Managing patients with acute, nonvariceal gastrointestinal hemorrhage: development and effectiveness of a clinical care pathway

Clinical Pathway for Enhanced Recovery in the Management of Non-Variceal Upper Gastrointestinal Bleeding: A Randomized Controlled Trial

Purpose

To explore the effects of the clinical pathway on the outcomes of patients with non-variceal upper gastrointestinal bleeding.

Materials and Methods

Randomized controlled trial. The study was conducted in two medical centers in China from 1 June 2022 to 31 December 2022. Patients with a diagnosis of non-variceal upper gastrointestinal bleeding who provided written informed consent were consecutively assigned to the intervention group. The patients in the intervention group were treated using the clinical pathway, while the control group received routine care and follow-up. Time, cost, complications, and prognostic indicators were analyzed. Intentional-to-treat analysis and per-protocol analysis were used for data analysis.

Results

A total of 114 eligible patients with non-variceal upper gastrointestinal bleeding were randomly divided into two groups and included in the intention-to-treat analysis. In addition, 106 patients were included in the per-protocol analysis. The median age of the 106 patients was 57 years (range, 18-92 years) and 83.0% were male. There were no significant differences between groups regarding the baseline characteristics. The intervention group demonstrated a statistically significantly shorter length of stay, lower hospital cost (ie, cost during hospitalization, cost in the emergency room, and cost in the ward), significantly fewer cases of complications, and a higher level of patient satisfaction when compared with the control group. There was no significant difference between the two groups in the rates of transfusion, repeat endoscopy, rebleeding readmission, and mortality.

Conclusion

The implementation of the clinical pathway for patients with non-variceal upper gastrointestinal bleeding may help improve patient outcomes and satisfaction.

Trial Registration Number

ChiCTR2200060316.

Registration Link

https://www.chictr.org.cn/.

White Coats at the Coalface: The Standardizing Work of Professionals at the Frontline

This study advances theory on professionals by introducing a novel ‘coalface perspective’ to study frontline professionals’ standardizing work. Our multimethod quantitative and qualitative approach explores when, why and how medical professionals in German university hospitals actively maintain care pathway enactment – a technique to standardize day-to-day medical work – in their everyday patient treatment. Professionals’ actively standardizing their work is an understudied yet highly relevant phenomenon that the established ‘autonomy perspective’ – which covers how professionals resist standardization – falls short of explaining. Introducing a coalface perspective overcomes this shortcoming by uncovering novel links between professionals’ day-to-day problem-driven motivations for standardizing work, the characteristics of everyday situations of frontline professional work and practices of standardizing work at the frontline. This study has implications for research on frontline professionals and coalface-perspective research in general.

Effects of Clinical Pathways: Do They Work?

Objective:

Evaluation of the effect of implementing clinical pathways is a relatively new field in health care research. Little is known about the way in which practice is influenced by the implementation of clinical pathways, and to what degree. This review takes significant steps in answering these questions by describing the parameters that are used in literature as indicators to evaluate clinical pathways.

Methods:

A Medline-based review of literature published between 2000 and 2002 was carried out using the keywords ‘clinical pathway’, ‘critical pathway’, ‘care map’, ‘care pathway’ and ‘integrated care pathway’. Articles were selected if they contained any form of evaluation, outcome or indicator concerning the use of clinical pathways. This included all types of research design and sample size. A total of 200 articles were selected. Relevant data were summarized using the following characteristics: country of origin, clinical field of expertise, research design, sample size, clinical outcome indicators, service indicators, team indicators, process indicators and financial indicators. For each domain a positive, negative or ‘no effect’ conclusion was recorded. Excel® and Statistica® were used to obtain percentages and graphics.

Results:

A total of 34% of the articles on clinical pathways contained some form of evaluation concerning the effect of the implementation. Out of these articles, clinical outcome was emphasized in 65.5%, financial effects in 53%) and process effects were investigated by 50% of the studies. Team and service effects were discussed less often (24% and 18.5%), respectively). For clinical outcome, team, process and financial effects a variety of indicators were recorded. Service effects were almost always measured as ‘patient satisfaction’. The majority of the literature concluded that positive effects result from the implementation of clinical pathways.

Conclusion:

On a macro level clinical pathways result globally in positive effects. Negative results, however, were also present in the literature. In particular for process, team and service evaluation concerning the use of clinical pathways there is still a great need for research.

Transcatheter arterial embolization for endoscopically unmanageable non-variceal upper gastrointestinal bleeding

OBJECTIVE

Transcatheter arterial embolization (TAE) is a therapeutic option for endoscopically unmanageable upper gastrointestinal (GI) bleeding. We aimed to assess the efficacy and clinical outcomes of TAE for acute non-variceal upper GI bleeding and to identify predictors of recurrent bleeding within 30 days.

MATERIALS AND METHODS

Visceral angiography was performed in 66 patients (42 men, 24 women; mean age, 60.3 ± 12.7 years) who experienced acute non-variceal upper GI bleeding that failed to be controlled by endoscopy during a 7-year period. Clinical information was reviewed retrospectively. Outcomes included technical success rates, complications, and 30-day rebleeding and mortality rates.

