users, although the data cannot exclude PPIs also being cost-effective treatment. This review focuses specifically on the current treatment of patients with acute bleeding from a peptic ulcer.

Outpatient management of nonvariceal upper gastrointestinal hemorrhage: unexpected mortality in Medicare beneficiaries

BACKGROUND & AIMS

Outpatient management of selected patients with nonvariceal upper gastrointestinal hemorrhage (UGIH) has been proposed as a mechanism to decrease resource utilization and expenditures. However, the true prevalence and outcomes of this practice have not been well evaluated in population-based studies.

METHODS

We identified a cohort of 9123 episodes of UGIH in 2004 Medicare claims data, including 3506 (38.4%) managed as outpatients. Clinical characteristics, treatment, and outcomes were compared between inpatient and outpatient groups. In order to adjust for potential selection bias in outpatient treatment, propensity score analysis was used to divide patients into quartiles of likelihood for inpatient treatment.

RESULTS

Inpatients tended to be older, with higher comorbidity scores, and were more likely to have a bleeding ulcer or tear. Inpatients were also more likely to undergo endoscopy, including early endoscopy and therapeutics, and require surgery. The overall 30-day mortality rate was 8.0% in the inpatient group and 6.3% in the outpatient group (P< .001), and in the quartile of patients most likely to be managed as inpatients, the 30-day mortality rate was higher in outpatients than in inpatients.

CONCLUSIONS

The prevalence of outpatient management of UGIH in the Medicare population was almost 40%, and although patients were likely selected for outpatient management based on clinical criteria, the overall mortality rate in outpatients was considerable. Any potential financial benefit should be balanced against significant mortality rates, at least some of which could possibly be avoided with hospitalization. More optimal selection of candidates for outpatient therapy is likely needed.

Validation of the Rockall scoring system for outcomes from non-variceal upper gastrointestinal bleeding in a Canadian setting

AIM: To validate the Rockall scoring system for predicting outcomes of rebleeding, and the need for a surgical procedure and death.

METHODS: We used data extracted from the Registry of Upper Gastrointestinal Bleeding and Endoscopy including information of 1869 patients with non-variceal upper gastrointestinal bleeding treated in Canadian hospitals. Risk scores were calculated and used to classify patients based on outcomes. For each outcome, we used χ² goodness-of-fit tests to assess the degree of calibration, and built receiver operating characteristic curves and calculated the area under the curve (AUC) to evaluate the discriminative ability of the scoring system.

RESULTS: For rebleeding, the χ² goodness-of-fit test indicated an acceptable fit for the model [χ² (8) = 12.83, P = 0.12]. For surgical procedures [χ² (8) = 5.3, P = 0.73] and death [χ² (8) = 3.78, P = 0.88], the tests showed solid correspondence between observed proportions and predicted probabilities. The AUC was 0.59 (95% CI: 0.55-0.62) for the outcome of rebleeding and 0.60 (95% CI: 0.54-0.67) for surgical procedures, representing a poor discriminative ability of the scoring system. For the outcome of death, the AUC was 0.73 (95% CI: 0.69-0.78), indicating an acceptable discriminative ability.

CONCLUSION: The Rockall scoring system provides an acceptable tool to predict death, but performs poorly for endpoints of rebleeding and surgical procedures.

Predicting outcome of acute non-variceal upper gastrointestinal haemorrhage without endoscopy using the clinical Rockall Score

BACKGROUND

The Rockall risk scoring system uses clinical criteria and endoscopy to identify patients at risk of adverse outcomes after acute upper gastrointestinal haemorrhage. A clinical Rockall score obtained using only the clinical criteria may be able to predict outcome without endoscopy.

AIM

To validate the clinical Rockall Score in predicting outcome after acute non-variceal upper gastrointestinal haemorrhage.

METHODS

A retrospective observational study of consecutive patients who were admitted with non-variceal acute upper gastrointestinal haemorrhage was undertaken. Medical records were abstracted using a standardised form.

