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ORIGINAL ARTICLE: Clinical Endoscopy
The AIMS65 score compared with the Glasgow-Blatchford score in
predicting outcomes in upper GI bleeding
Brian H. Hyett, MD,*,1,2
Marwan S. Abougergi, MD,*,1,2
Joseph P. Charpentier, MD,3
Navin L. Kumar, MD,2
Suzana Brozovic, MD,1,2
Brian L. Claggett, MA,4
Anne C. Travis, MD,1,2
John R. Saltzman, MD1,2
Boston, Worcester, Massachusetts, USA
Introduction: We previously derived and validated the AIMS65 score, a mortality prognostic scale for upper GI
bleeding (UGIB).
Objective: To validate the AIMS65 score in a different patient population and compare it with the Glasgow-
Blatchford risk score (GBRS).
Design: Retrospective cohort study.
Patients: Adults with a primary diagnosis of UGIB.
Main Outcome Measurements: Primary outcome: inpatient mortality. Secondary outcomes: composite clinical
endpoint of inpatient mortality, rebleeding, and endoscopic, radiologic or surgical intervention; blood transfu-
sion; intensive care unit admission; rebleeding; length of stay; timing of endoscopy. The area under the
receiver-operating characteristic curve (AUROC) was calculated for each score.
Results: Of the 278 study patients, 6.5% died and 35% experienced the composite clinical endpoint. The AIMS65
score was superior in predicting inpatient mortality (AUROC, 0.93 vs 0.68; P Ͻ .001), whereas the GBRS was
superior in predicting blood transfusions (AUROC, 0.85 vs 0.65; P Ͻ .01) The 2 scores were similar in predicting
the composite clinical endpoint (AUROC, 0.62 vs 0.68; P ϭ .13) as well as the secondary outcomes. A GBRS of
10 and 12 or more maximized the sum of the sensitivity and specificity for inpatient mortality and rebleeding,
respectively. The cutoff was 2 or more for the AIMS65 score for both outcomes.
Limitations: Retrospective, single-center study.
Conclusion: The AIMS65 score is superior to the GBRS in predicting inpatient mortality from UGIB, whereas the
GBRS is superior for predicting blood transfusion. Both scores are similar in predicting the composite clinical
endpoint and other outcomes in clinical care and resource use. (Gastrointest Endosc 2013;77:551-7.)
GI bleeding is the most common GI emergency, with
upper GI bleeding (UGIB) resulting in more than 300,000
hospital admissions per year in the United States.1,2 Inter-
national consensus guidelines from 2010 recommend
“early risk stratification, by using validated prognostic
scales” in the care of patients with UGIB as part of a
goal-oriented therapy.3 The recent American College of
Gastroenterology practice guidelines on the manage-
Abbreviations: AUROC, area under the receiver-operating characteristic
curve; GBRS, Glasgow-Blatchford risk score; ICU, intensive care unit;
PRBC, packed red blood cell; UGIB, upper GI bleeding.
DISCLOSURE: The authors disclosed no financial relationships relevant
to this publication.
*Drs Hyett and Abougergi contributed equally to this article.
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Copyright © 2013 by the American Society for Gastrointestinal Endoscopy
0016-5107/$36.00
http://dx.doi.org/10.1016/j.gie.2012.11.022
Received June 14, 2012. Accepted November 19, 2012.
Current affiliations: Department of Medicine (1), Division of Gastroenterol-
ogy (2), Brigham and Women’s Hospital, Boston, Massachusetts, Depart-
ment of Internal Medicine (3), University of Massachusetts Medical Center,
Worcester,Massachusetts,DepartmentofBiostatistics(4),HarvardSchoolof
Public Health, Boston, Massachusetts, USA.
Preliminary results were presented at the American College of
Gastroenterology 2010 Annual Scientific Meeting, October 15-20, 2010;
San Antonio, Texas (Am J Gastroenterol 2010;105:S394 [abstract]).