RESULTS

TAE was feasible in 59 patients. The technical success rate was 98%. Rebleeding within 30 days was observed in 47% after an initial TAE and was managed with re-embolization in 8, by endoscopic intervention in 5, by surgery in 2, and by conservative care in 12 patients. The 30-day overall mortality rate was 42.4%. In the case of initial endoscopic hemostasis failure (n = 34), 31 patients underwent angiographic embolization, which was successful in 30 patients (96.8%). Rebleeding occurred in 15 patients (50%), mainly because of malignancy. Two factors were independent predictors of rebleeding within 30 days by multivariate analysis: coagulopathy (odds ratio [OR] = 4.37; 95% confidence interval [CI]: 1.25-15.29; p = 0.021) and embolization in ≥2 territories (OR = 4.93; 95% CI: 1.43-17.04; p = 0.012). Catheterization-related complications included hepatic artery dissection and splenic embolization.

CONCLUSION

TAE controlled acute non-variceal upper GI bleeding effectively. TAE may be considered when endoscopic therapy is unavailable or unsuccessful. Correction of coagulopathy before TAE is recommended.

Assessment of the validity of the clinical pathway for colon endoscopic submucosal dissection

AIM: To determine the effective hospitalization period as the clinical pathway to prepare patients for endoscopic submucosal dissection (ESD).

METHODS: This is a retrospective observational study which included 189 patients consecutively treated by ESD at the National Cancer Center Hospital from May 2007 to March 2009. Patients were divided into 2 groups; patients in group A were discharged in 5 d and patients in group B included those who stayed longer than 5 d. The following data were collected for both groups: mean hospitalization period, tumor site, median tumor size, post-ESD rectal bleeding requiring urgent endoscopy, perforation during or after ESD, abdominal pain, fever above 38  °C, and blood test results positive for inflammatory markers before and after ESD. Each parameter was compared after data collection.

RESULTS: A total of 83% (156/189) of all patients could be discharged from the hospital on day 3 post-ESD. Complications were observed in 12.1% (23/189) of patients. Perforation occurred in 3.7% (7/189) of patients. All the perforations occurred during the ESD procedure and they were managed with endoscopic clipping. The incidence of post-operative bleeding was 2.6% (5/189); all the cases involved rectal bleeding. We divided the subjects into 2 groups: tumor diameter ≥ 4 cm and < 4 cm; there was no significant difference between the 2 groups (P = 0.93, χ² test with Yates correction). The incidence of abdominal pain was 3.7% (7/189). All the cases occurred on the day of the procedure or the next day. The median white blood cell count was 6800 ± 2280 (cells/μL; ± SD) for group A, and 7700 ± 2775 (cells/μL; ± SD) for group B, showing a statistically significant difference (P = 0.023, t-test). The mean C-reactive protein values the day after ESD were 0.4 ± 1.3 mg/dL and 0.5 ± 1.3 mg/dL for groups A and B, respectively, with no significant difference between the 2 groups (P = 0.54, t-test).

CONCLUSION: One-day admission is sufficient in the absence of complications during ESD or early post-operative bleeding.

[Current management of nonvariceal upper gastrointestinal bleeding in Spain]

BACKGROUND

Mortality related to nonvariceal upper gastrointestinal bleeding (NVUGIB) has not changed. More information is needed to improve the management of this entity. The aims of this study were: a) to determine the characteristics of bleeding episodes, b) to describe the clinical approaches routinely used in NVUGIB, and c) to identify adverse outcomes related to endoscopic or medical treatments in Spain.

METHODS

The European survey of nonvariceal upper GI bleeding (ENERGiB) was an observational, retrospective cohort study on NVUGIB with endoscopic evaluation carried out across Europe. The present study focused on Spanish patients in the ENERGiB study. The patients were managed according to routine care. The mean and standard deviation were calculated for quantitative variables and absolute and relative frequencies were calculated for categorical variables.

RESULTS

Patients (n=403) were mostly men (71%), with a mean age of 65 years, and co-morbidities (62.5%). Most of the patients were managed by gastroenterologists (57.1%) or internal medicine teams (25.1%). A proton pump inhibitor was used empirically in 80% before endoscopy. Bleeding persistence occurred in 6.4% and recurrence in 6.7%. The mortality rate at 30 days was 3.5%.

CONCLUSIONS

This study contributes to the characterization of Spanish patients and NVUGIB episodes in a real clinical setting and identifies the routine management of this entity, which is in line with the standards proposed by recent clinical practice guidelines. A notable finding was that age and the number of comorbidities in NVUGIB patients were increasing. These factors could explain the persistent mortality rate, despite the evident advances in the management of this entity.

Impact of a bleeding care pathway in the management of acute upper gastrointestinal bleeding

OBJECTIVES

Upper gastrointestinal (UGI) bleeding carries high morbidity and mortality. The use of a bleeding care pathway (BCP) may improve outcomes, but the results are inconsistent in various studies.

METHODS

A BCP for patients with UGI bleed with admission in a bleeding care unit (BCU) has been in use at our hospital since 2005. Prior to this, a high dependency unit was used for management of all emergencies including UGI bleeding. We compared the length of stay in the bleeding care/high dependency unit, total hospital stay, time to UGI endoscopy after admission, and survival between pre-2005 and post-2005 patients.

