Trends in characteristics, management, and outcomes of patients presenting with gastrointestinal bleeding to emergency departments in the United States from 2006 to 2019

Abstract

Background: Recent epidemiologic studies of trends in gastrointestinal bleeding (GIB) provided results through 2014 or earlier and assessed only hospitalised patients, excluding patients presenting to emergency departments (EDs) who are not hospitalised.

Aims: To provide the first U.S. nationwide epidemiological evaluation of all patients presenting to EDs with GIB METHODS: We used the Nationwide Emergency Department Sample for 2006-2019 to calculate yearly projected incidence of patients presenting to EDs with primary diagnoses of GIB, categorised by location and aetiology. Outcomes were assessed with multivariable analyses.

Results: The age/sex-adjusted incidence for GIB increased from 378.4 to 397.5/100,000 population from 2006 to 2019. Upper gastrointestinal bleeding (UGIB) incidence decreased from 2006 to 2014 (112.3-94.4/100,000) before increasing to 116.2/100,000 by 2019. Lower gastrointestinal bleeding (LGIB) incidence increased from 2006 to 2015 (146.0 to 161.0/100,000) before declining to 150.2/100,000 by 2019. The proportion of cases with one or more comorbidities increased from 27.4% to 35.9% from 2006 to 2019. Multivariable analyses comparing 2019 to 2006 showed increases in ED discharges (odds ratio [OR] = 1.45; 95% confidence interval [CI] = 1.43-1.48) and decreases in red blood cell (RBC) transfusions (OR = 0.62; 0.61-0.63), endoscopies (OR = 0.60; 0.59-0.61), death (OR = 0.51; 0.48-0.54) and length of stay (relative ratio [RR] = 0.81; 0.80-0.82). Inpatient cost decreased from 2012 to 2019 (RR = 0.92; 0.91-0.93).

Conclusions: The incidence of GIB in the U.S. is increasing. UGIB incidence has been increasing since 2014 while LGIB incidence has been decreasing since 2015. Despite a more comorbid population in 2019, case fatality rate, length of stay and costs have decreased. More patients are discharged from the ED and the rate of RBC transfusions has decreased, possibly reflecting changing clinical practice in response to updated guidelines.

Figure 1.

Incidences (per 100,000 population) and percent change from 2006 to 2019 for gastrointestinal bleeding (GIB) as the primary diagnosis for emergency department visit stratified by male, female, and all (A) and stratified by upper and lower GIB (B). Percentages indicate overall percent change from 2006 to 2019. *P<0.05 for trend.

Figure 2.

Age- and sex-adjusted incidences (per 100,000 population) and percent change from 2006 to 2019 for different sources of upper gastrointestinal bleed (A) and lower gastrointestinal bleed (B). Percentages indicate overall percent change from baseline year of 2006 to 2019.

Figure 3.

Trends and percent change from 2006 to 2019 for in-hospital red blood cell transfusion (A), in-hospital case fatality (B), emergency department discharge (C), in-hospital endoscopy (D), inpatient length of stay (E), and inpatient cost (F) in patients with upper gastrointestinal bleeds (UGIB), stratified by different sources of UGIB. Percentages indicate overall percent change from baseline year of 2006 to 2019. *P<0.05 for trend. RBC = red blood cell; ED = emergency department; UGIB = upper gastrointestinal bleed.

Figure 4.

Trends and percent change from 2006 to 2019 for in-hospital red blood cell transfusion (A), in-hospital case fatality (B), emergency department discharge (C), in-hospital endoscopy (D), inpatient length of stay (E), and inpatient cost (F) in patients with lower gastrointestinal bleeds (LGIB), stratified by different sources of LGIB. Percentages indicate overall percent change from baseline year of 2006 to 2019. *P<0.05 for trend. RBC = red blood cell; ED = emergency department; LGIB = lower gastrointestinal bleed.