Elsevier

Gastrointestinal Endoscopy

Volume 50, Issue 6, December 1999, Pages 755-761
Gastrointestinal Endoscopy

Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial,☆☆,

Presented in part during the Digestive Disease Week in 1997, Washington, D.C., and 1998 New Orleans, Louisiana.
https://doi.org/10.1016/S0016-5107(99)70154-9Get rights and content

Abstract

Background:  Many patients with upper gastrointestinal (GI) bleeding have a benign outcome and could receive less intensive and costly care if accurately identified. We sought to determine whether early endoscopy performed shortly after admission in the emergency department could significantly reduce the health care use and costs of caring for patients with nonvariceal upper GI bleeding without adversely affecting the clinical outcome. Methods:  All eligible patients with upper GI bleeding and stable vital signs were randomized after admission to undergo endoscopy in 1 to 2 days (control) or early endoscopy in the emergency department. Patients with low-risk findings on early endoscopy were discharged directly from the emergency department. Clinical outcomes and costs were prospectively assessed for 30 days. Results:  We randomized 110 consecutive stable patients with nonvariceal upper GI bleeding during the 12-month study period. The baseline demographic features, endoscopic findings, and the clinical outcomes were no different between the two groups. However the findings of the early endoscopy allowed us to immediately discharge 26 of 56 (46%) patients randomized to that group. No patient discharged from the emergency department suffered an adverse outcome. The hospital stay (median of 1 day [interquartile range of 0 to 3 days] vs. 2 days [interquartile range of 2 to 3 days], p = 0.0001) and the cost of care ($2068 [interquartile range of $928 to $3960] versus $3662 [interquartile range of $2473 to $7280], p = 0.00006) were significantly less for the early endoscopy group. Conclusions:  Early endoscopy performed shortly after admission in the emergency department safely triaged 46% of patients with nonvariceal upper GI bleeding to outpatient care, which significantly reduced hospital stay and costs. (Gastrointest Endosc 1999;50:755-61.)

Section snippets

PATIENTS AND METHODS

We prospectively screened all patients admitted with upper GI bleeding from our emergency department. Upper GI bleeding was defined as a history of vomiting or defecating fresh or altered blood in the preceding 7 days. Consecutive patients with upper GI bleeding were randomized only after they had been admitted and had a hospital bed assigned by the emergency department physician to exclude patients with trivial bleeding. Formal criteria were not used to assign the location of the admission to

RESULTS

Of 12,966 consecutive patients admitted from the emergency department during the 12-month study period, 312 had a diagnosis of upper GI bleeding. Two hundred six patients met at least one of the exclusion criteria including hemodynamic instability (80), known or suspected variceal bleeding (69), inability to consent (15), and miscellaneous reasons (37). Five eligible patients were missed from enrollment. Table 1 shows the baseline demographic and clinical characteristics of the study patients.

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DISCUSSION

Our results show that endoscopy performed shortly after admission significantly decreased the use of health care resources and costs associated with caring for stable patients with nonvariceal upper GI bleeding by improving diagnostic and prognostic accuracy and expediting treatment. We discharged 46% of the patients who had low-risk findings on early endoscopy, none of whom experienced an adverse event. These results are similar to a smaller nonrandomized, uncontrolled study of early

Acknowledgements

We thank Drs. Steve Schutz and Martin L. Freeman for their thoughtful discussion of the manuscript.

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    Supported in part by grants from the American Digestive Health Foundation and the Hibbard E. Williams Research Award from the University of California, Davis Health System.

    ☆☆

    Reprint request: John G. Lee, MD, Division of Gastroenterology, UC Davis Medical Center, 4150 V St., Room 3500, Sacramento, CA 95817; fax: 916-734-7908; e-mail: [email protected].

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