Reprint requests: John R. Saltzman, MD, Endoscopy Center, Brigham and
Women’s Hospital, 75 Francis Street, Boston, MA 02115.
If you would like to chat with an author of this article, you may contact Dr
Saltzman at jsaltzman@partners.org.
www.giejournal.org Volume 77, No. 4 : 2013 GASTROINTESTINAL ENDOSCOPY 551
ment of patients with ulcer bleeding also recommends
that “risk assessment should be performed to stratify
patients into higher and lower risk categories, and may
assist in initial decisions such as timing of endoscopy,
time of discharge, and level of care.”4 Risk stratification
on presentation to the emergency department enables
rapid and accurate triage as well as appropriate re-
source use. This is vital for timely administration of
lifesaving therapies to patients and for achieving more
appropriate health care expenditure.
Several prognostic scores have been created to pre-
dict outcomes in UGIB.5-8 The most widely used scores
are the Glasgow-Blatchford risk score (GBRS)7 and the
Rockall score.8 Derived from a cohort of 1748 patients in
the United Kingdom, the GBRS predicts a composite of
inpatient mortality, in-hospital rebleeding, endoscopic
or surgical intervention, and blood transfusion. The
Rockall score is formed from a pre-endoscopic (age,
comorbidities, presence of shock) and an endoscopic
(the etiology of bleeding and the presence of active
bleeding) part. The GBRS, the full Rockall score, and the
pre-endoscopic Rockall score have previously been
compared in their ability to predict several clinically
significant outcomes (the need for hospital-based inter-
vention or 30-day mortality, suitability for early dis-
charge, likelihood of rebleeding, transfusion, endosur-
gical intervention, and death) The GBRS was shown to
be consistently equal or superior to the Rockall scores in
these studies.9-13 The GBRS, however, has limitations: it
is weighted and assigns points to elements in the pa-
tient’s medical history, some of which lack a clear def-
inition (Table 1). Despite recommendations to incorpo-
rate risk stratification scores in UGIB, the GBRS has not
been adopted in routine clinical practice.
We previously derived and validated a novel score, the
AIMS65 score, to predict inpatient mortality.14 We used
recursive partitioning in a patient population of 29,222
patients and validated the findings in a second cohort of
32,507 patients in Pennsylvania. The AIMS65 score assigns
1 point for each of the following: albumin level less than
3.0, international normalized ratio greater than 1.5, altered
mental status, systolic blood pressure less than 90 mm Hg,
and age older than 65 years (Table 1). Compared with
existing scores, the AIMS65 score has the advantages of
being derived from a large database and not being
weighted, which makes it easy to memorize and use. In
addition, the AIMS65 score does not rely on the patient’s
medical history, but rather on laboratory values routinely
obtainable in the emergency department in addition to the
patient’s mental status.
The primary objective of this study was to revalidate
the AIMS65 score as predictor of inpatient mortality in a
patient population different from the one in which it
was derived. The current study population was drawn
from a single teaching tertiary referral center with a
higher overall inpatient mortality rate compared with
the original validation population. The latter was drawn
from 187 hospitals, both teaching and nonteaching, and
community and referral centers, with an inpatient mor-
tality rate lower than the current study population. In
addition to this revalidation, the secondary objective
was to compare the AIMS65 score’s performance with
that of the GBRS with regard to the primary outcome of
mortality and secondary outcomes of (a) a composite
clinical endpoint of inpatient mortality and rebleeding
and endoscopic, radiologic, or surgical intervention; (b)
blood transfusion requirement; (c) intensive care unit
(ICU) admission; (d) rebleeding; (e) hospital length of
stay; and (f) timing of endoscopy.
