Oakland Score to identify low-risk patients with lower gastrointestinal bleeding performs well among emergency department patients

Abstract

Background: The Oakland Score predicts risk of 30-day adverse events among hospitalized patients with lower gastrointestinal bleeding (LGIB) possibly identifying patients who may be safe for discharge. The Oakland Score has not been studied among emergency department (ED) patients with LGIB. The Oakland Score composite outcome includes re-bleeding, defined as additional blood transfusion requirements and/or a further decrease in hematocrit (Hct) >/= 20% after 24 hours in clinical stability; red blood cell transfusion; therapeutic intervention to control bleeding, including surgery, mesenteric embolization, or endoscopic hemostasis; in-hospital death, all cause; and re-admission with further LGIB within 28 days. Prediction variables include age, sex, previous LGIB admission, systolic blood pressure, heart rate, and hemoglobin concentration, and scores range from 0 to 35 points, with higher scores indicating greater risk. Methods: Retrospective cohort study of adult (≥18 years old) patients with a primary ED diagnosis of LGIB across 21 EDs from March 1^st, 2018, through March 21^st, 2020. We excluded patients who were more likely to have upper gastrointestinal bleeding (esophago-gastroduodenoscopy without LGIB evaluation), patients who left against medical advice or prior to ED provider evaluation, ED patients without active health plan membership, and patients with incomplete Oakland Score variables. We assessed predictive accuracy by reporting the area under the receiver operator curve (AUROC) and sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios at multiple clinically relevant thresholds. Results: We identified 8,283 patients with LGIB, 52% were female, mean age was 68, 49% were non-white, and 27% had an adverse event. The AUROC for predicting an adverse event was 0.85 (95% CI: 0.84 to 0.86). There were 1,358 patients with an Oakland Score of </=8; 4.9% had an adverse event, and sensitivity of the Oakland Score at this threshold was 97% (95% CI 0.96 to 0.98). Conclusion: The Oakland Score had high predictive accuracy among ED patients with LGIB. Prospective evaluation is needed to understand if the risk score could augment ED decision-making and improve outcomes and resource utilization.