Mortality and Time to Endoscopy in Upper GI Hemorrhage
Mortality and Time to Endoscopy in Upper GI Hemorrhage
Background We analysed nationwide in-patient data from 2002 to 2007 to determine significant demographic variables when predicting mortality and receipt of prompt oesophagogastroduodenoscopy (OGD) for acute variceal haemorrhage (AVH) and nonvariceal upper gastrointestinal haemorrhage (NVUGIH).
Aim To study the effects of demographic variables in predicting time to endoscopy and mortality in AVH and NVUGIH.
Methods We analysed the United States' Nationwide Inpatient Sample (NIS), for risk factors for mortality and receipt of OGD within 1 day of admission for upper gastrointestinal haemorrhage.
Results Risk factors for increased mortality in AVH included: age >60, men, African Americans, comorbidities, insurance type and delayed OGD. Risk factors for increased mortality in NVUGIH were similar to AVH, except race which was not significant. After correction for factors such as insurance type, comorbidity, hospital location and time to endoscopy, this increased risk of mortality persisted, suggesting that none of these factors was the primary cause of the observed differences. For AVH, OGD within 1 day of admission was more likely in men, White Americans, patients aged 18–40 years, privately insured and those with no comorbidities. OGD within 1 day of admission in NVUGIH was more likely in men, patients age 40–60, Whites, Hispanics, privately insured and those with a single comorbidity.
Conclusions In multivariate analysis, in-patient mortality in AVH and NVUGIH increased with age, comorbidity, male gender, and delayed time to endoscopy. Young, healthier men were most likely to receive OGD within 1 day of admission. African Americans were less likely to receive OGD within 1 day of admission and had increased mortality in cases of AVH.
Upper gastrointestinal haemorrhage (UGIH) is a common emergency with substantial patient morbidity and medical expense. The direct medical costs exceed #1 billion and lead to more than 300 000 admissions annually. Nonvariceal upper GI haemorrhage (NVUGIH) has an incidence of 37–172 cases per 100 000 adults, with an overall mortality rate that still remains relatively unchanged over the years, around 3–14%, and likely reflects the increasing age of affected patients and their increasing number of comorbidities. Several studies in the US and worldwide suggest that hospitalisations and mortality for the most common cause of UGIH, peptic ulcer disease, have decreased.
Acute variceal haemorrhage (AVH) accounts for approximately 4–14% of UGIH and 50–60% of upper GI bleeding in cirrhotic patients. Although AVH has a lower incidence than NVUGIH, its mortality rate is 11–50%, with 30% of patients dying from a first bleed and 66% dying within 1 year. Recent studies also suggest that mortality due to variceal haemorrhage is also declining.
Oesophagogastroduodenoscopy (OGD) is the preferred first test for UGIH because of its diagnostic and interventional capabilities. After the patient achieves hemodynamic stability and airway protection, urgent endoscopy (within 12–24 h of initial presentation) is often advocated and has been shown to be beneficial. Emergent endoscopy has been defined as OGD within 12 h, while urgent is defined as OGD within 24 h of admission. Several studies of emergent endoscopy have not shown any significant differences in mortality compared to urgent endoscopy, which has been shown to be beneficial. Urgent endoscopy improves outcomes in UGIH by accurately diagnosing and treating patients as well as preventing and predicting rebleeding, reducing transfusion requirements, shortening the length of a hospital stay and reducing mortality.
To date, there are no large scale analyses of demographic risk factors in both AVH and NVUGIH to predict in-patient mortality and receipt of OGD within 1 day of admission. Existing studies focus on specific healthcare systems, such as the Veterans Affairs (VA) Hospital System or selected populations in endoscopy databases. The purpose of this study was to analyse a diverse, nationwide in-patient database to identify demographic risk factors that predict disparities in treatment and mortality outcomes in patients with UGIH.
Abstract and Introduction
Abstract
Background We analysed nationwide in-patient data from 2002 to 2007 to determine significant demographic variables when predicting mortality and receipt of prompt oesophagogastroduodenoscopy (OGD) for acute variceal haemorrhage (AVH) and nonvariceal upper gastrointestinal haemorrhage (NVUGIH).
Aim To study the effects of demographic variables in predicting time to endoscopy and mortality in AVH and NVUGIH.
Methods We analysed the United States' Nationwide Inpatient Sample (NIS), for risk factors for mortality and receipt of OGD within 1 day of admission for upper gastrointestinal haemorrhage.
Results Risk factors for increased mortality in AVH included: age >60, men, African Americans, comorbidities, insurance type and delayed OGD. Risk factors for increased mortality in NVUGIH were similar to AVH, except race which was not significant. After correction for factors such as insurance type, comorbidity, hospital location and time to endoscopy, this increased risk of mortality persisted, suggesting that none of these factors was the primary cause of the observed differences. For AVH, OGD within 1 day of admission was more likely in men, White Americans, patients aged 18–40 years, privately insured and those with no comorbidities. OGD within 1 day of admission in NVUGIH was more likely in men, patients age 40–60, Whites, Hispanics, privately insured and those with a single comorbidity.
Conclusions In multivariate analysis, in-patient mortality in AVH and NVUGIH increased with age, comorbidity, male gender, and delayed time to endoscopy. Young, healthier men were most likely to receive OGD within 1 day of admission. African Americans were less likely to receive OGD within 1 day of admission and had increased mortality in cases of AVH.
Introduction
Upper gastrointestinal haemorrhage (UGIH) is a common emergency with substantial patient morbidity and medical expense. The direct medical costs exceed #1 billion and lead to more than 300 000 admissions annually. Nonvariceal upper GI haemorrhage (NVUGIH) has an incidence of 37–172 cases per 100 000 adults, with an overall mortality rate that still remains relatively unchanged over the years, around 3–14%, and likely reflects the increasing age of affected patients and their increasing number of comorbidities. Several studies in the US and worldwide suggest that hospitalisations and mortality for the most common cause of UGIH, peptic ulcer disease, have decreased.
Acute variceal haemorrhage (AVH) accounts for approximately 4–14% of UGIH and 50–60% of upper GI bleeding in cirrhotic patients. Although AVH has a lower incidence than NVUGIH, its mortality rate is 11–50%, with 30% of patients dying from a first bleed and 66% dying within 1 year. Recent studies also suggest that mortality due to variceal haemorrhage is also declining.
Oesophagogastroduodenoscopy (OGD) is the preferred first test for UGIH because of its diagnostic and interventional capabilities. After the patient achieves hemodynamic stability and airway protection, urgent endoscopy (within 12–24 h of initial presentation) is often advocated and has been shown to be beneficial. Emergent endoscopy has been defined as OGD within 12 h, while urgent is defined as OGD within 24 h of admission. Several studies of emergent endoscopy have not shown any significant differences in mortality compared to urgent endoscopy, which has been shown to be beneficial. Urgent endoscopy improves outcomes in UGIH by accurately diagnosing and treating patients as well as preventing and predicting rebleeding, reducing transfusion requirements, shortening the length of a hospital stay and reducing mortality.
To date, there are no large scale analyses of demographic risk factors in both AVH and NVUGIH to predict in-patient mortality and receipt of OGD within 1 day of admission. Existing studies focus on specific healthcare systems, such as the Veterans Affairs (VA) Hospital System or selected populations in endoscopy databases. The purpose of this study was to analyse a diverse, nationwide in-patient database to identify demographic risk factors that predict disparities in treatment and mortality outcomes in patients with UGIH.
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