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

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.

Discharge of patients with an acute upper gastrointestinal bleed from the emergency department using an extended Glasgow-Blatchford Score

“…Chronic GI bleeds were defined as a bleed that has been occurring for longer than 3 days or the presentation of an iron deficiency anaemia. 20 …”

Comparison of three risk scores to predict outcomes in upper gastrointestinal bleeding; modifying Glasgow-Blatchford with albumin

“…Despite the fact that use of risk scores in management of UGIB is recommended in several studies and guidelines [2,13,14], its role in actual clinical decisions and hospital guidelines is still unclear [17]. Although, some studies proved that risk scores are a stronger predictor than clinical decision, others believe the opposite [2,18,19].…”

“…Following the introduction of these systems, numerous studies have been conducted to validate them [2] and the discrepancy in results led to the idea that variation in geographical region and health care system affects the accuracy of risk scores [17][18][19]. Although, many guidelines suggest that low risk patients can be managed as outpatient, In our hospital all patients with UGIB undergo endoscopy and the timing is mostly within the first 24 hours of admission [14,20].…”

Improving Acute GI Bleeding Management Through Artificial Intelligence: Unnatural Selection?

“…The GBS was developed using a logistic regression model to predict the need for hospital-based intervention in upper GIB. Although accurate in identifying low-risk patients who can potentially be discharged early from the emergency department (ED) (GBS ≤ 1), the score is infrequently used in health systems to guide decision making [3]. Despite the evidence base and guideline support for its use, several challenges to widespread implementation exist.…”