R1. 최태웅 / Pf. 김정욱

INTRODUCTION Acute upper gastrointestinal bleeding (AUGIB) : incidence of 50–150 cases/100,000 : outcomes → by preexisting comorbidity, patient characteristics, severity of bleeding processes of care directed at controlling bleeding : Inpatient (IP) status at the time of developing bleeding - particularly high mortality

INTRODUCTION aim of this study : to compare the clinical characteristics, processes of care, outcomes between outpatients and inpatients : to determine how far differences in their outcomes by differences in baseline risk, severity of bleeding, or processes of care

METHODS

Data collection - all National Health Service hospitals(n=257) → total of 223 agreed → 212 (82%) hospitals submitted data - all adults (16 years or over) who presented with AUGIB between ~ demography, clinical characteristics, laboratory results, transfusion, endoscopy(including endoscopic therapy and rebleeding), radiology, surgery, length of stay (LOS), and mortality

METHODS

Baseline patient characteristics - gender - age - regular medication taken before the onset of bleeding (specifically aspirin, clopidogrel, non-steroidal anti-infl ammatory drugs, warfarin, and proton pump inhibitors (PPIs)) - presence of comorbidities (ischemic heart disease, cardiovascular disease, respiratory disease, renal disease, liver disease, malignancy, cerebrovascular disease, and dementia) - admission-related characteristics

METHODS Bleeding characteristics - presenting symptoms of AUGIB (hemodynamic shock, hematemesis, and melena), - hematological/biochemical indicator (hemoglobin and urea concentrations, and coagulopathy) - etiology of bleeding (peptic ulcer bleeding, variceal bleeding, or other) - degree of stigmata of hemorrhage(high risk, low risk, or no stigmata)

METHODS Processes of care - administration of a PPI - transfusion or not of blood components (including red blood cells, fresh frozen plasma, and platelets) - use of endoscopy (including time to index endoscopy, performance of therapeutic endoscopy, number of endoscopies, performance of endoscopy in/out of normal hours, availability of emergency endoscopy service for GI bleeding)

METHODS Outcomes - mortality - rebleeding - need for surgery/radiological embolization to control bleeding - length of hospital day

METHODS Statistical methods - (a) whether outcomes varied between IPs and OPs (b) whether these differences could be explained by the underlying risk, severity of bleeding, or processes of care ⇒ five analyses for each outcome : (i) unadjusted for covariates (ii) adjusted for baseline clinical characteristics alone (iii) adjusted for severity of bleeding alone (iv) adjusted for baseline characteristics and severity of bleeding (v) adjusted for baseline characteristics, severity of bleeding, processes of care

Patient characteristics

Bleeding characteristics

RESULTS

Results

Results – Subgroup analyses Out-of-hours emergency endoscopy rota - adjusting for baseline characteristics, severity of bleeding, processes of care → no evidence of a difference in the effect of patients status on death, rebleeding, need for surgery/radiological intervention length of hospital stay

Results – Subgroup analyses Variceal vs. non-variceal bleeding - no evidence of a difference in the effect of patients status on death, rebleeding, need for surgery/radiological intervention length of hospital stay

Conclusion IPs → higher baseline risks and more severe bleeding Differences in baseline characteristics explain some(not all) the greater mortality of IPs with AUGIB