Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study

Abstract

Objective: To compare the predictive accuracy and clinical utility of five risk scoring systems in the assessment of patients with upper gastrointestinal bleeding.

Design: International multicentre prospective study.

Setting: Six large hospitals in Europe, North America, Asia, and Oceania.

Participants: 3012 consecutive patients presenting over 12 months with upper gastrointestinal bleeding.

Main outcome measures: Comparison of pre-endoscopy scores (admission Rockall, AIMS65, and Glasgow Blatchford) and post-endoscopy scores (full Rockall and PNED) for their ability to predict predefined clinical endpoints: a composite endpoint (transfusion, endoscopic treatment, interventional radiology, surgery, or 30 day mortality), endoscopic treatment, 30 day mortality, rebleeding, and length of hospital stay. Optimum score thresholds to identify low risk and high risk patients were determined.

Results: The Glasgow Blatchford score was best (area under the receiver operating characteristic curve (AUROC) 0.86) at predicting intervention or death compared with the full Rockall score (0.70), PNED score (0.69), admission Rockall score (0.66, and AIMS65 score (0.68) (all P<0.001). A Glasgow Blatchford score of ≤1 was the optimum threshold to predict survival without intervention (sensitivity 98.6%, specificity 34.6%). The Glasgow Blatchford score was better at predicting endoscopic treatment (AUROC 0.75) than the AIMS65 (0.62) and admission Rockall scores (0.61) (both P<0.001). A Glasgow Blatchford score of ≥7 was the optimum threshold to predict endoscopic treatment (sensitivity 80%, specificity 57%). The PNED (AUROC 0.77) and AIMS65 scores (0.77) were best at predicting mortality, with both superior to admission Rockall score (0.72) and Glasgow Blatchford score (0.64; P<0.001). Score thresholds of ≥4 for PNED, ≥2 for AIMS65, ≥4 for admission Rockall, and ≥5 for full Rockall were optimal at predicting death, with sensitivities of 65.8-78.6% and specificities of 65.0-65.3%. No score was helpful at predicting rebleeding or length of stay.

Conclusions: The Glasgow Blatchford score has high accuracy at predicting need for hospital based intervention or death. Scores of ≤1 appear the optimum threshold for directing patients to outpatient management. AUROCs of scores for the other endpoints are less than 0.80, therefore their clinical utility for these outcomes seems to be limited.Trial registration Current Controlled Trials ISRCTN16235737.

Conflict of interest statement

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that: (1) no authors have support from any company for the submitted work; (2) no authors have relationships with any company that might have an interest in the submitted work (3) no author, their spouses, partners, or children have financial relationships that may be relevant to the submitted work and (4) no authors have any non-financial interests that may be relevant to the submitted work.

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Figures

Fig 1 Comparisons of scores in prediction of need for any intervention (transfusion, endoscopic treatment, interventional radiology or surgery) or 30 day mortality (n=1704). All figures compare patients with complete data for all compared scores. AUROC=area under the receiver operating characteristic curve

Fig 2 Comparisons of pre-endoscopic scores in prediction of need for endoscopic treatment (n=2478). AUROC=area under the receiver operating characteristic curve

Fig 3 Comparisons of scores in prediction of 30 day mortality (n=1707). AUROC=area under the receiver operating characteristic curve