METHODS
Database and patient selection
The Research Patient Data Registry at Brigham and
Women’s Hospital was used to identify patients who pre-
sented to the emergency department with UGIB between
2004 and 2009. The Research Patient Data Registry is a
centralized clinical data registry that gathers clinical and
laboratory data on each patient admitted to the Partners
Healthcare System, which includes Brigham and Women’s
Hospital. The initial query was performed by using any
ICD-9-CM (International Classification of Diseases, Ninth
Revision, Clinical Modification) diagnosis codes that indi-
cate UGIB (see Online Appendix available at www.
giejournal.org). The search was then limited to patients
with a primary diagnosis of UGIB. Patients were excluded
if the emergency department data required for calculation
of the AIMS65 score or the GBRS were incomplete. Two
independent auditors (B.H.H., N.L.K.) reviewed each pa-
tient’s medical record, including discharge summaries, ad-
mission and progress notes, laboratory values, and endos-
copy reports to confirm the presence of UGIB. A third
auditor (J.R.S.) resolved disagreements when necessary. If
an eligible patient was admitted more than once during
the study period, only the earliest visit was included in the
analysis. The study was approved by the Partners Health-
care System Institutional Review Board on August 20,
2009.
Take-home Message
● The AIMS65 score and Glasgow-Blatchford risk score are
similar in predicting elements useful in triage decisions
(rebleeding) and resource use (intensive care unit
admission, hospital length of stay, and time to
endoscopy).
● Because the AIMS65 score is easy to calculate and only
uses data available on initial presentation, its routine use
might assist in initial decisions such as level of care and
timing of endoscopy for patients with upper GI bleeding.
AIMS65 predicts outcomes in upper GI bleeding Hyett et al
552 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 4 : 2013 www.giejournal.org
Data collection and outcome ascertainment
For each patient, the following data were collected
through manual chart review: age, sex, medical history,
albumin level, international normalized ratio, blood
urea nitrogen, hemoglobin, systolic blood pressure,
pulse, mental status, presence of melena or syncope,
and medication use, including oral or intravenous pro-
ton pump inhibitor therapy. For patients with multiple
laboratory tests or vital signs collected in the emergency
department, the most abnormal values were recorded. A
patient was considered to have a change in mental
status if the Glasgow Coma Scale score on presentation
was less than 14 or a designation of disoriented, leth-
argy, stupor, or coma was written in the chart by a
physician.14 Outcomes were ascertained through chart
review. The primary outcome was inpatient mortality.
The secondary outcomes were (a) a composite endpoint
of inpatient mortality, in-hospital rebleeding, and endo-
scopic, radiologic, or surgical intervention; (b) blood
transfusion requirement; (c) intensive care unit (ICU)
admission; (d) rebleeding; (e) hospital length of stay;
and (f) timing of endoscopy. The exposures of interest
were the AIMS65 score and the GBRS (Table 1).
Receiver-operating characteristic curves were con-
structed to assess the relationship between each score
and the occurrence of the primary and secondary out-
comes. For inpatient mortality and inpatient rebleeding,
a cutoff point was chosen that maximizes the sum of the
sensitivity and the specificity for each score. Patients
were considered to be in the low-risk group for each
score if they fell below the cutoff point or in the high-
risk group otherwise.15-17
TABLE 1. Comparison of the AIMS65 and the Glasgow-Blatchford scores
AIMS65 Score Glasgow-Blatchford Risk Score
Risk factor Score Risk factor Score
Albumin Ͻ3.0 mg/dL 1 BUN, mg/dL
INR Ͼ1.5 1 Ն18.2 to Ͻ22.4 2
Altered mental status 1 Ն22.4 to Ͻ28.0 3
SBP Ͻ90 mm Hg 1 Ն28.0 to Ͻ70.0 4
Age Ͼ65 y 1 Ն70.0 6
Maximum score 5 Hemoglobin, men g/dL
Ն12.0 to Ͻ13.0 1
Ն10.0 to Ͻ12.0 3
Ͻ10.0 6
Hemoglobin, women g/dL
Ն10.0 to Ͻ12.0 1
Ͻ10.0 6
SBP, mm Hg
100-109 1
90-99 2
Ͻ90 3
Other markers
Heart rate Ն100 bpm bpmbbpmbpm 1
Melena 1
Syncope 2
Hepatic diseases 2
Heart failure 2
Maximum score 23
BUN, Blood urea nitrogen; INR, international normalized ratio; SBP, systolic blood pressure; bpm, beats per minute.
