Imperiale Thomas F, Dominitz Jason A, Provenzale Dawn T, Boes Lynn P, Rose Cynthia M, Bowers Jill C, Musick Beverly S, Azzouz Faouzi, Perkins Susan M
Department of Medicine, Roudebush Veterans Affairs Medical Center, The Center of Excellence on Implementing Evidence-Based Practice, Indiana University School of Medicine, Indianapolis 46202, USA.
Arch Intern Med. 2007 Jun 25;167(12):1291-6. doi: 10.1001/archinte.167.12.1291.
Uncertainty about the outcome of acute upper gastrointestinal bleeding often results in a longer-than-necessary hospital stay.
We derived and internally validated clinical prediction rules (CPRs) to predict outcome from upper gastrointestinal bleeding. This multisite, prospective cohort study involved consecutive patients admitted for acute upper gastrointestinal bleeding. Multivariate logistic regression was used to derive CPRs on two thirds of the cohort (derivation set) that predicted bleeding-specific outcomes (rebleeding, need for urgent surgery, or hospital death [poor outcome 1]) and bleeding-specific outcomes plus new or worsening comorbidity (poor outcome 2). Both CPRs were then tested on the remaining third of the cohort (validation set).
A total of 391 individuals (99% men; mean age, 63.4 years) were enrolled, of which 4.6% rebled and 3.1% died. Independent predictors of poor outcome 1 were APACHE (Acute Physiology and Chronic Health Evaluation) II score of 11 or greater, esophageal varices, and stigmata of recent hemorrhage. Predictors of poor outcome 2 were these 3 factors plus unstable comorbidity on admission. Of patients with no risk factors, only 1 (1.1%) of 92 experienced poor outcome 1 and only 6 (6.2%) of 97 experienced poor outcome 2. Risks in the validation set were comparable. The CPRs identified 37.8% and 32.2% of patients in the derivation and validation sets, respectively, who were eligible for a shorter hospital stay.
Patients admitted with acute upper gastrointestinal bleeding were unlikely to have a poor outcome if these risk factors were absent. These CPRs might make hospital management more efficient by identifying low-risk patients for whom early hospital discharge is possible.
急性上消化道出血结局的不确定性常常导致住院时间长于必要时长。
我们推导并进行了内部验证临床预测规则（CPR），以预测上消化道出血的结局。这项多中心前瞻性队列研究纳入了因急性上消化道出血连续入院的患者。使用多变量逻辑回归在三分之二的队列（推导集）中推导CPR，以预测出血特异性结局（再出血、紧急手术需求或医院死亡[不良结局1]）以及出血特异性结局加新发或恶化的合并症（不良结局2）。然后在队列的其余三分之一（验证集）上测试这两种CPR。
共纳入391例个体（99%为男性；平均年龄63.4岁），其中4.6%发生再出血，3.1%死亡。不良结局1的独立预测因素为急性生理与慢性健康状况评估（APACHE）II评分11分及以上、食管静脉曲张和近期出血征象。不良结局2的预测因素为这3个因素加上入院时不稳定的合并症。在无危险因素的患者中，92例中只有1例（1.1%）发生不良结局1，97例中只有6例（6.2%）发生不良结局2。验证集中的风险与之相当。CPR分别在推导集和验证集中识别出37.8%和32.2%的患者符合缩短住院时间的条件。
如果不存在这些危险因素，因急性上消化道出血入院的患者不太可能出现不良结局。这些CPR可能通过识别可早期出院的低风险患者，提高医院管理效率。
