January 16, 2017
By Will Boggs MD
NEW YORK (Reuters Health) - Among the five most widely studied risk scores for upper gastrointestinal bleeding, the Glasgow Blatchford score (GBS) appears best at predicting the need for hospital-based intervention or death, according to new research.
"This study show that the GBS is accurate worldwide at identifying low-risk patients with upper GI bleeding who do not need admission, but can be managed as out-patients," Dr. Adrian J. Stanley from Glasgow Royal Infirmary in Glasgow, U.K., told Reuters Health by email.
Risk assessment scores are widely used to predict clinically relevant outcomes, and several studies have compared scores in their ability to predict various outcomes.
In their prospective study of more than 3,000 patients, Dr. Stanley and colleagues compared five endoscopic and pre-endoscopic risk assessment scores for their ability to predict clinically relevant endpoints such as the need for hospital-based intervention or death, endoscopic treatment and re-bleeding within seven days. The scoring systems included the GBS, AIMS65, admission Rockall, full Rockall, and PNED (progetto nazionale emorragia digestive).
Forty-five percent of the patients needed hospital based intervention or died within 30 days of presenting with acute upper GI bleeding. Based on area-under-the-receiver-operating-characteristic curves, the GBS had the highest discriminative ability at predicting need for intervention or death, followed by the full Rockall score, the PNED score, the AMIS65 score, and the admission Rockall score.
A GBS score of 1 or less had a sensitivity of 98.6% and a specificity of 34.6% for predicting patients at very low risk, who did not require intervention and survived; the positive predictive value was 96.6% and the negative predictive value, 56.0%.
Only 3.4% of patients with GBS of 1 or less experienced intervention or death, compared with 14% to 25% of patients with minimal results on other scoring systems.
The GBS was also best for predicting endoscopic treatment, and the AIMS65 and PNED were the best for predicting mortality, but accuracy and clinical utility were relatively low for these endpoints, the researchers report in The BMJ, online January 4.
"Better risk scores are required to help identify those patients needing emergency endoscopy," Dr. Stanley said.
"The GBS should be calculated on all patient presenting to hospital with an upper GI bleed (hematemesis or melena)," he added. "If the GBS is <=1 (incorporates approximately 20% of patients), the patient does not need to be admitted and can be offered an out-patient endoscopy. All other patients should be admitted and offered endoscopy within 24 hrs."
"The accurate identification of these low-risk patients who can avoid admission will reduce costs and allow resources to be focused on those (more ill) patients who need admitted," he said.
Dr. Dominik Kralj from "Sestre milosrdnice" University Hospital Centre in Zagreb, Croatia, who recently compared three of these scoring systems, told Reuters Health by email, "There were no great surprises in this study, but it is interesting to note that all of the scores underperform regarding rebleeding rates (important for deciding admittance to an intensive care/monitoring unit) and hospital stay."
His advice: "Use scores to predict the initial need for urgent endoscopy, but do not count on them to predict complications or outcomes."
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