Hyett et al AIMS65 predicts outcomes in upper GI bleeding
www.giejournal.org Volume 77, No. 4 : 2013 GASTROINTESTINAL ENDOSCOPY 553
Statistical analysis
The area under the receiver-operating characteristic
curve (AUROC) was calculated for each score and bino-
mial outcome, with exact binomial confidence intervals.
AUROCs were tested for equality by using the Delong ␹2
test. The concordance between the scoring systems and
various continuous outcomes were compared by using
Somer’s D statistic. Comparisons between the low- and
high-risk groups within each score were performed by
using the Fisher exact test. All P values were 2 sided, with
the value .05 considered to be the threshold for statistical
significance. The data analysis was performed by using
STATA, version 12.0 (StataCorp, College Station, Tex).
RESULTS
Patient characteristics
There were 5252 patients with any ICD-9-CM code
indicating a diagnosis of UGIB in the Partners network, of
whom 325 patients were treated at our institution and had
UGIB as the main diagnosis (retrospectively determined at
the end of the admission). Complete records were avail-
able for 278 of the 325 patients. These patients comprised
the study cohort. Table 2 shows the patient characteristics.
Fifty-four percent of the patients were male; 10 patients
had UGIB as inpatients. The median age was 63 years
(range 50-77 years).
Inpatient mortality
The overall mortality was 6.5%. Inpatient mortality in-
creased with increasing AIMS65 score. There were no
deaths among patients with an AIMS65 score of 0. For
AIMS65 scores of 1, 2, 3, 4, and 5, mortality was 0.9%,
7.4%, 42.9%, 75.0%, and 100.0%, respectively (Fig. 1). The
AUROC for AIMS65 score predicting mortality was 0.93
(range 0.89-0.96) (Fig. 2). The AIMS65 score was superior
to GBRS for predicting mortality (AUROC, 0.93 vs 0.71;
P Ͻ .01), even after patients were stratified according to
their level of care: 0.90 (range 0.81-0.96) and 0.54 (range
0.43-0.66), respectively, P Ͻ .01 for patients in the ICU and
0.89 (range 0.84-0.93) and 0.64 (range 0.57-0.70), respec-
tively, P ϭ .01 for patients out of the ICU.
The cutoff point that maximized the sum of the sensi-
tivity and the specificity was 2 for the AIMS65 score (sen-
sitivity, 0.94; specificity, 0.76; total, 1.70) and 10 for the
GBRS (sensitivity, 0.83; specificity, 0.48; total, 1.32). Mor-
tality for patients with a low-risk AIMS65 score was 0.5%
TABLE 2. Patient characteristics
Overall 278 100%
Male 150 54.0%
Medical history
Liver cirrhosis 9 3.2%
Peptic ulcer disease 47 16.9%
Gastritis 24 8.6%
Esophagitis 9 3.2%
Duodenitis 6 2.2%
GERD 41 14.7%
Myocardial infarction 46 16.5%
Peripheral vascular disease 22 7.9%
Cerebrovascular disease 23 8.3%
Diabetes mellitus 73 26.3%
Any malignancy 81 29.1%
Leukemia and lymphoma 10 3.6%
Renal disease 21 7.6%
Previous endoscopy 100 36.0%
Medications
Selective serotonin reuptake
inhibitors
30 10.8%
Nonsteroidal anti-inflammatory
drugs
124 44.6%
Steroids 18 6.5%
Clopidogrel 26 9.4%
Warfarin 45 16.2%
Proton pump inhibitors 258 92.8%
Score components
Age at admission, y 63 (50-70)
Albumin 3.5 (3.1-3.9)
International normalized ratio 1.1 (1.0-1.4)
Mental status change 22 7.9%
Systolic blood pressure 112 (93-133)
Hematochezia 16 5.8%
Hematemesis 145 52.2%
Hemoglobin 9.4 (7.7-11.7)
Pulse 91 (76-108)
Melena 176 63.3%
Blood urea nitrogen 33 (21-48)
Syncope 33 11.9%
TABLE 2. Continued
Liver disease 27 9.7%
Congestive heart failure 34 12.2%
Proportions are presented as percentage. Continuous variables are
presented as median (interquartile range).
