Outcomes in high and low volume hospitals in patients with acute hematochezia in a cohort study

Naoki Ishii,Kazuhiro Mizukami,Yuta Fuyuno,Naoyuki Tominaga,Yorinobu Sumida,Yuga Komaki,Tetsu Kinjo,Naohiko Gunji,Hiroki Sato,Jun Omori,Takaaki Kishino,Atsushi Yamauchi,Kuniko Miki,Tatsuya Mikami ,Noriatsu Imamura,Yuzuru Kinjo,Akinari Takao,Akira Mizuki,Takahiko Yano,Yosuke Toya,Shu Kiyotoki,Tsunaki Sawada,Minoru Fujita,Sadahiro Funakoshi,Masaki Murata,Takashi Ikeya,Koji Nagaike,Takuzo Funabiki ,Yoshinori Sato,Naoyoshi Nagata,Sho Suzuki,Kana Kawagishi,Fumio Omata,Katsumasa Kobayashi,Taiki Aoyama,Takahiro Uotani,Ryosuke Gushima,Kazuhiro Watanabe,Shunji Fujimori,Yasutoshi Shiratori,Tamotsu Matsuhashi,Noriaki Manabe,Ken Kinjo,Atsuo Yamada,Hiroyuki Fujii,Toshiaki Narasaka,Kazuyuki Narimatsu,Junnosuke Hayasaka,Mitsuru Kaise

doi:10.1038/s41598-021-99832-6

Abstract

Outcomes of acute lower gastrointestinal bleeding have not been compared according to hospital capacity. We aimed to perform a propensity score-matched cohort study with path and mediation analyses for acute hematochezia patients. Hospitals were divided into high- versus low-volume hospitals for emergency medical services. Rebleeding and death within 30 days were compared. Computed tomography, early colonoscopy (colonoscopy performed within 24 h), and endoscopic therapies were included as mediators. A total of 2644 matched pairs were yielded. The rebleeding rate within 30 days was not significant between high- and low-volume hospitals (16% vs. 17%, P = 0.44). The mortality rate within 30 days was significantly higher in the high-volume cohort than in the low-volume cohort (1.7% vs. 0.8%, P = 0.003). Treatment at high-volume hospitals was not a significant factor for rebleeding (odds ratio [OR] = 0.91; 95% confidence interval [CI], 0.79–1.06; P = 0.23), but was significant for death within 30 days (OR = 2.03; 95% CI, 1.17–3.52; P = 0.012) on multivariate logistic regression after adjusting for patients’ characteristics. Mediation effects were not observed, except for rebleeding within 30 days in high-volume hospitals through early colonoscopy. However, the direct effect of high-volume hospitals on rebleeding was not significant. High-volume hospitals did not improve the outcomes of acute hematochezia patients.

Highlights

Outcomes of acute lower gastrointestinal bleeding have not been compared according to hospital capacity
Early colonoscopy, and endoscopic therapies were included as mediators
To the best of our knowledge, this study is the first to compare the management and clinical outcomes of patients with acute hematochezia according to hospital characteristics and perform path and mediation analyses

Summary

Introduction

Outcomes of acute lower gastrointestinal bleeding have not been compared according to hospital capacity. The rebleeding rate within 30 days was not significant between high- and low-volume hospitals (16% vs 17%, P = 0.44). Mediation effects were not observed, except for rebleeding within 30 days in high-volume hospitals through early colonoscopy. Medical centers are classified as high or low-volume centers in terms of the treatment strategies followed and clinical outcomes achieved for different diseases[1,2,3]. The differences between these settings in terms of clinical outcomes for the management of patients with acute hematochezia— acute lower gastrointestinal bleeding (ALGIB)— have not been sufficiently investigated. Because the clinical course of most ALGIB cases, including colonic diverticular hemorrhage, are generically mild with spontaneous resolution of bleeding episodes in 70–80% of c ases[6,7], there may be a possibility of equal outcomes irrespective of hospital capacity.

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