title: Adherence to guidelines: a national audit of the management of acute upper gastrointestinal bleeding. The REASON registry.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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]).
  
  
  CONCLUSIONS
  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.
authors.forename: Yidan
authors.initials: Y
authors.lastname: Lu
authors.forename: Alan N
authors.initials: AN
authors.lastname: Barkun
authors.forename: Myriam
authors.initials: M
authors.lastname: Martel
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D002170:Canada / Q000453:epidemiology; D015331:Cohort Studies; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000401:mortality / Q000628:therapy*; D019983:Guideline Adherence; D016558:Hemostasis, Endoscopic / Q000379:methods; D006801:Humans; D015994:Incidence; D007297:Inpatients / Q000706:statistics & numerical data; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D010437:Peptic Ulcer / Q000150:complications; D017410:Practice Guidelines as Topic; D054328:Proton Pump Inhibitors / Q000627:therapeutic use; D011787:Quality of Health Care; D012307:Risk Factors; D015996:Survival Rate; D016896:Treatment Outcome
chemical_list: D054328:Proton Pump Inhibitors