AIMS65 predicts outcomes in upper GI bleeding Hyett et al
554 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 4 : 2013 www.giejournal.org
and was 21% for patients with a high-risk AIMS65 score
(P Ͻ .01). Mortality for patients with a low-risk GBRS was
2% and 10% for patients with a high-risk GBRS (P ϭ .01).
Composite endpoint of significant clinical
outcomes
Ninety-eight patients (35.2%) experienced 1 or more
components of the composite endpoint: 18 died (6.5%),
14 rebled (5.0%), 72 required endoscopic therapy
(25.9%), 4 required radiologic intervention (1.4%), and 5
required surgical intervention (1.8%). When comparing
the AUROCs of the AIMS65 score and GBRS for the com-
posite clinical endpoint, we found that the AIMS65 score
was similar to the GBRS, with AUROCs of 0.62 (range
0.56-0.68) and 0.68 (range 0.62-0.73), respectively (P ϭ
.13).
Rebleeding, blood transfusion requirement,
and ICU admission
The AIMS65 score and the GBRS had similar AUROCs
for rebleeding (0.63 [range 0.57-0.69] and 0.63 [0.57-0.69],
respectively, P ϭ .97) and for ICU admission (0.69 [range
0.63-0.74] and 0.63 [0.57-0.69], respectively, P ϭ 0.35).
However, the GBRS was superior to the AIMS65 for pre-
dicting the need for and the number of packed red blood
cell (PRBC) transfusions (0.85 [range 0.80-0.89] and 0.65
[range 0.59-0.70], respectively; P Ͻ .01 for need for PRBC
transfusion and 0.49 [range 0.42-0.57] and 0.22 [range 0.13-
0.30], respectively, P Ͻ .01 for number for PRBCs
transfused).
For inpatient rebleeding, the cutoff point that maxi-
mized the sum of the sensitivity and the specificity was 2
for the AIMS65 score (sensitivity, 0.57; specificity, 0.73;
total, 1.30) and 12 for the GBRS (sensitivity, 0.57; specific-
ity, 0.67; total, 1.24). Rebleeding in patients with a low-risk
AIMS65 score was 3% and 10% for patients with a high-risk
AIMS65 score (P ϭ .03). Rebleeding in patients with a
low-risk GBRS was 3% and 8% for patients with a high-risk
GBRS (P ϭ .08).
Hospital length of stay and time to endoscopy
Both the AIMS65 score and GBRS could predict length
of stay and time to endoscopy, with higher scores predict-
ing shorter time to endoscopy (Ϫ0.12 [range Ϫ0.23 to
Ϫ0.01] and Ϫ0.21 [range Ϫ0.33 to Ϫ0.1] days, respec-
tively) and longer length of stay (0.15 [range 0.06-0.23] and
0.17 [range 0.07-0.26], respectively). However, there was
no difference between the 2 scores in predicting either of
the outcomes (P ϭ .151 and P ϭ .67, respectively).
DISCUSSION
This study confirms that the AIMS65 score accurately
predicts inpatient mortality in patients with UGIB. In ad-
dition, the AIMS65 score was superior to the GBRS for
predicting inpatient and in and out of ICU mortality,
whereas the GBRS is superior to the AIMS65 score for
predicting PRBC transfusion. The 2 scores had similar
predictive ability when a composite clinical endpoint of
inpatient mortality, rebleeding, and endoscopic, radio-
logic, or surgical intervention was considered as well as
hospital length of stay, time to endoscopy, rebleeding, and
ICU admission. Finally, the appropriate cutoffs for GBRS
risk group stratification seem to be 10 or more for inpatient
mortality and 12 or more for inpatient rebleeding, whereas
they are 2 and more for the AIMS65 score.