RESULTS

102 cases were identified (51 men and 51 women; mean age 59 years). 38 (37%) patients considered to be at low risk of adverse outcomes (clinical Rockall Score 0) had no adverse outcomes and did not require transfusion. Patients with a clinical Rockall Score of 1-3 had no adverse outcomes, although 13 of 45 (29%) patients required blood transfusions. Clinical Rockall Scores >3 (n = 19) were associated with adverse outcomes (rebleeding in 4 (21%), surgery in 1 (5%) and death in 2 (10%)).

CONCLUSIONS

The clinical Rockall Score without endoscopy may be a useful prognostic indicator in this cohort of patients with acute non-variceal upper gastrointestinal haemorrhage. This score may reduce the need for urgent endoscopy in low-risk patients, which can instead be carried out on a more elective outpatient basis.

Risk assessment and outpatient management in bleeding peptic ulcer

AIMS

1) To review clinical and endoscopic variables in patients hospitalized for upper gastrointestinal bleeding (UGIB) due to peptic gastroduodenal lesions over a period of 3 years; 2) to identify factors associated with unfavorable evolution; and 3) to evaluate characteristics of patients discharged immediately after endoscopy.

METHODS

A 3-year retrospective analysis of all UGIB episodes was performed. Patients with gastroduodenal ulcer or erosive gastritis/duodenitis at endoscopy were included. The prognostic value of several clinical, endoscopic, and analytical variables was assessed. Persistence or recurrence of bleeding, surgery, and mortality were considered as outcome variables (evolution was classified as "unfavorable" when any of these was observed).

RESULTS

A total of 341 patients were identified, with a mean age of 62 years. Melena was the most frequent UGIB presentation (70%). Forty-five percent had associated diseases, and 45% were taking gastroerosive drugs. Duodenal ulcer was the most frequent cause of UGIB (48%), followed by gastric ulcer (32%). The evolution of UGIB was unfavorable in 7% of cases. Variables associated with unfavorable evolution in the multivariate analysis were: systolic blood pressure < or = 100 mm Hg, heart rate > or = 100 bpm, and a Forrest endoscopic classification of severe. Only 10% of patients were immediately discharged, with no subsequent complications. However, if predictive variables obtained in the multivariate analysis had been used, hospitalization could have been prevented in 115 patients (34%) without subsequent complications.

CONCLUSIONS

A number of clinical and endoscopic variables (blood pressure, heart rate, and endoscopic stigmata of bleeding) with prognostic value have been identified. These are easy to obtain and apply in clinical practice and allow an accurate estimation of the evolution of UGIB. This diagnostic strategy identifies a relatively high proportion of UGIB patients who can be managed on an outpatient basis.

A randomized study of the safety of outpatient care for patients with bleeding peptic ulcer treated by endoscopic injection

BACKGROUND

Outpatient management is safe for patients with non-variceal upper-GI bleeding who are at low risk of recurrent bleeding and death. However, outpatient care cannot be offered to many patients because of the presence of risk factors (severe comorbid disorders, major endoscopic stigmata of bleeding, significant hemorrhage). The present study assessed the safety of outpatient management for selected high-risk patients with bleeding peptic ulcer.

METHODS

Patients hospitalized with upper-GI bleeding because of peptic ulcer with a non-bleeding vessel were eligible for inclusion in the study. Inclusion criteria were the following: ulcer size less than 15 mm, absence of hypovolemia, no associated severe disease, and appropriate family support. After endoscopic therapy (injection of epinephrine and polidocanol), patients were randomized to outpatient or hospital care. Patients remained in the emergency ward for a minimum of 6 hours before discharge, during which time omeprazole was administered intravenously. Outpatients were contacted by telephone daily during the first 3 days; a 24-hour telephone hotline was provided for any queries. For both groups, outpatient visits were scheduled at 7 to 10 and 30 days after discharge.

