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• W2022381207 abstract "Potential advantages of early endoscopy in nonvariceal upper GI hemorrhage may include rapid diagnosis, risk stratification, risk-based allocation of resources (eg, deferred admission or lower level of care with early discharge for low-risk patients, or ICU admission for high-risk patients), and application of endoscopic hemostasis.A widely studied health services research model of the quality of healthcare postulates that the structure and the process of healthcare delivery systems are linked to outcomes. As defined in this conceptual model, the process of care may be of particular interest to practicing physicians, because it describes variations in the technical and interpersonal aspects of interactions between patients and their healthcare providers. In healthcare, unlike other traditional industries (eg, automobile manufacturing), the link between process and outcome is often difficult to establish for any particular condition. Thus, a high-quality healthcare process may be defined not only by evidence, suggesting a causal link to improved outcomes, but also by community standards or expert opinion. Potential advantages of early endoscopy in nonvariceal upper GI hemorrhage may include rapid diagnosis, risk stratification, risk-based allocation of resources (eg, deferred admission or lower level of care with early discharge for low-risk patients, or ICU admission for high-risk patients), and application of endoscopic hemostasis. Nonvariceal upper-GI hemorrhage is among the most common and clinically significant emergent conditions treated by practicing endoscopists. Perhaps the best studied metric of the process of care for this condition is the time from the patient's presentation to the performance of diagnostic/therapeutic endoscopy. As with many metrics in medicine, the continuous variable of “time to endoscopy” is traditionally stratified into 2 categories: early and delayed endoscopy. The definition of early endoscopy has varied from 1 to 24 hours in the published literature, with 24 hours being probably the most commonly used cutoff point. Potential advantages of early endoscopy in nonvariceal upper-GI hemorrhage may include rapid diagnosis, risk stratification, risk-based allocation of resources (eg, deferred admission or lower level of care with early discharge for low-risk patients, or intensive care unit [ICU] admission for high-risk patients), and application of endoscopic hemostasis. Potential disadvantages include complications associated with performance of endoscopy in unstable patients; missed opportunities for care of other healthcare problems; the risk of aspiration or the need for repeat endoscopy when gastric lavage is incomplete; and the cost of providing routine, around-the-clock, endoscopy services. A prior systematic review of published studies on this topic found reasonable evidence that early endoscopy was safe and effective for patients with nonvariceal upper-GI hemorrhage, although the investigators found that the strength of the evidence was greater for patients at lower risk of adverse outcomes.1Spiegel B.M. Vakil N.B. Ofman J.J. Endoscopy for acute nonvariceal upper gastrointestinal tract hemorrhage: is sooner better? A systematic review.Arch Intern Med. 2001; 161: 1393-1404Crossref PubMed Scopus (161) Google Scholar Published consensus guidelines from Barkun et al2Barkun A. Bardou M. Marshall J.K. Nonvariceal Upper GI Bleeding Consensus Conference Group. Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding.Ann Intern Med. 2003; 139: 843-857Crossref PubMed Scopus (498) Google Scholar defined early endoscopy as occurring within 24 hours and are consistent with the systematic review in finding better evidence in support of its use for low-risk than for high-risk patients. In prior studies, the proportion of hospitalized patients with nonvariceal upper-GI hemorrhage undergoing early endoscopy (ie, within 24 hours of presentation) varied from 40% to 80%.1Spiegel B.M. Vakil N.B. Ofman J.J. Endoscopy for acute nonvariceal upper gastrointestinal tract hemorrhage: is sooner better? A systematic review.Arch Intern Med. 2001; 161: 1393-1404Crossref PubMed Scopus (161) Google Scholar, 3Targownik L.E. Gralnek I.M. Dulai G.S. et al.Management of acute nonvariceal upper gastrointestinal hemorrhage: comparison of an American and a Canadian medical centre.Can J Gastroenterol. 2003; 17: 489-495Crossref PubMed Scopus (13) Google Scholar An improved understanding of the reasons for the variation in time to endoscopy could lead to interventions aimed at decreasing time to endoscopy. A decrease in the average time to endoscopy might in turn lead to improved healthcare outcomes. In this issue of Gastrointestinal Endoscopy, da Silveira et al4da Silveira E.B. Lam E. Martel M. et al.The importance of process issues as predictors of time to endoscopy in patients with acute upper-GI bleeding using the RUGBE data.Gastrointest Endosc. 