International consensus statements and ACG practice
guidelines emphasize use of prognostic scales in the care
of patients with UGIB to help guide management. How-
ever, studies have shown that actual patient management
for several medical conditions varies by geographic region
and hospital characteristics.18-20 Use of a score such as
AIMS65 may help standardize practice because it is an
Figure 1. Inpatient mortality rate by AIMS65 score. Inpatient mortality
increased with increasing AIMS65 scores.
Figure 2. Receiver-operating characteristic curves (AUROCs) for the
AIMS65 and Glasgow-Blatchford risk scores as predictors of inpatient
mortality. AUROCs for the AIMS65 score was superior to the Glasgow-
Blatchford risk score for predicting inpatient mortality from upper GI
bleeding.
Hyett et al AIMS65 predicts outcomes in upper GI bleeding
www.giejournal.org Volume 77, No. 4 : 2013 GASTROINTESTINAL ENDOSCOPY 555
easy-to-calculate, nonweighted score that relies on ele-
ments readily obtainable in the emergency department.
We sought to validate the AIMS65 score in a patient pop-
ulation that differed from the original study’s validation
cohort and to compare it directly with the best known and
most comparable risk score in the literature, the GBRS,
which also does not rely on endoscopic findings for cal-
culation. Our results indicate that not only does the
AIMS65 score perform as well in a tertiary referral center as
it did in the initial validation patient population that in-
cluded multiple types of hospitals,14 but that it is also
superior or equal to the GBRS with regard to many clini-
cally relevant outcomes except blood transfusion.
Use of either AIMS65 score or GBRS may also aid with
triage of patients with UGIB. In fact, although the AUROC
for the AIMS65 was higher than that for the GBRS in
predicting ICU admission, this difference was not statisti-
cally significant. However, the AIMS65 score’s superiority
in predicting mortality both in and out of the ICU, in
addition to its equivalence with the GBRS in predicting the
need for intervention, makes it an attractive triage tool.
Predicting resource use in addition to prognosis is becom-
ing increasingly important in the current health care envi-
ronment. Both the AIMS65 score and the GBRS equally
predict important aspects of the process of care and re-
source use, including length of stay, ICU admission, and
timing of endoscopy.
Previous studies have used a GBRS score of 2 or more
to classify patients into high- and low-risk groups.18-20
Although those are useful for the purpose of determining
which patient can potentially be managed in an outpatient
setting, we demonstrate that a more appropriate cutoff
may be 10 and more for mortality and 12 or more for
rebleeding. Because our study was not designed to test
this hypothesis and because it might lack the appropriate
power to do so, more research is needed to validate those
cutoffs before their use in clinical practice. Those cutoffs
are 2 or more for the AIMS65 score for both outcomes.
We directly compared the AIMS65 score and the GBRS.
Our results show that the AIMS65 score is superior to the
GBRS for predicting inpatient mortality, whereas the GBRS
was superior for predicting PRBC transfusion. This is not
surprising because the AIMS65 score was derived to pre-
dict inpatient mortality, whereas PRBC transfusion was
part of the composite outcome for which the GBRS was
derived. We also compared the performance or the 2
scores for predicting the composite endpoint of clinically
meaningful outcomes: inpatient mortality, rebleeding, and
endoscopic, radiologic, or surgical intervention. The 2
scores did not differ in predicting this composite endpoint.
We chose this endpoint because it includes meaningful
clinical outcomes that could aid with patient triage.
The composite clinical endpoint is similar to the one
used in the original derivation and validation of the GBRS.7
Blatchford et al7 used inpatient mortality, in-hospital re-
bleeding, endoscopic or surgical intervention, need for
blood transfusion, and a significant decrease in the hemat-
ocrit as a composite endpoint that predicted the need for
intervention. Radiologic intervention was not included
originally, likely because it was not widely available at that
time. We did not include blood transfusion because the
need for a blood transfusion does not necessarily indicate
the need for an intervention or a high-risk outcome. For
similar reasons and because it was not clearly defined in
the GBRS derivation and validation study, we did not
include a significant drop in hematocrit in the composite
clinical endpoint used in this study. A prospective study
comparing the AIMS65 score and the GBRS in predicting
clinically significant endpoints or usefulness in triage is
needed.
