Assessment of Prognostic Scores for Emergency Department Patients With Upper Gastrointestinal Bleeding - 01/08/24

Doi : 10.1016/j.annemergmed.2024.06.024

Pierre-Clément Thiebaud, MSc ^a,^b,^⁎ , Eliana Wassermann, PhD ^c, Mathilde de Caluwe ^d, Clément Prebin ^d, Florent Noel, MD ^d, Agnès Dechartres, PhD ^e, Pierre-Alexis Raynal, MD ^d, Judith Leblanc, PhD ^f, Youri Yordanov, PhD ^b
^a Université de Paris Cité, INSERM, UMR-S 942, Improving Emergency Care University Hospital Federation, Paris, France
^b Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, UMR-S 1136, AP-HP, Hôpital Saint-Antoine, Service d'Accueil des Urgences, Paris, France
^c AP-HP.Sorbonne Université, Hôpital Saint-Antoine, Unité de recherche clinique de l'Est Parisien, Paris, France
^d AP-HP.Sorbonne Université, Hôpital Saint-Antoine, Service d'Accueil des Urgences, Paris, France
^e Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, UMR-S 1136, AP-HP, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Paris, France
^f Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, Unité de recherche clinique Est Parisien, Paris, France

^∗Corresponding Author.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Thursday 01 August 2024

Abstract

Study objective

Early prognostic stratification could optimize the management of patients with upper gastrointestinal bleeding and reduce unnecessary hospitalizations. The aim of this study was to assess and compare the performance of existing prognostic scores in predicting therapeutic intervention and death.

Methods

A systematic search of the literature identified existing prognostic scores. A multicenter retrospective cohort study included adult patients hospitalized for upper gastrointestinal bleeding from January 1, 2019, to December 31, 2020. The primary outcome was a composite including therapeutic intervention within 7 days (blood transfusion, endoscopic, surgical, or interventional radiology hemostasis) and/or 30-day death. Discrimination performance was estimated by the area under the curve (AUC). The ability to identify low-risk patients was analyzed using sensitivity and negative predictive value (NPV) for defined thresholds.

Results

The systematic search identified 39 prognostic scores, 12 of which could be analyzed. Among the 990 patients included, therapeutic intervention and/or death occurred in 755 (76.4%) patients. Scores with the highest discriminative performance to predict the primary composite outcome were Glasgow-Blatchford score (GBS) (AUC 0.869 [0.842 to 0.895]), modified GBS (AUC 0.872 [0.847 to 0.898]) and modified GBS 2 (AUC 0.855 [0.827 to 0.884]). The best performance to identify low-risk patients was for GBS≤1 (sensitivity 0.99 [0.99 to 1.00], NPV 0.89 [0.75 to 0.97]) and modified GBS=0 (sensitivity 0.99 [0.98 to 1.00], NPV 0.84 [0.71 to 0.94]).

Conclusions

The GBS and the modified GBS are the 2 best performing scores because they achieve both key objectives: stratifying patients based on their risk of therapeutic intervention and/or death and identifying low-risk patients who may qualify for outpatient management.

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Plan

Introduction

Background

Goals of This Investigation

Methods

Study Design and Settings

Selection of Participants

Score Identification and Selection

Data Collection and Management

Patient Characteristics

Primary Composite Outcome

Secondary Outcomes

Inter-rater Reliability

Limitations

Discussion

	Supervising editor: Allan B. Wolfson, MD. Specific detailed information about possible conflict of interest for individual editors is available at editors.
	Author contributions: PCT, JL, and YY conceived the study, designed the trial, and obtained legal permissions. PCT supervised the conduct of the trial. AD was involved in the systematic review of the literature. PCT, PAR, and YY reviewed the literature. EW and JL performed the selection of patient data. PCT, MDC, CP, and FN collected data. PCT managed and analyzed the data. PCT and YY were involved in data interpretation and drafted the initial manuscript. All authors contributed substantially to its revision. PCT takes responsibility for the manuscript as a whole.
	Data sharing statement: Data supporting this study can be made available on reasonable request to the corresponding author, on condition that the research project is accepted by the scientific and ethics committee of the Greater Paris University Hospital health data warehouse.
	All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Funding and support: By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). This study was conducted without financial support. The authors have no conflict of interest relevant to this article to disclose.
	Trial registration number: This study was registered on clinicaltrials.gov (NCT05927493).
	Please see page XX for the Editor’s Capsule Summary of this article.