RESULTS

Five hundred and fifty-one patients were admitted with acute UGI bleed in the last 5 years; 121 belonged to pre-BCP (2004) period and 430 after implementation of the pathway (2005-2008). The mean (SD) time to UGI endoscopy improved from 21.3 (7.4) hours in the pre-BCU era to 9.4 (9.9) hours in BCU, p < 0.001. BCU stay was shorter from 2.41 (1.4) days pre-BCP to 1.93 (1.32) days post-BCP, (p < 0.001). The total hospital stay in pre-BCU (4.0 [2.08] days) as compared to BCU (4.13 [2.62] days; p = 0.58) was similar; there was no impact of BCU on survival.

CONCLUSION

A BCU implementation showed improvement in time to UGI endoscopy, and did not reduce BCU stay or impact survival.

The impact of endoscopy and specialist care on 30-day mortality among patients with acute non-variceal upper gastrointestinal hemorrhage: an Italian population-based study

OBJECTIVE

To analyze the effects of endoscopy and care in a gastroenterology ward on 30-day mortality among Italian patients hospitalized for acute non-variceal upper gastrointestinal hemorrhage (UGIH).

METHODS

We conducted a population-based study based on administrative data contained in the Regional Hospital Information System (RHIS) for the Lazio Region (Italy). We identified all hospitalizations with a main diagnosis of UGIH during period 2000-2005. Discharge data were analyzed for procedures performed, ward where the patient was cared for, comorbidities, vital status at discharge. Vital status 30 days after admission was cross-checked with the Regional Registry of Causes of Death. Logistic regression models were performed taking into account patients' risk factors (OR and C.I. 95%).

RESULTS

A total of 13,427 hospitalizations for UGIH (mean patient age, 68 years; 60% males) were identified. The 30-day mortality was 6.9%. Significantly lower rates were observed among hospitalizations that included endoscopy (OR 0.30, 95% C.I. 0.26-0.34), specialist care (OR 0.55, 95% C.I. 0.37-0.82), or both (OR 0.12, 95% C.I. 0.07-0.22). The protective effects of endoscopy and specialist care remained strong after adjustment for potential risk factors.

CONCLUSIONS

Endoscopy, per se, reduces mortality among patients hospitalized for UGIH, and care in a gastroenterology ward may offer additional protective effects.

Therapeutic endoscopy for acute upper gastrointestinal bleeding

Endoscopy is the primary diagnostic and therapeutic tool for upper gastrointestinal bleeding (UGIB). The performance of endoscopic therapy depends on findings of stigmata of recent hemorrhage (SRH). For peptic ulcer disease-the most common etiology of UGIB-endoscopic therapy is indicated for findings of major SRH, such as active bleeding, oozing, or the presence of a nonbleeding visible vessel, but not indicated for minor SRH, such as a pigmented flat spot or a simple ulcer with a homogeneous clean base. Endoscopic therapies include injection, ablation, and mechanical therapy. Monotherapy reduces the risk of rebleeding in patients with peptic ulcer disease with major SRH to about 20%. Combination therapy, especially injection followed by either ablation or mechanical therapy, is generally recommended to further reduce the risk of rebleeding to about 10%. Endoscopic dual hemostasis by an experienced endoscopist reduces the risk of rebleeding, the need for surgery, the number of blood transfusions required, and the length of hospital stay. This Review article comprehensively analyzes the principles, indications, instrumentation, techniques, and efficacy of endoscopic hemostasis.

Changing trends in acute upper-GI bleeding: a population-based study

BACKGROUND

Advances in medical practice in recent decades have influenced the etiology and management of acute upper-GI bleeding (UGIB), but their impact on the incidence and mortality is unclear.

OBJECTIVE

To analyze the time trends of UGIB in 2 different management eras.

DESIGN

Prospective observational study.

SETTING

General university-affiliated hospital.

PATIENTS AND INTERVENTIONS

A total of 587 patients who presented with UGIB during the 1983-to-1985 period were compared with 539 patient in the 2002-to-2004 period.

RESULTS

The overall incidence of UGIB decreased from 112.5 to 89.8 per 100,000/y, which corresponds to a 35.5% decrease after adjustment for age (95% CI, 24.2%-46.8%). The age standardized incidence of ulcer bleeding decreased by 41.6% (95% CI, 27.2%-56%); the decrease occurred only in people younger than 70 years of age. The rate of history of peptic ulcer disease decreased from 32.7% in the 1983-to-1985 period versus 19.5% in the 2002-to-2004 period (P < .001). The mean age increased from 61.0 to 68.7 years (P < .001), and the male:female ratio decreased from 2.7 to 1.8 (P = .002). The comorbidities increased from 69% to 75% (P = .01), the use of nonsteroidal anti-inflammatory drugs from 40.0% to 46.4% (P = .03), and the cases of bleeding occurring during hospitalization from 10.4% to 17.1% (P < .001). In the 1983-to-1985 cohort, the endoscopy was solely diagnostic, and antisecretory therapy consisted of H2-antagonists drugs. In the second period, 39.3% of patients underwent endoscopic therapy, whereas proton pump inhibitors were administered in 47%. Rebleeding rates decreased from 32.5% to 7.4% (P < .001) and surgery from 10.2% to 2.0% (P < .001). Overall mortality decreased from 17.1 to 8.2 per 100,000/y, which corresponded to a 60.8% decrease after adjustment for age (95% CI, 46.5%-75.1%). The age standardized mortality rate for ulcer bleeding decreased by 56.5% (95% CI, 41.9%-71.1%).

