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CC BY-NC-ND 4.0 · Endosc Int Open 2017; 05(10): E950-E958
DOI: 10.1055/s-0043-117880
Original article
Eigentümer und Copyright ©Georg Thieme Verlag KG 2017

Glasgow Blatchford Score of limited benefit for low-risk urban patients: a mixed methods study

David A. Leiman
1   Division of Gastroenterology, Duke University of School of Medicine, 2301 Erwin Road, Durham, NC, USA
,
Angela M. Mills
2   Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania, United States
,
Frances S. Shofer
2   Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania, United States
,
Andrew T. Weber
3   Department of Internal Medicine, Geffen School of Medicine at the University of California at Los Angeles, 757 Westwood Plaza, Los Angeles, California, United States
,
Erin R. Leiman
4   Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States
,
Brian P. Riff
5   Advanced Endoscopy Center, St. Jude Medical Center, Fullerton, California, United States
,
James D. Lewis
6   Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
,
Shivan J. Mehta
6   Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
› Author Affiliations
Further Information

Publication History

submitted 23 February 2017

accepted after revision 26 June 2017

Publication Date:
29 September 2017 (online)

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Abstract

Background and study aims Most patients with upper gastrointestinal bleeding (UGIB) are hospitalized. Risk-stratifying UGIB with scoring tools may decrease avoidable admissions, thereby reducing the cost of care. We sought to describe how frequently low-risk UGIB patients present to urban emergency departments (ED) and the proportion who are admitted to examine how incorporating risk scores into decision support might diminish healthcare utilization in this population.

Patients and methods This is a retrospective cohort study of ED patients presenting from 2009 – 2013 to three urban hospitals that do not use electronic UGIB decision support. We used ED disposition diagnosis codes (ICD-9) to identify patients followed by manual chart review for verification and additional data collection. Patients with a Glasgow Blatchford Score (GBS) of 0 were classified as low risk. We also surveyed ED physicians at these hospitals to assess their beliefs about UGIB decision support.

Results Over the study period, 66 patients (13.2 per year) presented to the ED with low-risk UGIB. Of these, 10 patients (15.2 %) were admitted and none required endoscopic hemostasis. Most survey respondents (55.6 %, n = 20) were aware of UGIB risk scores but a minority (19.4 %, n = 7) used one.

Conclusions Low-risk UGIB patients infrequently present to the ED and only a minority are admitted. Despite advocacy to incorporate decision support into routine clinical care, ED physicians independently identified low risk patients. There is insufficient evidence to suggest the magnitude of this problem is large enough to warrant implementation of decision support for low risk UGIB.

 