Several features of our study support the generalizabil-
ity of our findings. First, inclusion criteria were few and
simple. All adults with a confirmed UGIB were included.
Second, the only exclusion criterion was the unavailability
of data to calculate both risk scores. Only 15% of patients
were excluded, and although it is conceivable that patients
with incomplete data behaved differently from those with
complete data, this percentage is similar to the lost-to-
follow-up rates in most randomized, controlled trials.
Certain limitations in the study’s design and methods
should be pointed out. First, the study was retrospective,
and thus exposure measurement and outcome ascertain-
ment were based on existing clinical records. However,
we reviewed individual charts and used a standardized
collection tool to minimize variability. In addition, 2 inde-
pendent reviewers examined each chart, with discrepan-
cies resolved by a third reviewer when needed. Second,
because our study is retrospective, different clinicians de-
termined and recorded the exposures used to calculate the
AIMS65 score and the GBRS in a nonstandardized fashion.
Fortunately, 4 of the 5 components of the AIMS65 score
are objective values. The only subjective component is
altered mental status, which was recorded for most pa-
tients by using the Glasgow Coma Scale, a standardized
and widely used scale in emergency departments. The
Glasgow Coma Scale score was directly recorded from the
initial assessment documented in the chart of patients who
bled on presentation to the emergency department. The
score was inferred from the charts of the patients who bled
after presentation to the emergency department. This
might have introduced a degree of subjectivity in the score
determination. However, only 10 patients (Ͻ4% of the
study population) bled after presentation to the emer-
gency department. The definitions of the medical history
elements that are part of the GBRS score were more diffi-
cult to standardize. We used the definition Blatchford et al
used in their original work: the presence of those elements
in the medical chart. Third, the lack of difference between
the 2 scores in predicting the composite clinical endpoint
and the difference in ICU admission rate between the
high- and low-risk GBRS groups could have been due to a
true equivalence or to too few patients to detect a differ-
AIMS65 predicts outcomes in upper GI bleeding Hyett et al
556 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 4 : 2013 www.giejournal.org
ence. Fourth, the primary outcome was inpatient mortality
rather than 30-day mortality because the AIMS65 score was
derived to predict inpatient mortality and because our
database recorded inpatient mortality. Finally, the study
population was that of a teaching referral tertiary-care
center, which may make it difficult to extrapolate the
results to other types of institutions, especially nonteach-
ing, community-based hospitals. However, we previously
demonstrated that the AIMS65 score performs well in a
cohort of patients gathered from hospitals with varied
characteristics.14
CONCLUSIONS
In this study, we validate the AIMS65 score as a predic-
tor of inpatient mortality in a different patient population
from that used in the original derivation study, with com-
parable results. We have also demonstrated that the
AIMS65 score is superior to the GBRS in predicting inpa-
tient mortality, whereas the GBRS is superior to the
AIMS65 score in predicting PRBC transfusion. In addition,
we show that both scores are equivalent in predict-
ing several clinically useful outcomes including hospital
length of stay, time to endoscopy, rebleeding, and ICU
admission. Finally, the appropriate cutoffs for GBRS risk
group stratification seem to be 10 or more for inpatient
mortality and 12 or more for inpatient rebleeding, whereas
the cutoffs are 2 or more for the AIMS65 score. Further
prospective studies that compare the AIMS65 score with
other risk scores in patients with UGIB are warranted.
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Blatchford Score. Eur J Gastroenterol Hepatol 2009;21:1340-6.