LIMITATIONS

A single-center study and a potential lack of generalizability.

CONCLUSIONS

From the 1983-to-1985 period to the 2002-to-2004 period, major changes occurred in the incidence of UGIB, features of patients, management, and outcomes. The incidence and mortality of UGIB overall and ulcer bleeding decreased significantly, and the decline of incidence occurred only in patients younger than 70 years old.

Effectiveness of coil embolization in angiographically detectable versus non-detectable sources of upper gastrointestinal hemorrhage

PURPOSE

To determine whether the effectiveness of arterial embolization in patients with acute upper gastrointestinal hemorrhage is related to the visualization of contrast medium extravasation at angiography.

MATERIALS AND METHODS

Transcatheter embolization was performed in 108 patients who experienced acute upper gastrointestinal hemorrhage during a 5-year period. Patient charts were retrospectively reviewed. Thirty-six patients who underwent embolization after angiography demonstrated active contrast medium extravasation from an involved artery. Seventy-two patients underwent embolization in the absence of contrast medium extravasation into a bowel lumen. Embolization technique, requirement for further blood products, need for further surgery, and 30-day mortality were recorded.

RESULTS

The gastroduodenal artery (GDA) was embolized in 26 of the 36 patients (72%) with extravasation, and the left gastric artery was embolized in 10 (28%). The GDA was embolized in 64 of the 72 patients (89%) without extravasation, and the left gastric artery was embolized in 13 (18%). After embolization, 23 of the 36 patients (64%) with extravasation and 44 of the 72 (61%) without extravasation required additional blood product transfusions. Seven of the 36 patients (19%) with extravasation and 16 of the 72 (22%) without extravasation required subsequent surgery secondary to bleeding. Thirty-day hemorrhage-related mortality was 17% (six of 36 patients) in the positive extravasation group and 22% (16 of 72 patients) in the negative extravasation group. The treatment success rate was 44% (16 of 36 patients) in the positive extravasation group and 44% (32 of 72 patients) in the negative extravasation group.

CONCLUSIONS

In patients with acute upper gastrointestinal hemorrhage, arterial embolization is equally effective in patients who demonstrate active contrast medium extravasation at angiography as in those who do not show contrast extravasation.

Introducing a clinical pathway for acute peptic ulcer bleeding in general internal medicine wards

OBJECTIVE

Management of acute peptic ulcer bleeding (PUB) is expensive and there is little evidence to prove the cost-effectiveness of a clinical pathway. The purpose of this study was to introduce a clinical pathway in hospitalized patients with acute PUB to evaluate its impact on costs and other outcomes.

MATERIAL AND METHODS

The clinical pathway was designed for and implemented in hospitalized patients, and a physicians reminder system that included chief residents, checklists, and case review meetings was also utilized. Use of medicine for acid suppression, length of hospital stay (LOS), and treatment costs were compared between patients before and after implementation of the clinical pathway. Outcome measures included the rate of recurrent bleeding, rate of repeat upper gastrointestinal (UGI) endoscopy, and rate of readmission within 30 days of discharge.

RESULTS

This clinical pathway significantly reduced the use of intravenous medicine for acid suppression from 88% to 34%, with mean LOS down from 6.7 to 3.6 days, mean cost of medications decreased from New Taiwan Dollars (NTD) 8768 to NTD 3940 (cost down 55.1%), mean cost of diagnostic tests lowered from NTD 12,560 to NTD 9493 (cost down 24.4%), and mean total hospital cost down from NTD 33,142 to NTD 19,519 (cost down 41.1%). Outcome measures were not significantly different.

CONCLUSIONS

Introduction of a clinical pathway is an effective method for reducing costs while maintaining quality of care in the management of PUB.

Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy

Acute upper gastrointestinal bleeding is a relatively common, potentially life-threatening medical emergency responsible for more than 300,000 hospital admissions and about 30,000 deaths per annum in America. The initial assessment focuses on bleeding activity, bleeding severity, hemodynamic compromise from the bleeding, and differentiating upper from lower gastrointestinal bleeding. The initial supportive therapy includes fluid resuscitation to reverse the hypovolemia, blood transfusions to replete the lost blood, respiratory support as necessary, and proton pump inhibitor therapy to stabilize mucosal blood clots and promote hemostasis. Esophagogastroduodenoscopy is the best test to determine the bleeding site and cause.

Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy

Acute upper gastrointestinal bleeding is a relatively common,potentially life-threatening condition that causes more than 300,000 hospital admissions and about 30,000 deaths per annum in America. Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper gastrointestinal bleeding lesions. Endoscopic therapy is indicated for lesions with high risk stigmata of recent hemorrhage, including active bleeding, oozing, a visible vessel, and possibly an adherent clot. Endoscopic therapies include injection therapy, such as epinephrine or sclerosant injection; ablative therapy, such as heater probe or argon plasma coagulation; and mechanical therapy, such as endoclips or endoscopic banding. Endoscopic therapy reduces the risk of rebleeding,the need for blood transfusions, the requirement for surgery, and patient morbidity.

