Hospital-based Disparities in Care and Outcomes for Upper Gastrointestinal Bleeding

Abstract

Introduction: Major teaching hospitals and urban centers are often recognized for offering advanced treatment options, but whether these centers provide better care for common illness than non teaching and rural hospitals is not clear. The objective of this study is to examine the association of location and hospital teaching status with outcomes for patients with acute upper gastrointestinal bleeding (UGIB). Methods: The Nationwide Inpatient Sample (NIS) was used to identify patients who presented with upper gastrointestinal bleeding between 2003 and 2010. Data was collected on the utilization of surgical intervention and diagnostic procedures based on hospital location and hospital teaching status. Logistic regression models were used to evaluate the outcomes disparities based on hospital characteristics. Results: Of the 478,921 patients included in the study, 76.2% of patients received an EGD while 1.9% had some form of surgical intervention. Patients treated at rural hospitals were less likely to receive an EGD (68.9%) than those treated at urban institutions (77.7%) (p < 0.001). Of those patients treated at rural institutions 1.2% received surgical intervention while 2% received surgical intervention at urban institutions, with gastrostomy being less commonly performed at rural vs. urban institutions (p=0.005). Patients receiving care at teaching hospitals were more likely to undergo an EGD than patients in non teaching hospitals (77.7% v. 75.3%, p < 0.001). They were also more likely to have intervention at time of EGD including esophageal ligation or injection (p=0.042). At teaching institutions 2.2% of patients underwent surgical intervention, with more laparoscopy/laparotomies being performed at teaching hospitals vs. non teaching institutions (p=0.021). At rural and non teaching hospitals patients were more likely to receive blood transfusions during their inpatient course (p < 0.001 & p < 0.001, respectively). Patients at urban and teaching hospitals were more likely to have a longer length of stay (p < 0.001) and increased health care cost (p < 0.001). Conclusion: Treatment for patients with UGIB including rate of surgical intervention, rate of blood transfusion, length of stay and care cost are dependent on hospital characteristics. Recognizing disparities of care and addressing possible causes are essential to ensure that all patients admitted for acute gastrointestinal bleeding receive access to high quality care.