Hospitalized Incidence and Case Fatality for Upper Gastrointestinal Bleeding from 1999 to 2007

A Record Linkage Study

L. A. Button; S. E. Roberts; P. A. Evans; M. J. Goldacre; A. Akbari; R. Dsilva; S. Macey; J. G. Williams

Disclosures

Aliment Pharmacol Ther. 2011;33(1):64-76. 

In This Article

Abstract and Introduction

Abstract

Background Upper gastrointestinal (GI) bleeding is the most common emergency managed by gastroenterologists.
Aim To establish the hospitalized incidence and case fatality for upper GI bleeding, and to determine how they are associated with factors including day of admission, hospital size, social deprivation and distance from hospital.
Methods Systematic record linkage of hospital in-patient and mortality data for 24 421 admissions for upper GI bleeding among 22 299 people in Wales from 1999 to 2007.
Results The hospitalized incidence of upper GI bleeding was 134 per 100 000. Case fatality was 10.0%. Incidence was stable from 1999 to 2007; case fatality fell from 11.4% in 1999–2000 to 8.6% in 2006–7. Incidence was associated significantly with social deprivation. Compared with weekday admissions, case fatality was 13% higher for weekend admissions and 41% higher for admissions on public holidays. There was little variation in case fatality according to social deprivation, hospital size or distance from hospital.
Conclusions Incidence, but not case fatality, was associated significantly with social deprivation. The higher mortality for weekend and public holiday admissions could not be explained by measures of case mix and may indicate a possible impact of reduced staffing levels and delays to endoscopy at weekends in some hospitals.

Introduction

Upper gastrointestinal (GI) bleeding is the most common emergency managed by gastroenterologists with approximately 25 000 in-patient admissions annually in the UK.[1] Upper GI bleeding occurs largely among people in older age groups, and has a higher incidence in males than in females.[2–4]

Upper GI bleeding in the UK and in Europe has been caused most frequently by peptic ulcer – particularly duodenal ulcer – followed by other aetiologies including varices, gastritis/erosions, oesophagitis, Mallory–Weiss tear, upper GI malignancies, duodenitis, gastric antral vascular ectasia and portal hypertension.[5–7] Many upper GI bleeds are caused by long-term use of nonsteroidal anti-inflammatory drugs, especially among older people, although patterns of prescribing have changed over time.[8] Other upper GI bleeding aetiologies are linked to alcohol consumption – such as oesophageal varices, Mallory–Weiss tear and oesophageal malignancies – which are increasing over time in some regions.[6,9] With an ageing population, and with sharp increases in alcohol consumption in the UK in the last 50 years,[10,11] upper GI bleeding is an important disorder.

The incidence of upper GI bleeding varies across the UK, with highest incidence reported in Scotland,[4,12,13] compared with lower rates often reported in southern England.[2,3,14,15] Upper GI bleeding has been associated with high levels of social deprivation in one study of the west of Scotland,[4] although little else has been reported on the relationship between upper GI bleeding and social inequality, particularly on a national scale. Local studies indicate that as the incidence of upper GI bleeding has increased over time, there has been little recent improvement in case fatality, which remains at about 10%.[6,7] There is also current interest in whether prognosis for emergency disorders varies according to the day of admission,[16,17] the size of hospital,[18] and the distance travelled to hospital,[19] although little has been reported about these for upper GI bleeding.

The main objectives of this study were to establish the incidence of hospital admissions for upper GI bleeding in Wales and case fatality at 30 days following admission, and to investigate whether case fatality is higher for admissions on weekends and public holidays. Further objectives were to assess trends over time in incidence and case fatality, and whether they are associated with factors including social deprivation, distance from hospital and hospital size.

Our main study hypotheses are that the incidence of upper GI bleed is associated strongly with social deprivation and that case fatality is increased for people who are admitted on weekends and public holidays – rather than on weekdays – and may be lower for people admitted to 'medium' size rather than to small or large hospitals.

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