Effect of Physician Specialty and Call Back Endoscopy Teams in Non-Variceal Upper Gastrointestinal Bleeding: A Comparison between Two Health Regions

Abstract

Purpose: Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common medical emergency and a frequent cause for admission to Canadian hospitals. There is significant morbidity and mortality associated with these admissions. In certain Canadian health regions, many NVUGIB are admitted to general surgical wards and many do not have call back endoscopy teams. The effect of these factors on mortality and re-bleeding is unknown. Methods: We examined two similar health regions which differed in the management of NVUGIB. The Saskatoon Health Region (SHR) has no formal call back endoscopy team and 40% of NVUGIB patients were admitted to a general surgery ward. In contrast, the Regina Qu'Appelle Health Region (RQHR) has a formal call back team and 80% of patients are admitted to a GI ward. ICD-10 codes were used to identify patients with a primary or secondary diagnosis of NVUGIB admitted to the SHR or RQHR between January 2008 and February 2010. The primary outcomes of interest were mortality and 30-day re-bleeding rates. Primary outcomes were also stratified by health region, endoscopist specialty, and weekend admission. Descriptive statistics using mean, medians and ranges were used to describe demographic and patient variables. Group comparisons of proportions and means were performed using Chi-square analysis and Student's t-test. Results: The mortality rate across both health regions for NVUGIB was 12.4% with 15.8% experiencing rebleeding and 3.6% readmitted within thirty days due to re-bleeding. There was no significant mortality difference between health regions (14.7% vs. 10.1% p=0.1), but there was a significant increase in rebleeding (23.1% vs. 8.5% p=<0.001; CI 0.17-0.30) and readmission (6.9% vs. 0.6% p=0.002; CI 0.03-0.11) in the SHR. This was unchanged when adjusted for age and comorbidities by logistic regression with an odds ratio of 3.11 (p=0.001; CI 1.6-5.9). Mortality and rebleeding rates were similar independent of endoscopist specialty. Readmission rates were higher across both health regions if admitted to a general surgeon versus gastroenterologist (7.5% vs. 1.9% p=0.01; CI 0.89-0.99). There was no significant weekend effect. Early endoscopy (<24 hrs) was significantly more frequent within the RQHR (84.7% vs. 65.0%; p<0.001; CI 1.13-1.36) and if the attending physician was a gastroenterologist (80.5% vs. 65.1% p=0.009; CI 1.13-1.36). Conclusion: Mortality rates across both health regions were higher than the national average, but not statistically different between the two. The presence of gastroenterologists admitting a larger proportion of NVUGIB and formal call back teams was associated with decreased rebleeding rates, readmission rates, and increased rates of early endoscopy.