Urban-Rural Disparities and Temporal Trends in Peptic Ulcer Disease Epidemiology, Treatment, and Outcomes in the United States.

INTRODUCTION: The incidence of peptic ulcer disease (PUD) has been decreasing over time with Helicobacter pylori eradication and use of acid-suppressing therapies. However, PUD remains a common cause of hospitalization in the United States. We aimed to evaluate contemporary national trends in the incidence, treatment patterns, and outcomes for PUD-related hospitalizations and compare care delivery by hospital rurality. METHODS: Data from the National Inpatient Sample were used to estimate weighted annual rates of PUD-related hospitalizations. Temporal trends were evaluated by joinpoint regression and expressed as annual percent change with 95% confidence intervals (CIs). We determined the proportion of hospitalizations requiring endoscopic and surgical interventions, stratified by clinical presentation and rurality. Multivariable logistic regression was used to assess independent predictors of in-hospital mortality and postoperative morbidity. RESULTS: There was a 25.8% reduction (P < 0.001) in PUD-related hospitalizations from 2005 to 2014, although the rate of decline decreased from -7.2% per year (95% CI: 13.2% to -0.7%) before 2008 to -2.1% per year (95% CI: 3.0% to -1.1%) after 2008. In-hospital mortality was 2.4% (95% CI: 2.4%-2.5%). Upper endoscopy (84.3% vs 78.4%, P < 0.001) and endoscopic hemostasis (26.1% vs 16.8%, P < 0.001) were more likely to be performed in urban hospitals, whereas surgery was performed less frequently (9.7% vs 10.5%, P < 0.001). In multivariable logistic regression, patients managed in urban hospitals were at higher risk for postoperative morbidity (odds ratio 1.16 [95% CI: 1.04-1.29]), but not death (odds ratio 1.11 [95% CI: 1.00-1.23]). DISCUSSION: The rate of decline in hospitalization rates for PUD has stabilized over time, although there remains significant heterogeneity in treatment patterns by hospital rurality.

Using Hemospray Improves the Cost-effectiveness Ratio in the Management of Upper Gastrointestinal Nonvariceal Bleeding.

GOALS: We compared the cost-effectiveness of traditional recommended endoscopic hemostatic therapies and Hemospray alone or in combination when treating nonvariceal upper gastrointestinal bleeding (NVUGIB). BACKGROUND: Hemospray (TC-325) is a novel endoscopic hemostatic powder, achieving hemostasis through adherence to actively bleeding biological surfaces. STUDY: A decision tree of patients with NVUGIB assessed 4 possible treatment strategies: traditional therapy alone (T), Hemospray alone (H), traditional therapy completed by Hemospray if needed (T+H), or Hemospray completed by traditional therapy if needed (H+T). Using published probabilities, effectiveness was the likelihood of avoiding rebleeding over 30 days. Costs in 2014 US$ were based on the US National Inpatient Sample. A third-party payer perspective was adopted. Sensitivity and subgroup analyses were performed. RESULTS: For all patients, T+H was more efficacious (97% avoiding rebleeding) and less expensive (average cost per patient of US$9150) than all other approaches. The second most cost-effective approach was H+T (5.57% less effective and US$635 more per patient). Sensitivity analyses showed T+H followed by a strategy of H+T remained more cost-effective than H or T alone when varying all probability assumptions across plausible ranges. Subgroup analysis showed that the inclusion of H (especially alone) was least adapted for ulcers and was more cost-effective when treating lesions at low risk of delayed rebleeding. CONCLUSIONS: Hemospray improves the effectiveness of traditional hemostasis, being less costly in most NVUGIB patient populations. A Hemospray first approach is most cost-effective for nonulcer bleeding lesions at low risk of delayed hemorrhage.

Impact of day of admission on mortality and other outcomes in upper GI hemorrhage: a nationwide analysis.

BACKGROUND: Studies have reached varying conclusions regarding the association between day of admission and outcomes in patients with upper GI hemorrhage (UGIH). OBJECTIVES: To evaluate whether important outcomes in UGIH, including in-hospital mortality, differ between patients admitted on weekends versus weekdays. DESIGN AND SETTING: Retrospective cohort study by using the 2009 Nationwide Inpatient Sample. PATIENTS: Patients were included if they were adults with a principal diagnosis of acute UGIH. Patients admitted between midnight Friday and midnight Sunday were classified as weekend admissions. MAIN OUTCOME MEASUREMENTS: In-hospital mortality, in-hospital endoscopy, endoscopic therapy, length of stay, and total hospitalization charges. RESULTS: The study included 199,008 patients with nonvariceal UGIH and 3251 patients with variceal UGIH. Compared with patients admitted on weekdays, patients with nonvariceal UGIH admitted on weekends had similar adjusted in-hospital mortality rates (odds ratio [OR] 1.11; 95% confidence interval [CI], 0.93-1.30), endoscopic therapy rates (OR 0.98; 95% CI, 0.92-1.04), and length of stay (P = .09), but had lower early endoscopy rates (within 24 hours)(OR 0.64; 95% CI, 0.60-0.67), lower in-hospital endoscopy rates (OR 0.84; 95% CI, 0.78-0.91), and higher hospitalization charges (mean increase, $1558; P = .01). Patients with variceal UGIH admitted on weekends and weekdays did not differ in any of these outcomes. LIMITATIONS: Retrospective data, administrative database. CONCLUSIONS: Compared with patients admitted on weekdays, patients with nonvariceal UGIH admitted on weekends had similar mortality rates and lengths of stay, but lower endoscopy rates and higher hospitalization charges. Patients with variceal GI hemorrhage had similar outcomes regardless of day of admission.