2006; 64: 299-309Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar present findings from an exploratory study aimed at identifying factors associated with variation in time to endoscopy. This was a multicenter retrospective cohort study that used descriptive data on a random sample of hospitalized patients with nonvariceal upper-GI hemorrhage who underwent endoscopy; it was collected from 12 university and 6 community medical centers across Canada from 1999 to 2002. This study was funded by Altana Pharma Canada, marketers of an intravenous proton pump inhibitor. Patients experiencing inpatient bleeding after admission for other reasons were enrolled, along with patients admitted with acute bleeding. The full database includes 217 variables on 1869 patients, 62% of whom were recruited by 6 centers. The original purpose of the database was to use it to describe predictors of outcomes for these patients, including the role of proton pump inhibitors.5Barkun A. Sabbah S. Enns R. et al.The Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy (RUGBE): endoscopic hemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting.Am J Gastroenterol. 2004; 99: 1238-1246Crossref PubMed Scopus (313) Google Scholar For the current study, the investigators selected 50 independent variables for use in a linear regression model to determine which of these factors were associated with time to endoscopy. Only 33 of these variables were analyzed because of missing data in the other 17. The time to endoscopy was measured from presentation to the hospital (for outpatients) or from the onset of bleeding (for inpatients) to the performance of an endoscopy. Patients transferred from another hospital, those with missing data, as well as those having a time to endoscopy >48 hours were excluded, leaving 1325 patients for analysis. The median time to endoscopy was 12.0 hours, 95% confidence interval (CI) 10.0-12 hours for outpatients and 15.5 hours, 95% CI 13.0-18.0 hours for outpatients. The vast majority (84%) of all patients underwent endoscopy within 24 hours. A linear model was created with variables that best fit the data—except for rectal examination, age, and health status, which were forced into the model. The final model was also analyzed according to inpatient vs outpatient presentation. The implicit hypothesis was that the 33 independent variables studied would not be associated with time to endoscopy. In the final model, variables having statistically significant association with a decreased time to endoscopy included absence of dyspnea, absence of chest pain, presence of on-call endoscopy nurse, endoscopy performed after hours (vs during the day), admission to ICU (vs other level of care), use of an intravenous proton pump inhibitor, failure to perform or to record a rectal examination (vs rectal examination without gross blood), and outpatient presentation (vs inpatient bleed). The investigators characterized time of day that the endoscopy was performed, level of care on admission, availability of on-call nurse, and hospital status at presentation as “process” rather than clinical parameters. Of these, the strongest association was with hospital status (outpatient vs inpatient presentation), suggesting that, after adjustment for other factors, inpatients in this study underwent endoscopy an average of nearly 15 hours after outpatients. All other factors were associated with time differences of ≤6 hours. A significant interaction was also found such that time to endoscopy decreased faster with declining health status for inpatients vs outpatients. The r2 for the final model was 0.14, suggesting that 14% of the observed variability in time to endoscopy was accounted for by the variables in the model. The investigators concluded that time to endoscopy is associated with both “process” and clinical parameters. The investigators and the endoscopists they studied are to be congratulated for the high proportion of all patients who underwent early endoscopy as defined by experts. The 84% rate reported is at the high end of published studies. A Hawthorne effect is possible, because endoscopists presumably knew that data were being entered into a registry and may have known that time to endoscopy was one of the metrics under consideration. The proportion is also slightly inflated because of exclusion of patients undergoing endoscopy >48 hours after presentation. Still, the finding is laudable. It is also remarkably consistent with prior findings from a comparative study of a Canadian and an American academic medical center in which early endoscopy was performed in 80% of patients in the former vs 56% in the latter.3Targownik L.E. Gralnek I.M. Dulai G.S. et al.Management of acute nonvariceal upper gastrointestinal hemorrhage: comparison of an American and a Canadian medical centre.Can J Gastroenterol. 