Patients over age 60 are considerably more likely to have a 30-day mortality

Reference: Bae, S., et al., Incidence and 30-day mortality of peptic ulcer bleeding in Korea. Eur J Gastroenterol Hepatol, 2012. 24(6): p. 675-682.

A study out from Korea on the incidence and 30-day mortality rate of peptic ulcer bleeding in Korea.

Brief Summary:  A peptic ulcer is an ulcer which occurs somewhere in the gastrointestinal tract (large or small intestine) and can provide complications in the form of peptic ulcer bleeding (PUB).  The main objective of this study was to estimate the rate of peptic ulcer bleed bleeding and the risk factors for 30 day mortality from a PUB event.  An improved PUB diagnostic algorithm which relied on a prescription of histamine type-2 receptor antagonists (H2RA) or proton pump inhibitors (PPI) was used to diagnose the PUB patients.

Results:  On the basis of the aforementioned diagnostic algorithm, the incidence rate for PUB was 22.1 per 100,000 individuals.  The 30-day mortality rate for patients with presenting PUB over 80 was 7.65%, between the ages of 60 and 79, 2.87%, and for those less than 60, 0.83%. The overall 30 day mortality rate for all patients was 2.15 percent.  Overall, in a uni-variate analysis, the risk factors which predicted a greater likelihood of mortality for PUB were over age 60, female sex, ulcer-related drug use (aspirin, oral glucocorticoids, vitamin K antagonists,etc.), and antiulcer drug use (proton pump inhibitors and H2 receptor antagonists).   When adjusting for all the factors, only age was found to be a significant 30-day risk factor.  

Implications for Practice: Doctors need to be more wary of patients who are older than 60 and present with a peptic ulcer bleeding, because these patients are considerably more likely to have a 30-day mortality event. 

Discussion: Really interesting study here.   The incidence of gastrointestinal conditions can really vary from one geographical region to another, because the environmental and dietary variables can really vary from one region to another, and thus studies like this is important.  Whenever this geographical dependency occurs, it is important to limit the analysis to a certain sub-population in the world as this investigation did.   

It was surprising to see that the PPV jumped so significantly with the use of a more restrictive diagnostic algorithm (prescription of the PPI or H2RA).  The PPV went from 53 to 88 percent – astounding increase! I am interested to see whether other epidemiological based studies could take advantage of this prescription fix. 

Also, I liked the discussion section that the author’s wrote-up.  In short, they gave a detailed but succinct description of the various risk factors, and their influence on the eventual disease.   The authors noted that patients of age greater than 75 are more likely to have a peptic ulcer than those between the ages of 25 and 44 due to consumption of NSAID/aspirin or the high prevalence of H. pylori among the elderly.  This would seem to be the main causative factor here.      

Also, the author’s noted that the result for gender was different for this study compared to past studies.  Past studies showed that males have a higher incidence rate due to higher rates of alcohol consumption and smoking among men, which are known to be risk factors of PUB. It seems as if a significantly more work needs to be done to elucidate the exact effect of gender here – especially given the confliction results from this investigation to past.  It no doubt has something to do with the inherent differences in the sub-populations under study.    

Commentary on Statistics and Study Design: Overall, the investigators did a really good job with the statistical analysis.  I like how the author’s reported both the un-adjusted (uni-variate) and un-adjusted (multi-variate) results.  This is really important in a study like this, because it’s important to give the reader a final set of risk factors (variables) which are most associated with the response (morbidity).   For instance, it’s highly suspicious that the use of an ulcer-related drug – which was significant in the uni-variate analysis – would also be significant in the multi-variate analysis when also adjusting for age. 

Also, I really like how the authors used the Charlson co-morbidity index and used this as a controlling factor multi-variate analysis. This is obviously crucial to do, since the presence of another disease could seriously confound the experiment.  Typically, many investigators would just totally exclude any patients from the study all-together with the presence of another disease, but in doing this, the analyst is essentially losing data samples. It is better just to control for the confounding factor if possible. 

I guess my only suggestion for the authors would be to include a more explicit description of the odds ratios which were presented in Table 3 which detailed the individual risk factors for the un-adjusted (uni-variate) model.  For instance, say something like “the odds of a 30 day mortality increase by 350% for patients who are between the ages of 60 to 79 compared to those patients who are less than 60.”  This type of succinct yet explicit detail can be really helpful.  Other than that, everything looks good!  I really liked the tables and figures – not too much to say there.

As the authors alluded to in the discussion section, there are several lifestyle variables (smoking, alcohol consumption, etc.) which could have been included in the study.  In fact, the introduction of these lifestyle variables would probably change the relationship with 30-day co-morbidity significantly.  For instance, I bet you that sex will not even be significant if you introduce these lifestyle variables, but this is another good study for the future.

A big thanks to our Korea pals for doing this!