Can J Gastroenterol Hepatol. 2014 Oct;28(9):495-501. doi: 10.1155/2014/252307.
To assess process of care in nonvariceal upper gastrointestinal bleeding (NVUGIB) using a national cohort, and to identify predictors of adherence to 'best practice' standards.
Consecutive charts of patients hospitalized for acute upper gastrointestinal bleeding across 21 Canadian hospitals were reviewed. Data regarding initial presentation, endoscopic management and outcomes were collected. Results were compared with 'best practice' using established guidelines on NVUGIB. Adherence was quantified and independent predictors were evaluated using multivariable analysis.
Overall, 2020 patients (89.4% NVUGIB, variceal in 10.6%) were included (mean [± SD] age 66.3±16.4 years; 38.4% female). Endoscopy was performed in 1612 patients: 1533 with NVUGIB had endoscopic lesions (63.1% ulcers; high-risk stigmata in 47.8%). Early endoscopy was performed in 65.6% and an assistant was present in 83.5%. Only 64.5% of patients with high-risk stigmata received endoscopic hemostasis; 9.8% of patients exhibiting low-risk stigmata also did. Intravenous proton pump inhibitor was administered after endoscopic hemostasis in 95.7%. Rebleeding and mortality rates were 10.5% and 9.4%, respectively. Multivariable analysis revealed that low American Society of Anesthesiologists score patients had fewer assistants present during endoscopy (OR 0.63 [95% CI 0.48 to 0.83), a hemoglobin level <70 g⁄L predicted inappropriate high-dose intravenous proton pump inhibitor use in patients with low-risk stigmata, and endoscopies performed during regular hours were associated with longer delays from presentation (OR 0.33 [95% CI 0.24 to 0.47]).
There was variability between the process of care and 'best practice' in NVUGIB. Certain patient and situational characteristics may influence guideline adherence. Dissemination initiatives must identify and focus on such considerations to improve quality of care.
使用全国性队列评估非静脉曲张性上消化道出血（NVUGIB）的治疗过程，并确定符合“最佳实践”标准的预测因素。
对 21 家加拿大医院因急性上消化道出血住院的患者连续病历进行回顾性分析。收集初始表现、内镜治疗和结局的数据。结果与 NVUGIB 的既定指南进行比较，以确定“最佳实践”。使用多变量分析评估一致性和独立预测因素。
共纳入 2020 例患者（89.4%为 NVUGIB，10.6%为静脉曲张性出血）（平均[±标准差]年龄 66.3±16.4 岁；38.4%为女性）。1612 例患者进行了内镜检查：1533 例 NVUGIB 患者有内镜下病变（63.1%为溃疡；47.8%有高危征象）。早期内镜检查率为 65.6%，有 83.5%的患者有助手在场。仅有 64.5%的高危征象患者接受内镜止血治疗；9.8%的低危征象患者也接受了治疗。内镜止血后，95.7%的患者给予静脉质子泵抑制剂。再出血和死亡率分别为 10.5%和 9.4%。多变量分析显示，美国麻醉医师协会评分低的患者在进行内镜检查时助手较少（比值比 0.63[95%置信区间 0.48 至 0.83]），血红蛋白水平＜70 g⁄L 提示低危征象患者接受不适当的大剂量静脉质子泵抑制剂治疗，而在常规时间进行的内镜检查与从就诊到治疗的时间延迟较长有关（比值比 0.33[95%置信区间 0.24 至 0.47]）。
NVUGIB 的治疗过程与“最佳实践”之间存在差异。某些患者和情况特征可能影响指南的依从性。传播计划必须确定并关注这些因素，以提高护理质量。
