Outpatient Management of Nonvariceal Upper Gastrointestinal Hemorrhage: Unexpected Mortality in Medicare Beneficiaries

Background & Aims

Outpatient management of selected patients with nonvariceal upper gastrointestinal hemorrhage (UGIH) has been proposed as a mechanism to decrease resource utilization and expenditures. However, the true prevalence and outcomes of this practice have not been well evaluated in population-based studies.

Methods

We identified a cohort of 9123 episodes of UGIH in 2004 Medicare claims data, including 3506 (38.4%) managed as outpatients. Clinical characteristics, treatment, and outcomes were compared between inpatient and outpatient groups. In order to adjust for potential selection bias in outpatient treatment, propensity score analysis was used to divide patients into quartiles of likelihood for inpatient treatment.

Results

Inpatients tended to be older, with higher comorbidity scores, and were more likely to have a bleeding ulcer or tear. Inpatients were also more likely to undergo endoscopy, including early endoscopy and therapeutics, and require surgery. The overall 30-day mortality rate was 8.0% in the inpatient group and 6.3% in the outpatient group (P < .001), and in the quartile of patients most likely to be managed as inpatients, the 30-day mortality rate was higher in outpatients than in inpatients.

Conclusions

The prevalence of outpatient management of UGIH in the Medicare population was almost 40%, and although patients were likely selected for outpatient management based on clinical criteria, the overall mortality rate in outpatients was considerable. Any potential financial benefit should be balanced against significant mortality rates, at least some of which could possibly be avoided with hospitalization. More optimal selection of candidates for outpatient therapy is likely needed.

Abbreviations used in this paper: CPT-4, Current Procedural Terminology, 4th Edition, EGD, esophagogastroduodenoscopy, ICD-9-CM, International Classification of Diseases, 9th Revision, Clinical Modification, UGIH, upper gastrointestinal hemorrhage