Are the outcomes of clinical pathways evidence-based? A critical appraisal of clinical pathway evaluation research

AIM AND OBJECTIVE

To evaluate the validity of study outcomes of published papers that report the effects of clinical pathways (CP).

METHOD

Systematic review based on two search strategies, including searching Medline, CINAHL, Embase, Psychinfo and Picarta from 1995 till 2005 and ISI Web of Knowledge SM. We included randomized controlled or quasi-experimental studies evaluating the efficacy of clinical pathway application. Assessment of the methodological quality of the studies included randomization, power analysis, selection bias, validity of outcome indicators, appropriateness of statistical tests, direct (matching) and indirect (statistical) control for confounders. Outcomes included length of stay, costs, readmission rate and complications. Two reviewers independently assessed the methodological quality of the selected papers and recorded the findings with an evaluation tool developed from a set of items for quality assessment derived from the Cochrane Library and other publications.

RESULTS

The study sample comprised of 115 publications. A total of 91.3% of the studies comprised of retrospective studies and 8.7% were randomized controlled studies. Using a quality-scoring assessment tool, 33% of the papers were classified as of good quality, whereas 67% were classified as of low quality. Of the studies, 10.4% controlled for confounding by matching and 59.1% adopted parametric statistical tests without testing variables on normal distribution. Differences in outcomes were not always statistically tested.

CONCLUSION

Readers should be cautious when interpreting the results of clinical pathway evaluation studies because of the confounding factors and sources of contamination affecting the evidence-based validity of the outcomes.

[Transcatheter embolization for endoscopically unmanageable acute nonvariceal upper gastrointestinal hemorrhage]

OBJECTIVES

Evaluate the efficacy of endovascular embolization for patients with endoscopically unmanageable acute nonvariceal upper gastrointestinal hemorrhage as well as the factors that may influence mortality. MATERIALS AND METHODS. Retrospective study over a 4-year period including a historical cohort of 37 consecutive patients (22 men), with a mean age of 69.2 years (range, 22-93 years). In most cases (54%), the hemorrhage stemmed from a gastrointestinal ulcer. Technical, primary clinical, and secondary clinical success rates, as well as complication rates, were calculated. Several clinical and angiographic parameters were compared to the early mortality rate using Kruskal-Wallis or Fisher tests.

RESULTS

Technical, primary clinical, secondary clinical success rates, and complication rates were, respectively, 89.2%, 83.8%, 88.9%, and 10.8%. The early mortality rate was 32.4%. The APACHE II and IGS II scores were strongly correlated with mortality (p=0.001 and p=0.003, respectively).

CONCLUSION

Endovascular embolization in patients with endoscopically unmanageable acute nonvariceal upper gastrointestinal hemorrhage is effective. However, the mortality rate remains high because of the changes in the clinical condition of these patients.

An economic model of long-term use of celecoxib in patients with osteoarthritis

Background

Previous evaluations of the cost-effectiveness of the cyclooxygenase-2 selective inhibitor celecoxib (Celebrex, Pfizer Inc, USA) have produced conflicting results. The recent controversy over the cardiovascular (CV) risks of rofecoxib and other coxibs has renewed interest in the economic profile of celecoxib, the only coxib now available in the United States. The objective of our study was to evaluate the long-term cost-effectiveness of celecoxib compared with nonselective nonsteroidal anti-inflammatory drugs (nsNSAIDs) in a population of 60-year-old osteoarthritis (OA) patients with average risks of upper gastrointestinal (UGI) complications who require chronic daily NSAID therapy.

Methods

We used decision analysis based on data from the literature to evaluate cost-effectiveness from a modified societal perspective over patients' lifetimes, with outcomes expressed as incremental costs per quality-adjusted life-year (QALY) gained. Sensitivity tests were performed to evaluate the impacts of advancing age, CV thromboembolic event risk, different analytic horizons and alternate treatment strategies after UGI adverse events.

Results

Our main findings were: 1) the base model incremental cost-effectiveness ratio (ICER) for celecoxib versus nsNSAIDs was $31,097 per QALY; 2) the ICER per QALY was $19,309 for a model in which UGI ulcer and ulcer complication event risks increased with advancing age; 3) the ICER per QALY was $17,120 in sensitivity analyses combining serious CV thromboembolic event (myocardial infarction, stroke, CV death) risks with base model assumptions.

Conclusion

Our model suggests that chronic celecoxib is cost-effective versus nsNSAIDs in a population of 60-year-old OA patients with average risks of UGI events.

An assessment of endoscopic and concomitant management of acute variceal bleeding at a tertiary care centre

BACKGROUND

Several therapies have been demonstrated to be beneficial in the management of acute variceal bleeding (AVB). The aim of the present study was to characterize the use of these therapies at a Canadian tertiary care centre.

PATIENTS AND METHODS

A comprehensive chart review was performed to assess the management of all adult cirrhotic patients with AVB who were admitted to a university-affiliated, tertiary care centre between April 2001 and March 2004.

