Prediction scores or gastroenterologists’ Gut Feeling for triaging patients that present with acute upper gastrointestinal bleeding – NL de Groot, MGH van Oijen, K Kessels, M Hemmink, BLAM Weusten, R Timmer, WL Hazen, N van Lelyveld, JR Vermeijden, WL Curvers, LC Baak, R Verburg, JH Bosman, LRH de Wijkerslooth, J de Rooij, NG Venneman, M Pennings, K van Hee, RCH Scheffer, RL van Eijk, R Meiland, PD Siersema, AJ Bredenoord, 2014

Intended for healthcare professionals

Prediction scores or gastroenterologists’ Gut Feeling for triaging patients that present with acute upper gastrointestinal bleeding

Abstract

Introduction

Several prediction scores for triaging patients with upper gastrointestinal (GI) bleeding have been developed, yet these scores have never been compared to the current gold standard, which is the clinical evaluation by a gastroenterologist. The aim of this study was to assess the added value of prediction scores to gastroenterologists’ Gut Feeling in patients with a suspected upper GI bleeding.

Methods

We prospectively evaluated Gut Feeling of senior gastroenterologists and asked them to estimate: (1) the risk that a clinical intervention is needed; (2) the risk of rebleeding; and (3) the risk of mortality in patients presenting with suspected upper GI bleeding, subdivided into low, medium, or high risk. The predictive value of the gastroenterologists’ Gut Feeling was compared to the Blatchford and Rockall scores for various outcomes.

Results

We included 974 patients, of which 667 patients (68.8%) underwent a clinical intervention. During the 30-day follow up, 140 patients (14.4%) developed recurrent bleeding and 44 patients (4.5%) died. Gut Feeling was independently associated with all studied outcomes, except for the predicted mortality after endoscopy. Predictive power, based on the AUC of the Blatchford and Rockall prediction scores, was higher than the Gut Feeling of the gastroenterologists. However, combining both the Blatchford and Rockall scores and the Gut Feeling yielded the highest predictive power for the need of an intervention (AUC 0.88), rebleeding (AUC 0.73), and mortality (AUC 0.71 predicted before and 0.77 predicted after endoscopy, respectively).

Conclusions

Gut Feeling is an independent predictor for the need of a clinical intervention, rebleeding, and mortality in patients presenting with upper GI bleeding; however, the Blatchford and Rockall scores are stronger predictors for these outcomes. Combining Gut Feeling with the Blatchford and Rockall scores resulted in the most optimal prediction.

Introduction

There is an increasing role for evidence-based medicine in clinical practice. This is accompanied by the development of prediction scores and their use is increasingly being recommended and adopted in clinical guidelines.¹ A prediction score (or risk score/decision rule) is a tool for physicians based on several predictors – such as patients’ history, physical examination, test results, and other disease characteristics – which give an estimation on the probability of a likely diagnosis, prognosis, or response to treatment.² Such tools can be of added value for the physician in daily clinical practice.

Upper gastrointestinal (GI) bleeding is a common clinical problem and accounts for 25–35 hospitalizations per 100,000 person-years.^3,4 The severity of the disease may vary from no active bleeding to rapid exsanguinations, and yet the course remains difficult to predict. Almost all patients suspected for upper GI bleeding are therefore admitted to the hospital and endoscopy is being performed within 24 hours after hospitalization.⁵ This results in a high pressure on hospital capacity, possibly unnecessary discomfort for the patient, and high healthcare costs. Accurate predicting of the course and outcome of upper GI bleeding should ideally facilitate triage into low- and high-risk groups and would thus help clinical management.

Several prediction scores for upper GI bleeding have been developed.⁶ The most commonly used scores are the Blatchford and Rockall scores.^7,8 The Blatchford score is a validated score using pre-endoscopic variables, such as clinical and laboratory data, and has the primary goal to predict the need for an intervention, such as an upper endoscopy with a haemostatic procedure. The Rockall score is a validated score based on clinical, laboratory, and endoscopic variables and primarily predicts mortality. Although these scores are validated and recommended by international guidelines,⁵ it seems that gastroenterologists confronted with upper GI bleeding do not often incorporate these scores into clinical practice.

From previous studies we have learned that scores are more likely to be implemented if they are easy to use, if recommendations are being made based on the score (instead of just assessment), if they can be incorporated in the normal daily usual workflow, and if they are computerized.⁹ However, the willingness of a physician to use scores is also important. The reasons for a physician not using scores may be: they are difficult to calculate, they take time, and, most importantly, they do not add to their own clinical knowledge or ‘Gut Feeling’. Moreover, it has been reported that clinical decision making may be even better than prediction scores in predicting whether patients with upper GI bleeding should be admitted to the intensive care unit.¹⁰

In the current study, we assessed the added value of prediction scores to the Gut Feeling of gastroenterologists in patients with suspected upper GI bleeding presenting to the accident and emergency department (A&E).

Methods