title: Performance of new thresholds of the Glasgow Blatchford score in managing patients with upper gastrointestinal bleeding.
abstract: OBJECTIVE
  Upper gastrointestinal hemorrhage (UGIH) is a common cause of hospital admission. The Glasgow Blatchford score (GBS) is an accurate determinant of patients' risk for hospital-based intervention or death. Patients with a GBS of 0 are at low risk for poor outcome and could be managed as outpatients. Some investigators therefore have proposed extending the definition of low-risk patients by using a higher GBS cut-off value, possibly with an age adjustment. We compared 3 thresholds of the GBS and 2 age-adjusted modifications to identify the optimal cut-off value or modification.
  
  
  METHODS
  We performed an observational study of 2305 consecutive patients presenting with UGIH at 4 centers (Scotland, England, Denmark, and New Zealand). The performance of each threshold and modification was evaluated based on sensitivity and specificity analyses, the proportion of low-risk patients identified, and outcomes of patients classified as low risk.
  
  
  RESULTS
  There were differences in age (P = .0001), need for intervention (P < .0001), mortality (P < .015), and GBS (P = .0001) among sites. All systems identified low-risk patients with high levels of sensitivity (>97%). The GBS at cut-off values of ≤1 and ≤2, and both modifications, identified low-risk patients with higher levels of specificity (40%-49%) than the GBS with a cut-off value of 0 (22% specificity; P < .001). The GBS at a cut-off value of ≤2 had the highest specificity, but 3% of patients classified as low-risk patients had adverse outcomes. All GBS cut-off values, and score modifications, had low levels of specificity when tested in New Zealand (2.5%-11%).
  
  
  CONCLUSIONS
  A GBS cut-off value of ≤1 and both GBS modifications identify almost twice as many low-risk patients with UGIH as a GBS at a cut-off value of 0. Implementing a protocol for outpatient management, based on one of these scores, could reduce hospital admissions by 15% to 20%.
authors: Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark. Electronic address: stig.borbjerg.laursen@ouh.regionsyddanmark.dk.
authors: Stig B
authors: SB
authors: Laursen
authors: Gastrointestinal Unit, Royal Cornwall Hospital, Cornwall, United Kingdom.
authors: Harry R
authors: HR
authors: Dalton
authors: Gastrointestinal Unit, Dunedin Public Hospital, Dunedin, New Zealand.
authors: Iain A
authors: IA
authors: Murray
authors: Gastrointestinal Unit, Royal Cornwall Hospital, Cornwall, United Kingdom.
authors: Nick
authors: N
authors: Michell
authors: Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
authors: Matt R
authors: MR
authors: Johnston
authors: Department of Medicine, University of Otago, Dunedin, New Zealand.
authors: Michael
authors: M
authors: Schultz
authors: Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark.
authors: Jane M
authors: JM
authors: Hansen
authors: Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark.
authors: Ove B
authors: OB
authors: Schaffalitzky de Muckadell
authors: Public Health Department, University of Glasgow, Glasgow, United Kingdom.
authors: Oliver
authors: O
authors: Blatchford
authors: Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, United Kingdom.
authors: Adrian J
authors: AJ
authors: Stanley
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003661:Decision Support Techniques; D003718:Denmark; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis* / Q000473:pathology / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009520:New Zealand; D011379:Prognosis; D011446:Prospective Studies; D012189:Retrospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D006113:United Kingdom; D055815:Young Adult
keywords: Gastrointestinal Bleeding; Management; Outpatient; Prognosis; UGIH