  • References

  • 1 Myer PA, Mannalithara A, Singh G. et al. Clinical and economic burden of emergency department visits due to gastrointestinal diseases in the United States. Am J Gastroenterol 2013; 108: 1496-1507
    CrossrefPubMedGoogle Scholar
  • 2 Hwang JH, Fisher DA, Ben-Menachem T. et al. The role of endoscopy in the management of acute non-variceal upper GI bleeding. Gastrointest Endosc 2012; 75: 1132-1138
    CrossrefPubMedGoogle Scholar
  • 3 Stanley AJ, Ashley D, Dalton HR. et al. Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Lancet 2009; 373: 42-47
    CrossrefPubMedGoogle Scholar
  • 4 Laursen SB, Hansen JM, Schaffalitzky de Muckadell OB. The Glasgow Blatchford Score is the most accurate assessment of patients with upper gastrointestinal hemorrhage. Clin Gastroenterol Hepatol 2012; 10: 1130-1135 e1
    CrossrefPubMedGoogle Scholar
  • 5 Chen IC, Hung MS, Chiu TF. et al. Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding. Am J Emerg Med 2007; 25: 774-779
    CrossrefPubMedGoogle Scholar
  • 6 Meltzer AC, Ali MA, Kresiberg RB. et al. Video capsule endoscopy in the emergency department: a prospective study of acute upper gastrointestinal hemorrhage. Ann Emerg Med 2013; 61: 438-443 e1
    CrossrefPubMedGoogle Scholar
  • 7 Lee JG, Turnipseed S, Romano PS. et al. Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial. Gastrointest Endosc 1999; 50: 755-761
    CrossrefPubMedGoogle Scholar
  • 8 Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for uppergastrointestinal haemorrhage. The Lancet 2000; 356: 1318-1321
    CrossrefPubMedGoogle Scholar
  • 9 Stanley AJ. Update on risk scoring systems for patients with upper gastrointestinal haemorrhage. World J Gastroenterol 2012; 18: 2739-2744
    CrossrefPubMedGoogle Scholar
  • 10 Stephens JR, Hare NC, Warshow U. et al. Management of minor upper gastrointestinal haemorrhage in the community using the Glasgow Blatchford Score. Eur J Gastroenterol Hepatol 2009; 21: 1340-1346
    CrossrefPubMedGoogle Scholar
  • 11 Pang SH, Ching JY, Lau JY. et al. Comparing the Blatchford and pre-endoscopic Rockall score in predicting the need for endoscopic therapy in patients with upper GI hemorrhage. Gastrointest Endosc 2010; 71: 1134-1140
    CrossrefPubMedGoogle Scholar
  • 12 Gralnek IM, Dumonceau JM, Kuipers EJ. et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: a1-46
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Barkun ABM, Kuipers E, Sung J. et al. International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding. Ann Intern Med 2010; 152: 101-113
    CrossrefPubMedGoogle Scholar
  • 14 Greenspoon J, Barkun A, Bardou M. et al. Management of patients with nonvariceal upper gastrointestinal bleeding. Clin Gastroenterol Hepatol 2012; 10: 234-239
    CrossrefPubMedGoogle Scholar
  • 15 Kanwal F, Barkun A, Gralnek IM. et al. Measuring quality of care in patients with nonvariceal upper gastrointestinal hemorrhage: development of an explicit quality indicator set. Am J Gastroenterol 2010; 105: 1710-1718
    CrossrefPubMedGoogle Scholar
  • 16 Bensoussan K, Fallone C, Barkun A. et al. A sampling of Canadian practice in managing nonvariceal upper gastrointestinal bleeding before recent guideline publication: Is there room for improvement?. Can J Gastroenterol Hepatol 2005; 19: 487-495
    PubMedGoogle Scholar
  • 17 Piccoli L, Gilrain K, Holliday N. et al. 411 Is the Glasgow-Blatchford Bleeding Score Useful in Reducing Upper Gastrointestinal Bleed Admissions in a United States Hospital?. Ann Emerg Med 2011; 58: S317-S8
    PubMedGoogle Scholar
  • 18 Cooper GS, Chak A, LLoyd LE. et al. The accuracy of diagnosis and procedural codes for patients with upper GI hemorrahge. Gastrointest Endosc 2000; 51: 423-426
    CrossrefPubMedGoogle Scholar
  • 19 Kaji AH, Schriger D, Green S. Looking through the retrospectoscope: reducing bias in emergency medicine chart review studies. Ann Emerg Med 2014; 64: 292-298
    CrossrefPubMedGoogle Scholar