Higher hospital volume is associated with lower mortality in acute nonvariceal upper-GI hemorrhage.

BACKGROUND: Acute nonvariceal upper-GI hemorrhage (NVUGIH) is associated with significant morbidity and mortality. OBJECTIVE: To examine the relationship between hospital volume and outcomes of NVUGIH. DESIGN: A cross-sectional study. SETTING: Participating hospitals from the Nationwide Inpatient Sample 2004. PATIENTS: All discharged patients with a primary discharge diagnosis of NVUGIH based on the International Classification of Diseases, Clinical Modification, ninth edition codes. INTERVENTIONS: Patients were divided into 3 groups based on discharge from hospitals with annual discharge volumes of 1 to 125 (low), 126 to 250 (medium), and >250 (high). MAIN OUTCOME MEASUREMENTS: In-hospital mortality, length of stay, and hospitalization charges. RESULTS: The study included a total of 135,366, 132,746, and 123,007 discharges with NVUGIH occurred from low-volume, medium-volume, and high-volume hospitals, respectively. On multivariate analysis, when adjusting for age, comorbidity, and the presence of complications, patients at high-volume hospitals had significantly lower in-hospital mortality (odds ratio [OR] 0.85 [95% CI, 0.74-0.98]) than patients at low-volume hospitals. Patients at high-volume hospitals were also more likely to undergo upper-GI endoscopy (OR 1.52 [95% CI, 1.36-1.69]) or early endoscopy within 1 day of hospitalization compared with low-volume hospitals (60.5% vs 53.8%, adjusted OR 1.28 [95% CI, 1.02-1.61]). Undergoing endoscopy within day 1 was associated with shorter hospital stays (-1.08 days [95% CI, -1.24 to -0.92 days]) and lower hospitalization charges (-$1958 [95% CI, -$3227 to -$688]). LIMITATIONS: The study was based on an administrative data set. CONCLUSIONS: Higher hospital volume is associated with lower mortality and with higher rates of endoscopy and endoscopic intervention in patients with NVUGIH.

Clinical practice and evidence in endoscopic treatment of bleeding peptic gastroduodenal ulcer.

OBJECTIVE: To investigate treatment practice in non-variceal upper gastrointestinal bleeding (NVUGIB) caused by gastroduodenal ulcer and how it adheres to the best evidence as documented in randomized studies and meta-analyses. MATERIAL AND METHODS: The literature was surveyed to identify appropriate practices, and a structured multiple choice questionnaire developed and mailed to all departments in Denmark treating UGIB. RESULTS: All 42 departments responded. All had therapeutic gastroscopes and equipment necessary for endoscopic haemostasis; 90% of departments had written guidelines. Adjuvant pharmacologic treatment included tranexamic acid in 38%. Proton-pump inhibitors (PPIs) were used by all departments, with 29% starting prior to endoscopic treatment. Eight departments (19%) used continuous PPI infusion, three of them starting with a bolus dose. In 50% of departments an anaesthesiologist was always present regardless of whether endotracheal intubation (routinely used by 10%) was used or not. Ten percent did not treat Forrest IIa and IIb ulcers, while IIc ulcers were treated by 36%. In 10% of departments clots were never removed, while in 2/3 attempts were made to remove resistant clots by mechanic means. Seven departments (17%) used monotherapy with epinephrine, while 59% always used dual therapy; 19% injected less than 10 ml. In rebleeding, 92% attempted endoscopic treatment before surgery, and used epinephrine in 79% of cases, while the remainder used epinephrine or polidocanol at the discretion of the endoscopist. Two out of three departments used high-dependency or intensive-care units for surveillance. Seventeen percent applied scheduled second-look gastroscopy. CONCLUSIONS: Practice is variable, even in areas with established evidence based on randomized controlled studies, such as dosage and way of administration and duration of PPI treatment, injection treatment used as monotherapy and the volume used, including ulcers with clots for treatment, and the use of scheduled second-look endoscopy. Since the rebleeding rate has remained unchanged for decades, and rebleeding implies increased surgery and mortality rates, appropriate practices must be promoted in order to improve results. Development and implementation of national guidelines may facilitate the process.