Risk factors for nosocomial gastrointestinal bleeding and use of acid-suppressive medication in non-critically ill patients

Abstract

Background: It is unknown whether there exist certain subsets of patients outside of the intensive care unit in whom the risk of nosocomial gastrointestinal bleeding is high enough that prophylactic use of acid-suppressive medication may be warranted.

Objective: To identify risk factors for nosocomial gastrointestinal bleeding in a cohort of non-critically ill hospitalized patients, develop a risk scoring system, and use this system to identify patients most likely to benefit from acid suppression.

Design: Cohort study.

Patients: Adult patients admitted to an academic medical center from 2004 through 2007. Admissions with a principal diagnosis of gastrointestinal bleeding or a principal procedure code for cardiac catheterization were excluded.

Main measures: Medication, laboratory, and other clinical data were obtained through electronic data repositories maintained at the medical center. The main outcome measure-nosocomial gastrointestinal bleeding occurring outside of the intensive care unit-was ascertained via ICD-9-CM coding and confirmed by chart review.

Key results: Of 75,723 admissions (median age = 56 years; 40 % men), nosocomial gastrointestinal bleeding occurred in 203 (0.27 %). Independent risk factors for bleeding included age > 60 years, male sex, liver disease, acute renal failure, sepsis, being on a medicine service, prophylactic anticoagulants, and coagulopathy. Risk of bleeding increased as clinical risk score derived from these factors increased. Acid-suppressive medication was utilized in > 50 % of patients in each risk stratum. Our risk scoring system identified a high risk group in whom the number-needed-to-treat with acid-suppressive medication to prevent one bleeding event was < 100.

Conclusions: In this large cohort of non-critically ill hospitalized patients, we identified several independent risk factors for nosocomial gastrointestinal bleeding. With further validation at other medical centers, the risk model derived from these factors may help clinicians to direct acid-suppressive medication to those most likely to benefit.

Figure 1.

Relationship between clinical risk score and nosocomial gastrointestinal bleeding (bar graph) and acid-suppressive medication use (line graph). The bar graph demonstrates the rate of nosocomial gastrointestinal bleeding by increasing risk group in our cohort, in both the derivation and validation subsets. The line graph demonstrates the percent with acid-suppressive medication use in the different risk groups.