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Scoring tool targets hospitalized patients needing acid suppressants


 

FROM GENERAL INTERNAL MEDICINE

A scoring system based on demographics and comorbidities predicted which hospitalized patients were at risk for nosocomial gastrointestinal bleeding.

Used as a guideline for administering acid suppressors, the system found that treating fewer than 100 high-risk patients would prevent one case of bleeding, Dr. Shoshana Herzig and her colleagues wrote in the January online issue of General Internal Medicine (2013 [doi:10.1007/s11606-012-2296-x]).

"This scoring system allows identification of subsets of patients in whom the risk of nosocomial gastrointestinal bleeding may be higher enough to warrant the use of prophylactic acid-suppressive medication, in the absence of other indicators for use," said Dr. Herzig of Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, and her coauthors.

Dr. Shoshana Herzig

The model "allows for risk stratification of patients using readily available information, and can be used to guide more selective use of acid-suppressive medication in patients outside of the ICU," the investigators wrote. The investigators reviewed about 76,000 records of noncritically ill patients hospitalized for more than 3 days, from 2004 through 2007. Nosocomial gastrointestinal bleeding occurred in about 3% of the group.

The authors constructed the risk score by identifying several factors that could potentially affect bleeding, including age, sex, comorbid conditions, admission service, and the receipt of certain medications during hospitalization.

A multivariate analysis identified those factors that significantly correlated with gastrointestinal bleeding. These included:

• Age more than 60 years (odds ratio, 2.2).

• Male sex (OR, 1.6).

• Liver disease (OR, 2.1).

• Acute renal failure (OR, 1.9).

• Admission to a medical service (OR, 2.7).

• Prophylactic anticoagulation (OR, 1.7).

• Coagulotherapy without antiplatelet medication (OR, 2.6).

• Coagulotherapy with one antiplatelet agent (OR, 3.2).

• Coagulotherapy with dual antiplatelet agents (OR, 3.3).

Based on these factors, they constructed a points-based risk scoring system that significantly correlated with the incidence of gastrointestinal bleeding. Patients in the lowest-score quartile were at the least risk of bleeding (less than 0.3%), while those in the highest quartile had the highest risk (1.5%).

The number needed to treat (NNT) to prevent one bleed increased as the risk score increased. The NNT was 500 in patients whose score was at least 6, 179 in those whose score was at least 8, 95 in those whose score was at least 10 (moderate risk), and 48 in those whose score was at least 12 (high risk).

The patients’ mean age was 56 years, although the range was very wide (18-107 years); 40% were male. Most patients received an acid-suppressing medication (58%). Proton pump inhibitors were most commonly used (81%); 29% received a histamine-2 receptor antagonist.

"With further validation at other medical centers, this scoring system may help clinicians individualize the decision to prescribe acid-suppressive medication as prophylaxis," the authors said.

The study was funded by grants from the National Institute on Aging and the National Center for Research Resources. None of the authors reported any financial conflicts.

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