RESULTS

A total of 81 AVB patients were identified with a mean age of 53.7+/-13.2 years and a median model for end-stage liver disease score of 14. Endoscopy was performed within 8.2+/-7.6 h of admission. Variceal banding was performed for 87% of patients with esophageal varices, which were the most common source of bleeding (80%). Octreotide was used in 82% of patients for a mean duration of 74.3+/-35.4 h; prophylactic antibiotics were used in 25% of patients and beta-blockers were used in 24% of patients without any contraindications. Follow-up endoscopy was arranged for 46 of 71 (65%) survivors. Prophylactic antibiotic use was associated with the presence of ascites, while beta-blockers were used more often in the last year of the study.

CONCLUSIONS

There is a disconnection between the use of evidence-based recommendations and routine clinical practices in the management of AVB. Deficiencies identified include the lack of use of prophylactic antibiotics and beta-blockers, variable use of octreotide and inadequate follow-up recommendations. There is a need to identify measures to improve the process of care for patients with AVB which would ensure optimal management of these patients.

Trends in management and outcomes of acute nonvariceal upper gastrointestinal bleeding: 1993-2003

BACKGROUND & AIMS

ANVUGIB is a common reason for hospital admission and has been traditionally associated with a mortality rate of 5%-10%. There have been numerous innovations in the prevention and management of ANVUGIB in recent years, although the effect of these innovations on ANVUGIB incidence and outcomes is unknown.

METHODS

We used the Statistics Canada's Health Person Oriented Information Database [corrected], which contains data characterizing every inpatient hospital admission in Canada between 1993 and 2003. We identified admissions consistent with nonvariceal upper gastrointestinal bleeding using both a broad and narrow ICD-9/ICD-10-based definition. Data were extracted concerning patient demographics, incidence of surgery for complications of upper gastrointestinal bleeding, and overall mortality.

RESULTS

Between 1993 and 2003, ANVUGIB incidence decreased from 77.1 cases to 53.2 per 100,000/y for the broad definition, and from 52.4 to 34.3 cases per 100,000/y for the narrow definition. ANVUGIB incidence rose slightly in 2000, coincident with the introduction of COX-2 inhibitors. The proportion of ANVUGIB subjects requiring surgical intervention declined over the 10 years from 7.1% to 4.5%, although the rate of decline did not increase after the introduction of intravenous proton pump inhibitors (IV PPIs). The mortality rate remained steady at approximately 3.5%.

CONCLUSIONS

The incidence of ANVUGIB and the need for operative intervention has been steadily declining since 1993. ANVUGIB-associated mortality remained constant, although at a rate lower than traditionally reported. The impact of IV PPIs on mortality and operative intervention on a population-wide basis is likely minimal.

Treatment of gastrointestinal hemorrhage

BACKGROUND

We assessed the value of selective arteriography in the diagnosis and management of acute gastrointestinal hemorrhage.

METHODS

We reviewed the records of 107 consecutive patients who had gastrointestinal hemorrhage and underwent selective arteriography between January 1992 and October 2003: 10 had upper gastrointestinal bleeding, 79 had lower gastrointestinal bleeding, and 18 had varicose bleeding with portal hypertension. Selective embolization was attempted in 15 patients to obtain hemostasis. Angiographic findings were reviewed and prospective reports were compared with the final diagnosis and outcome.

RESULTS

Of 129 angiographic studies, 36 correctly revealed the bleeding site and 93 were negative. Extravasation was seen in 24 cases at the level of stomach (n = 2), duodenum (n = 1), small bowel (n = 5), or colon (n = 16). Indirect signs of bleeding sources were identified in 12 patients (stomach in one, small bowel in four, large bowel in four, liver in three). Transcatheter embolization induced definitive hemostasis in 11 of 15 patients (73%), namely in the stomach (n = 2), small bowel (n = 3), colon (n = 7), and liver (n = 3). Three patients required surgery after embolization.

CONCLUSION

Abdominal arteriography may localize gastrointestinal bleeding sources in approximately one-third of cases. Selective embolization may provide definitive hemostasis in most instances.

Clinical pathway for hip fractures in the elderly: the Hospital for Joint Diseases experience

Hip fractures are common injuries in the elderly and are associated with considerable morbidity and mortality. Although technical advances in the treatment of the elderly have resulted in improved fracture fixation and surgical outcomes, clinical pathways have been developed to further improve patient outcome while shortening hospital length of stay after hip fracture. We describe the clinical pathway used since 1990 at the Hospital for Joint Diseases. The outcomes of 747 patients treated before 1990 were compared with outcomes of 318 patients treated at our hospital after initiation of the clinical pathway. Use of the clinical pathway was associated with significant decreases in the acute care hospital length of stay, in-hospital mortality, and 1-year mortality.

Cost-effectiveness of proton pump inhibitor therapy for acute peptic ulcer-related bleeding

OBJECTIVE

The purpose of this investigation was to perform a cost-effectiveness analysis of adjunctive oral and intravenous proton pump inhibitor (PPI) therapies for patients with acute peptic ulcer-related bleeding of sufficient severity to warrant hospitalization.