RESULTS

A total of 82 patients were included: 40 were randomized to outpatient care and 42 to hospital care. Clinical and endoscopic variables were similar in both groups. The rate of recurrent bleeding was similar in both groups (4.8% outpatient, 5% hospital). There was no morbidity or mortality in either group at 30 days. Seven patients (17%) randomized to outpatient care received blood transfusion compared with 14 (38%) in the hospital care group (p=0.06). Mean cost of care per patient was significantly lower for the outpatient vs. the hospital group (970 US dollars vs. 1595 US dollars; p < 0.001).

CONCLUSIONS

Selected patients with bleeding peptic ulcer can be safely managed as outpatients after endoscopic therapy. This policy conserves health care resources without compromising standards of care.

A risk score system for identification of patients with upper-GI bleeding suitable for outpatient management

BACKGROUND

The aim of this study was to develop a risk score system for identification of patients with upper-GI hemorrhage who are suitable for outpatient management.

METHODS

From a prospective cohort of 983 consecutive patients with upper-GI hemorrhage not associated with portal hypertension, 581 cases that did not meet pre-established criteria for admission were selected, and a logistic regression analysis was performed to identify factors associated with two adverse outcomes: recurrent bleeding and/or the need for emergency surgery. The risk score system was developed by using the beta coefficients of the logistic model, and its performance was evaluated. The results of this model were combined with pre-established criteria for admission to build a simplified scoring system for identification of patients who can be managed safely on an outpatient basis.

RESULTS

Chronic alcoholism, active malignancy, prior upper digestive tract surgery, wasting syndrome, hemodynamic compromise, duodenal ulcer as the cause of upper-GI hemorrhage, and hemorrhage of unknown cause were independently associated with a greater risk of unfavorable outcomes in the group that did not meet pre-established criteria for admission. The logistic model showed a high capacity for discrimination (C statistic: 0.87) and good calibration (p value for Hosmer-Lemeshow goodness-of-fit test, 0.62), with a sensitivity of 100% and specificity of 64%. The simplified score had a sensitivity of 100% and specificity of 29% for adverse outcomes, and sensitivity of 78% and specificity of 38% for mortality.

CONCLUSIONS

The score system developed in this study may be helpful in deciding between hospitalization and outpatient management for patients with upper-GI hemorrhage, but it remains to be validated in patient groups other than those used for its development.

Hospital care for low-risk patients with acute, nonvariceal upper GI hemorrhage: a comparison of neighboring community and tertiary care centers

OBJECTIVES

The proportion of patients admitted to the hospital with acute upper GI hemorrhage (UGIH) who are at low risk for adverse outcomes may be substantial. The process of care for this low risk population likely varies across practice settings but has not been extensively studied. Use of the Rockall Risk score, a simple validated scoring index that predicts outcomes in UGIH, may help to identify these low risk patients.

METHODS

We evaluated and compared the incidence of low risk UGIH admissions, adverse outcomes, and level of healthcare resource use in a community hospital (SMH) and a neighboring tertiary care university hospital (CHS). Cases of UGIH were identified from administrative databases during 1997 and 1998. Medical record data were abstracted in a standardized manner. Cases were defined as low risk on the basis of Rockall risk scores of < or = 2.

RESULTS

The low risk study groups consisted of 49 of 187 (26%) SMH cases and 53/175 (30%) CHS cases (p = 0.40). Rebleeding was uncommon (6% at SMH; 4% at CHS) (p = 0.64). No deaths occurred; 71% at SMH versus 49% at CHS were admitted to a monitored bed (p = 0.04); and 92% at SMH versus 57% at CHS were prescribed i.v. H2 blockers for the acute bleeding event (p < 0.001). Low risk patients had a mean hospital length of stay of 3.3 + 2.4 days at SMH versus 2.6 + 2.1 days at CHS (p = 0.15).

CONCLUSIONS

In this study, the proportion of acute, low risk, nonvariceal, upper GI hemorrhage admissions to neighboring community and tertiary care medical centers was high, whereas adverse clinical outcomes in this group of patients was low. Use of healthcare resources seemed to be greater in the community hospital. This observed variation in the process of care for populations with similar disease severity and outcomes suggests an opportunity for evidence-based interventions aimed at improving the efficiency of care.