  • 20 Charlson M, Pompei P, Ales K. et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40: 373-383
    CrossrefPubMedGoogle Scholar
  • 21 Liang PS, Saltzman JR. A national survey on the initial management of upper gastrointestinal bleeding. J Clin Gastroenterol 2014; 48: e93-98
    PubMedGoogle Scholar
  • 22 Wang CH, Chen YW, Young YR. et al. A prospective comparison of 3 scoring systems in upper gastrointestinal bleeding. Am J Emerg Med 2013; 31: 775-778
    CrossrefPubMedGoogle Scholar
  • 23 Sengupta N, Tapper EB, Patwardhan VR. et al. High Glasgow Blatchford Score at admission is associated with recurrent bleeding after discharge for patients hospitalized with upper gastrointestinal bleeding. Endoscopy 2016; 48: 9-15
    Article in Thieme ConnectPubMedGoogle Scholar
  • 24 Barkun AN, Hawes IA, Armstrong D. et al. M1079 Improving Adherence to Guidelines When Managing Non-Variceal Upper Gastrointestinal Bleeding: A National Cluster Randomized Trial of a Multifaceted Strategy. Gastroenterology 2010; 138: S-327
    PubMedGoogle Scholar
  • 25 Hayes SM, Murray S, Dupuis M. et al. Barriers to the implementation of practice guidelines in managing patients with nonvariceal upper gastrointestinal bleeding: A qualitative approach. Can J Gastroenterol 2010; 24: 289-296
    CrossrefPubMedGoogle Scholar
  • 26 Pitts SR, Niska RW, Xu J. et al. National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary. Natl Health Stat Repor 2008; 6: 1-38
    PubMedGoogle Scholar
  • 27 Mohsin M, Forero R, Ieraci S. et al. A population follow-up study of patients who left an emergency department without being seen by a medical officer. Emerg Med J 2007; 24: 175-179
    CrossrefPubMedGoogle Scholar
  • 28 Grumbach K, Keane D, Bindman A. Primary care and public emergency department overcrowding. Am J Public Health 1993; 83: 372-378
    CrossrefPubMedGoogle Scholar
  • 29 Magid DJ, Wang Y, Herrin J. et al. Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute st-segment elevation myocardial infarction. JAMA 2005; 294: 803-812
    CrossrefPubMedGoogle Scholar
  • 30 Farooq FT, Lee MH, Das A. et al. Clinical triage decision vs risk scores in predicting the need for endotherapy in upper gastrointestinal bleeding. Am J Emerg Med 2012; 30: 129-134
    CrossrefPubMedGoogle Scholar
  • 31 Schiefer M, Aquarius M, Leffers P. et al. Predictive validity of the Glasgow Blatchford Bleeding Score in an unselected emergency department population in continental Europe. Eur J Gastroenterol Hepatol 2012; 24: 382-387
    PubMedGoogle Scholar
  • 32 Laursen SB, Dalton HR, Murray IA. et al. Performance of new thresholds of the Glasgow Blatchford Score in managing patients with upper gastrointestinal bleeding. Clin Gastroenterol Hepatol 2015; 13: 115-121 e2
    CrossrefPubMedGoogle Scholar
  • 33 Dulai GS, Gralnek IM, Oei TT. et al. Utilization of health care resources for low-risk patients with acute, nonvariceal upper GI hemorrhage: an historical cohort study. Gastrointest Endosc 2002; 55: 321-327
    CrossrefPubMedGoogle Scholar
  • 34 Horsky J, Schiff GD, Johnston D. et al. Interface design principles for usable decision support: a targeted review of best practices for clinical prescribing interventions. J Biomed Inform 2012; 45: 1202-1216
    CrossrefPubMedGoogle Scholar
  • 35 June IL, Gordon A, Farrugia D. et al. Safe discharge of patients with low-risk upper gastrointestinal bleeding (UGIB): can the use of Glasgow-Blatchford Bleeding Score be extended?. Acute Med 2011; 10: 176-181
    PubMedGoogle Scholar
  • 36 Stanley AJ, Laine L, Dalton HR. et al. Comaprison of scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study. BMJ 2017; 356: i6432
    PubMedGoogle Scholar
  • 37 Mustafa Z, Cameron A, Clark AE. et al. Outpatient management of low-risk patients with upper gastrointestinal bleeding: can we safely extend the Glasgow Blatchford Score in clinical practice?. Eur J Gastroenterol Hepatol 2015; 27: 512-515
    CrossrefPubMedGoogle Scholar