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A national survey on the initial management of upper gastrointestinal bleeding
Peter S Liang1, John R Saltzman
1*Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, WA †Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Insights
Physician agreement with upper gastrointestinal (GI) bleeding guidelines is high, but adherence, particularly to risk score use, is low in the US. This impacts the initial management of GI bleeding.
Area of Science:
- Gastroenterology
- Clinical Practice Guidelines
- Healthcare Quality Improvement
Background:
- Established guidelines exist for the initial management of upper gastrointestinal (GI) bleeding.
- Current adherence to these guidelines in clinical practice remains largely unquantified.
Purpose of the Study:
- To evaluate the adherence of US physicians to initial upper GI bleeding management guidelines.
- To assess the awareness, utilization, and barriers associated with early prognostic risk scores in upper GI bleeding.
Main Methods:
- A national survey was distributed to emergency physicians, internists, and gastroenterologists.
- Participants reported agreement and adherence to 9 preendoscopic quality indicators for upper GI bleeding.
- Physicians' awareness and use of risk scores, along with barriers, were also evaluated.
Main Results:
- High agreement with quality indicators was observed, with gastroenterologists showing greater agreement than non-gastroenterologists.
- Adherence to quality indicators did not differ by specialty or position.
- Only 30% of physicians had ever used an upper GI bleeding risk score, with gastroenterologists more likely to have heard of and used them.
- Lack of utility and knowledge were cited as primary barriers to risk score use.
Conclusions:
- US physicians demonstrate high agreement with upper GI bleeding management guidelines.
- Adherence to these guidelines, especially the use of prognostic risk scores, is notably low.
- Barriers to risk score adoption include perceived lack of utility and insufficient knowledge.
Goals:
To evaluate the initial management of upper gastrointestinal (GI) bleeding in the United States.
Background:
Various guidelines have addressed the initial management of upper GI bleeding, but the extent to which these guidelines are followed in clinical practice is unknown.
Study:
We conducted a national survey of emergency physicians, internists, and gastroenterologists practicing in hospitals affiliated with an ACGME-accredited gastroenterology fellowship. Participants rated their agreement and adherence to 9 preendoscopic quality indicators for the initial management of upper GI bleeding. Awareness, use, and barriers to the use of early prognostic risk scores were also assessed.
Results:
A total of 1402 surveys were completed, with an estimated response rate of 11.3%. Gastroenterologists and trainees agreed with the quality indicators more than nongastroenterologists and attending physicians, respectively. There was no difference in the application of the quality indicators by specialty or clinical position. Among all physicians, 53% had ever heard of and 30% had ever used an upper GI bleeding risk score. More gastroenterologists than nongastroenterologists had heard of (82% vs. 44%, P<0.001) and used (51% vs. 23%, P<0.001) a risk score. There was no difference between attending physicians and trainees. Gastroenterologists and attending physicians more often cited lack of utility as a reason to not use risk scores, whereas nongastroenterologists and trainees more often cited lack of knowledge.
Conclusions:
Among emergency physicians, internists, and gastroenterologists in the United States, agreement with upper GI bleeding initial management guidelines was high but adherence--especially pertaining to the use of risk scores--was low.
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