Impact of physician specialty on the cost of nonvariceal upper GI bleeding care

OBJECTIVE

Upper GI bleeding (UGIB) is a common medical emergency that leads to a high consumption of medical resources and costs. We aimed to analyze the influence of physician specialty on the costs of nonvariceal UGIB care.

METHODS

We retrospectively assessed 350 nonvariceal UGIB episodes that were primarily cared for by gastroenterologists (n = 142), internists (n = 67), or surgeons (n = 141). Gastroenterologists followed evidence-based clinical protocols that included early endoscopy and early hospital discharge for uncomplicated bleeding. A risk score system was used to control for severity of illness. Linear regression analyses were performed to find out predictors of costs and the influence of specialist care on length of stay (LOS).

RESULTS

The overall mean hospital cost was significantly lower in patients cared for by gastroenterologists (EUR 1,630) than in those managed by internists (EUR 3,745, p < 0.001) or surgeons (EUR 2,513, p < 0.05). The mean LOS was the variable with highest influence on total cost. Patients cared for by gastroenterologists had a mean LOS significantly shorter (7.3 days) than that of those treated by internists (16.2 days, p < 0.001) or surgeons (11 days, p < 0.001). Hospital costs and LOS differences were maintained when adjusting for severity of illness. In caring for low risk patients, nongastroenterologists had a higher probability of having a hospital stay longer than 4 days (odds ratio = 18.4, Cl = 4.6-73.6, p < 0.001).

CONCLUSION

The implementation of specific evidence-based protocols by gastroenterologists reduces length of hospital stay and saves medical costs in patients with nonvariceal UGIB, especially those at low risk.

[Clinical and endoscopic prognostic factors in patients with bleeding peptic ulcer]

BACKGROUND

The main objectives of this study were to review the clinic and endoscopic variables of patients with upper gastrointestinal bleeding (UGB) due to peptic gastroduodenal lesions who were evaluated in our hospital during one year, to identify the characteristics associated with a negative evolution of the UGB and to analyse the characteristics of those patients who were discharged immediately after the endoscopy was performed.

PATIENTS AND METHOD

A one-year retrospective analysis of all UGB episodes was performed. Patients having gastroduodenal ulcer or erosive gastritis/duodenitis at endoscopy were included. The prognostic value of several clinic, laboratory and endoscopic variables was evaluated. Persistence or recurrence of bleeding, surgery and mortality were considered as outcome variables (the variable evolution was categorized as negative when any of these was observed).

RESULTS

156 patients were identified, with a mean (SD) age of 61 (17) years. Melena was the most frequent UGB presentation (79%). 46% patients had associated diseases and 50% were taking gastroerosive drugs. Duodenal ulcer was the commonest cause of UGB (52%), followed by gastric ulcer (30%). The evolution of UGB was negative in 7% cases. Variables associated with a negative evolution in the multivariate analysis were: age, red hematemesis, systolic blood pressure >= 100 mmHg, heart rate >= 100 b.p.m. and a more severe Forrest endoscopic classification. 11% patients were discharged immediately, without complications afterwards. If predictive variables obtained in the multivariate analysis would have been applied, hospitalization would have been avoided in 59 patients (38%) without subsequent complications.

CONCLUSIONS

A number of clinic and endoscopic variables (UGB presentation form, blood pressure, heart rate, and Forrest endoscopic classification) with prognostic value have been identified in this study. These variables are easy to obtain and apply in clinical practice, allowing a precise estimate of the UGB evolution. Thus, a relatively high number of patients with UGB susceptible of ambulatory treatment and management can be reliably identified.