DESIGN

Cost-effectiveness investigation. Four clinical scenarios were considered: scenario 1, diagnostic endoscopy with oral PPI therapy; scenario 2, diagnostic and therapeutic endoscopy with high-dose intravenous PPI therapy; scenario 3, diagnostic and therapeutic endoscopy available with oral PPI therapy; and scenario 4, diagnostic and therapeutic endoscopy (no PPI). Effectiveness was evaluated in terms of episodes of bleeding averted and quality-adjusted life years.

SETTING

University teaching hospital in the United States.

PATIENTS

Hospitalized patients with acute peptic ulcer bleeding.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Therapeutic endoscopy with high-dose intravenous PPI therapy (scenario 2) was the most cost-effective approach in terms of bleeding episode averted (8,490 vs. 10,201 US dollars for scenario 1, 8,756 US dollars for scenario 3, and 12,459 US dollars for scenario 4) and per quality-adjusted life year (4,810 vs. 5,533 US dollars for scenario 1, 4,946 US dollars for scenario 3, and 5,876 US dollars for scenario 4). The high-dose intravenous PPI scenario was the dominant approach as evidenced by both superior effectiveness and lower costs over the range of probability and cost variables used in the sensitivity analysis. However, the dominance would be lost if the purchase cost of the intravenous PPI was substantially higher than the baseline cost assumed in this investigation (61 US dollars per 3-day course of therapy).

CONCLUSION

High-dose intravenous PPI therapy in conjunction with therapeutic endoscopy is the most cost-effective approach for the management of hospitalized patients with acute peptic ulcer bleeding.

The Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy (RUGBE): Endoscopic hemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting

OBJECTIVES

From the Canadian Registry of patients with Upper Gastrointestinal Bleeding and Endoscopy (RUGBE), we determined clinical outcomes and explored the roles of endoscopic and pharmacologic therapies in a contemporary real-life setting.

METHODS

Analysis of randomly selected patients endoscoped for nonvariceal upper gastrointestinal bleeding at 18 community and tertiary care institutions between 1999 and 2002. Covariates and outcomes were defined a priori and 30-day follow-up obtained. Logistic regression models identified predictors of outcomes.

RESULTS

One thousand eight-hundred and sixty-nine patients were included (66 +/- 17 yr, 38% female, 2.5 +/- 1.6 comorbid conditions, hemoglobin, 96 +/- 27 g/L, 54% received a mean of 2.9 +/- 1.7 units of blood). Endoscopy was performed within 24 h in 76%, with ulcers (55%) most commonly noted. High-risk endoscopic stigmata and endoscopic therapy were reported in 37%. Rebleeding, surgery, and mortality rates were 14.1%, 6.5%, and 5.4%, respectively. Decreased rebleeding was significantly and independently associated with PPI use (85% of patients, mean daily dose 56 +/- 53 mg) in all patients regardless of endoscopic stigmata, (odds ratio (OR):0.53, 95% confidence interval, 95% CI:0.37-0.77) and endoscopic hemostasis in patients with high-risk stigmata (OR:0.39, 95% CI:0.25-0.61). PPI use (OR:0.18, 95% CI:0.04-0.80) and endoscopic therapy (OR:0.31, 95% CI:0.11-0.91) were also each independently associated with decreased mortality in patients with high-risk stigmata.

CONCLUSIONS

These results appear to confirm the protective role of endoscopic therapy in patients with high-risk stigmata, and suggest that acute use of PPIs may be associated with a reduction of rebleeding in all patients, and lower mortality in patients with high-risk stigmata. Independent prospective validation of these observational findings is now required.

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.

Effectiveness of an upper-gastrointestinal haemorrhage unit: a prospective analysis of 900 consecutive cases using the Rockall score as a method of risk standardisation

OBJECTIVES

To assess the effectiveness of a centralised upper-gastrointestinal haemorrhage (UGIH) unit.

METHODS

The UK Audit of acute UGIH resulted in the formulation of a simple numerical scoring system. The Rockall score categorises patients by risk factors for death and allows case-mix comparisons. A total of 900 consecutive patients admitted to a UGIH unit between October 1995 and July 1998 were analysed prospectively. Patients were given an initial Rockall score and, if endoscopy was performed, a complete score. This method of risk stratification allowed the proportion of deaths (in our study) to be compared with the National Audit using risk standardised mortality ratios.

RESULTS

The distribution of both initial and final Rockall scores was significantly higher in our study than in the National Audit. A total of 73 (8.1%) patients died, compared with the National Audit mortality of 14%. Risk-standardised mortality ratios using both initial and complete Rockall scores were significantly lower in our study when compared with those in the National Audit.

CONCLUSION

A specialised UGIH unit is associated with a lower proportion of deaths from UGIH, despite comprising a greater number of high-risk patients than the National Audit. This lower mortality therefore cannot be attributed to a more favourable case mix and demonstrates that further improvements in mortality for UGIH can be made.

Success and shortcomings of a clinical care pathway in the management of acute nonvariceal upper gastrointestinal bleeding

OBJECTIVES

Acute nonvariceal upper gastrointestinal (GI) bleeding is the most common medical emergency encountered by gastroenterologists resulting in high patient morbidity and cost. We sought to establish if a GI bleeding clinical care pathway could improve the quality and cost effectiveness of inpatient medical care.