2003; 17: 489-495Crossref PubMed Scopus (13) Google Scholar Linear models, like the one used in the current study, are by necessity among the most commonly used analytic tools in health services research, but they have limitations. For instance, variables in such models are assumed to have a normal distribution. In this study, patients with outlying values for time to endoscopy (eg, >48 hours) were excluded from analysis. One might argue that these outliers are of particular interest. Patients with missing data for model variables must also be excluded or missing values inputted. In this study, patients with missing values were excluded. As pointed out by the investigators, a linear model may also attach statistical significance to changes in the dependent variable that may not have clinical significance. In this study, the availability of an on-call nurse was associated with a 2.5-hour average decrease in the time to endoscopy. It is not clear that a 3-hour difference in time to endoscopy alone would justify the expense of retaining a permanent on-call nursing service for all centers, especially if most patients were to still undergo endoscopy within 24 hours. Still, most investigators would agree that endoscopy should be performed as soon as possible. This study identified some factors that may be associated with time to endoscopy. Of those factors that the investigators identify as “process issues” (time of day that endoscopy is performed, level of care on admission, availability of on-call nurse, and hospital status at presentation), only the first 2 would seem to meet traditional definitions of process measures. The availability of an on-call nurse would seem to be a more natural measure of the structure of care, whereas hospital status at presentation is a clinical characteristic of the patient. Regardless of definition, it is reasonable and reassuring to find that these variables are associated with time to endoscopy in this study. Observational studies cannot account for unknown confounders, but they can attempt to account for those that are suspected. Important confounders that might have been included in a retrospective study on time to endoscopy include structural factors (number of endoscopists, presence of a dedicated endoscopic hemostasis service, availability of a specialty-run ward service, urban vs rural setting, academic vs community center, number and type of hospital beds), process factors (time from presentation to initial physical examination/laboratory tests/nasogastric tube lavage, time to initiation of resuscitation, time from presentation to calling GI consult), and other factors, such as time of day that the patient presented with a GI bleed, annual volume of patients with GI bleed seen by institution/endoscopist, and year of endoscopist graduation from medical school. Some of these factors might even be amenable to change in future interventions. The results of interventions designed to decrease time to endoscopy have been mixed.6Bjorkman D.J. Zaman A. Fennerty M.B. et al.Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study.Gastrointest Endosc. 2004; 60: 1-8Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar, 7Pfau P.R. Cooper G.S. Carlson M.D. et al.Success and shortcomings of a clinical care pathway in the management of acute nonvariceal upper gastrointestinal bleeding.Am J Gastroenterol. 2004; 99: 425-431Crossref PubMed Scopus (28) Google Scholar Early endoscopy is not perforce associated with improved outcomes, eg, decreased hospital length of stay.3Targownik L.E. Gralnek I.M. Dulai G.S. et al.Management of acute nonvariceal upper gastrointestinal hemorrhage: comparison of an American and a Canadian medical centre.Can J Gastroenterol. 2003; 17: 489-495Crossref PubMed Scopus (13) Google Scholar Clearly, this aspect of the process of care does not exist in a vacuum. Other clinical, structural, and procedural characteristics may play a critical role in determining outcomes. Future studies with more inclusive models might make the difference between a “try” and a “touchdown” in attempting to understand the contribution of process measures to the quality of care provided to patients presenting with acute nonvariceal upper-GI hemorrhage. I have no conflicts of interest or other disclosures to make." @default.
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