Utilization of health care resources for low-risk patients with acute, nonvariceal upper GI hemorrhage: an historical cohort study

BACKGROUND

Adults hospitalized with acute, nonvariceal upper GI hemorrhage can be accurately stratified according to their risk of subsequent adverse outcomes by using the Rockall score. Low-risk patients (Rockall score less-than-or-equal 2) may be candidates for early discharge.

METHODS

Cases were identified with ICD-9-CM codes for calendar years 1997 and 1998. Medical record data to determine patient Rockall risk score, health care resource utilization, and adverse outcomes were abstracted with standardized forms.

RESULTS

Fifty-three of 175 (30%) cases had Rockall scores < or =2. As predicted, those patients with Rockall scores < or =2 had a low risk of adverse outcomes with only 2 of 53 (4%) meeting criteria for recurrent bleeding as defined by the "Rebleed" variable, and no mortality. These low-risk patients had a mean hospital stay of 2.6 plus minus 2.1 days; 49% were admitted to an intermediate or intensive care unit bed and 57% were given H2 receptor antagonists intravenously.

CONCLUSIONS

The proportion of patients admitted with acute, nonvariceal, upper GI hemorrhage with Rockall Scores < or =2 was substantial. Adverse outcomes were rare. In contrast, the level of health care resource utilization appeared high. The Rockall score has potential as a clinically based concurrent decision rule to improve the quality of care by finding those patients less likely to require intensive health care services.

Outpatient management for low-risk nonvariceal upper GI bleeding: a randomized controlled trial

BACKGROUND

Patients with acute nonvariceal upper GI hemorrhage are routinely hospitalized, regardless of clinical status or endoscopic findings. The aim of this study was to compare outcomes for outpatient versus hospital care of patients with nonvariceal upper GI hemorrhage at low risk of recurrent bleeding.

METHODS

Endoscopic and clinical criteria were used to select patients at low risk for recurrent bleeding. Ninety-five consecutive patients were randomized for either early discharge and outpatient care (48) or hospital care (47). Baseline clinical and endoscopic features were comparable. During the first 30 days patients were examined daily by their primary care physician and contacted by a gastroenterologist by telephone to assess clinical status. Rates of recurrent bleeding, hospitalization, surgery, and mortality were determined.

RESULTS

All patients underwent endoscopy within 12 hours of the onset of hemorrhage. No patient underwent surgery or died. Rates of recurrent bleeding were 2.1% in the early discharge group and 2.2% in the hospital-treated group (1 patient in each group). Median costs were $340 for the outpatient group and $3940 for the hospital group (p = 0.001).

CONCLUSIONS

Outpatient care of patients at low risk for recurrent nonvariceal upper GI hemorrhage is safe and can lead to significant savings in hospital costs.

Prediction of resource utilization and case cost for acute nonvariceal upper gastrointestinal hemorrhage at a Canadian community hospital

OBJECTIVE

Upper gastrointestinal hemorrhage (UGIH) is common, and thus imposes a substantial burden on health care resources. We describe resource utilization and cost for management of acute nonvariceal UGIH, and studied their variation among population subgroups.

METHODS

Resource utilization and direct medical case costs were extracted for consecutive admissions for nonvariceal UGIH at a large community hospital in southern Ontario through chart review and adaptation of an administrative case cost database. Univariate and multiple regression models were then developed to identify independent demographic predictors of case cost and length of stay.

RESULTS

Among 116 eligible admissions the average length of stay and case cost were 4.26 days and Can$2690, respectively (Can$1 = US$0.70). Both cost and length of stay demonstrated significant univariate relationships with age, comorbid illness, prior peptic ulcer disease (PUD), and prior UGIH. Age and prior PUD persisted as independent predictors in multiple regression models. An inverse transformation of total case cost allowed these variables to explain 26% of the total variance.

CONCLUSIONS

Resource utilization for management of acute nonvariceal UGIH at a Canadian community hospital varies substantially among population subgroups, but correlates independently with age and prior ulcer history. Careful attention must be paid to practice environments and demographic profiles before economic models of strategies to prevent or treat UGIH are applied to specific subpopulations.