METHODS

A disease management program for acute upper GI bleeding was established. Length of stay, time to endoscopy, utilization of potentially unnecessary radiological tests, acid suppression, and cost of care were compared between patients pre- and postinitiation of GI bleeding pathway guidelines.

RESULTS

The instituted GI bleeding management program significantly reduced the use of intravenous H2-blockade from 65.3% to 47.7% (p = 0.002). The use of radiological tests, time to endoscopy, and length of hospital of stay were unchanged. There was a trend toward a reduction in total cost and variable direct cost per patient admitted with acute upper GI bleeding, from $5,381 to $4,627 and from $2,269 to $1,952, respectively.

CONCLUSION

A clinical care pathway may affect the management of acute upper GI bleeding and reduce costs. However, there are significant limitations and barriers to the overall effectiveness of such a pathway in actual clinical practice.

Risk factors for upper gastrointestinal bleeding among end-stage renal disease patients

BACKGROUND

The risk of upper gastrointestinal bleeding (UGIB) is increased among end-stage renal disease (ESRD) patients compared to the general population. However, correlates of UGIB among ESRD patients remain unknown. We conducted a cohort study of dialysis patients to ascertain risk factors for UGIB.

METHODS

Data from the United States Renal Data System Dialysis Morbidity and Mortality Studies, Waves 2-4 were used to identify risk factors for incident UGIB among ESRD patients. First hospitalizations for UGIB were identified using hospital diagnosis codes between 12/31/93 and 12/31/99. Cox regression was used to estimate the association between predictors of interest and first diagnosis of UGIB.

RESULTS

Cases of UGIB (698) were observed over 30648 patient years of follow-up. Before adjustment for confounding factors, increasing age, diabetes, former and current smoking, cardiovascular disease (CVD), lower serum albumin, malnutrition, and inability to ambulate independently were associated with an increased risk of UGIB, while African Americans and transplant patients had a lower risk of UGIB. After adjustment, African American race was associated with a lower risk of UGIB (RR = 0.90; 0.82, 0.98), while current smoking (RR = 1.11; confidence interval 1.03, 1.19), history of CVD (RR = 1.32; 1.10, 1.59), and inability to ambulate independently (RR = 1.32; 1.07, 1.63) were associated with a higher risk of UGIB. Age, gender, diabetes, lower serum albumin, nourishment, treatment modality, aspirin use, nonsteroidal anti-inflammatory drug (NSAID) use, and antiplatelet or anticoagulant medication use were not found to be significantly related to the risk of UGIB after adjustment for potential confounding factors.

CONCLUSION

CVD, current smoking, and risk factors suggesting more disability are associated with a greater risk of UGIB among patients with ESRD.

Improved patient survival after acute variceal bleeding: a multicenter, cohort study

OBJECTIVE

Existing literature indicates that the mortality rate with each variceal bleeding episode is 30-50%. Over the past 2 decades, there have been significant developments in the management of variceal bleeding. The effect of these developments on the natural history of variceal bleeding is unclear. Therefore, a retrospective, multicenter study was conducted to define the outcomes of variceal bleeding and to describe the patterns of current practice in the management of variceal bleeding.

METHODS

All patients with documented variceal bleeding hospitalized at four large county hospitals from January 1, 1997, to June 30, 2000, were included. Study outcomes were in-hospital, 6-wk, and overall mortality, rate of rebleeding, transfusion requirement, and length of stay. After discharge, patients were followed until death or study closure date, on June 30, 2000.

RESULTS

A total of 231 subjects were included, and their in-hospital, 6-wk, and overall mortality rates were 14.2%, 17.5%, and 33.5%, respectively. The frequency of rebleeding during follow-up was 29%. Median length of total hospital stay was 8 days (0-34 days). Median number of packed red cell units transfused was 4 U (0-60 U). Upper endoscopy was performed in 95% of patients within 24 h, and endoscopic therapy was done in all but eight patients (ligation 64%, sclerotherapy 33%). Octreotide was administered in 74% of the patients. Portasystemic shunts were performed in 7.5% of the patients for controlling acute variceal bleeding.

CONCLUSIONS

The mortality rate after variceal bleeding in this study was substantially lower than previously reported. This suggests that advances made in the management of variceal bleeding have improved outcomes after variceal bleeding.

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.

Meeting the Challenge of Managing Vaso-Occlusive Crisis

Quality improvement efforts in patient care are most successful when the entire healthcare team is involved in care planning. This article discusses a multidisciplinary approach to the development of a protocol for patients with sickle cell disease experiencing vaso-occlusive crisis. The protocol's goal was to improve the quality and consistency of care for these patients. Outcomes, which were based on data from the 6 months before and after the protocol initiation, demonstrated an increased treat-and-release rate from the emergency department, a decreased average length of stay, and a decrease in the percentage of patient days down-graded by payers.

Management of gastrointestinal haemorrhage

A variety of endoscopic haemostatic techniques have enabled major advances in the management of not only bleeding peptic ulcers and bleeding varices, but also in a variety of bleeding lesions in the small intestine and in the colon. Indeed, the development and widespread implementation of endoscopic haemostasis has been one of the most important developments in clinical gastroenterology in the past two decades. An increasingly ageing cohort of patients with multiple co-morbidity are being treated and therefore improving the outcome of gastrointestinal bleeding continues to pose major challenges.