Hyett et al AIMS65 predicts outcomes in upper GI bleeding
www.giejournal.org Volume 77, No. 4 : 2013 GASTROINTESTINAL ENDOSCOPY 557

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2013 04 aims65 vs blatchford

  • 1. ORIGINAL ARTICLE: Clinical Endoscopy The AIMS65 score compared with the Glasgow-Blatchford score in predicting outcomes in upper GI bleeding Brian H. Hyett, MD,*,1,2 Marwan S. Abougergi, MD,*,1,2 Joseph P. Charpentier, MD,3 Navin L. Kumar, MD,2 Suzana Brozovic, MD,1,2 Brian L. Claggett, MA,4 Anne C. Travis, MD,1,2 John R. Saltzman, MD1,2 Boston, Worcester, Massachusetts, USA Introduction: We previously derived and validated the AIMS65 score, a mortality prognostic scale for upper GI bleeding (UGIB). Objective: To validate the AIMS65 score in a different patient population and compare it with the Glasgow- Blatchford risk score (GBRS). Design: Retrospective cohort study. Patients: Adults with a primary diagnosis of UGIB. Main Outcome Measurements: Primary outcome: inpatient mortality. Secondary outcomes: composite clinical endpoint of inpatient mortality, rebleeding, and endoscopic, radiologic or surgical intervention; blood transfu- sion; intensive care unit admission; rebleeding; length of stay; timing of endoscopy. The area under the receiver-operating characteristic curve (AUROC) was calculated for each score. Results: Of the 278 study patients, 6.5% died and 35% experienced the composite clinical endpoint. The AIMS65 score was superior in predicting inpatient mortality (AUROC, 0.93 vs 0.68; P Ͻ .001), whereas the GBRS was superior in predicting blood transfusions (AUROC, 0.85 vs 0.65; P Ͻ .01) The 2 scores were similar in predicting the composite clinical endpoint (AUROC, 0.62 vs 0.68; P ϭ .13) as well as the secondary outcomes. A GBRS of 10 and 12 or more maximized the sum of the sensitivity and specificity for inpatient mortality and rebleeding, respectively. The cutoff was 2 or more for the AIMS65 score for both outcomes. Limitations: Retrospective, single-center study. Conclusion: The AIMS65 score is superior to the GBRS in predicting inpatient mortality from UGIB, whereas the GBRS is superior for predicting blood transfusion. Both scores are similar in predicting the composite clinical endpoint and other outcomes in clinical care and resource use. (Gastrointest Endosc 2013;77:551-7.) GI bleeding is the most common GI emergency, with upper GI bleeding (UGIB) resulting in more than 300,000 hospital admissions per year in the United States.1,2 Inter- national consensus guidelines from 2010 recommend “early risk stratification, by using validated prognostic scales” in the care of patients with UGIB as part of a goal-oriented therapy.3 The recent American College of Gastroenterology practice guidelines on the manage- Abbreviations: AUROC, area under the receiver-operating characteristic curve; GBRS, Glasgow-Blatchford risk score; ICU, intensive care unit; PRBC, packed red blood cell; UGIB, upper GI bleeding. DISCLOSURE: The authors disclosed no financial relationships relevant to this publication. *Drs Hyett and Abougergi contributed equally to this article. Use your mobile device to scan this QR code and watch the author in- terview. Download a free QR code scanner by searching ‘QR Scanner’ in your mobile device’s app store. Copyright © 2013 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2012.11.022 Received June 14, 2012. Accepted November 19, 2012. Current affiliations: Department of Medicine (1), Division of Gastroenterol- ogy (2), Brigham and Women’s Hospital, Boston, Massachusetts, Depart- ment of Internal Medicine (3), University of Massachusetts Medical Center, Worcester,Massachusetts,DepartmentofBiostatistics(4),HarvardSchoolof Public Health, Boston, Massachusetts, USA. Preliminary results were presented at the American College of Gastroenterology 2010 Annual Scientific Meeting, October 15-20, 2010; San Antonio, Texas (Am J Gastroenterol 2010;105:S394 [abstract]). Reprint requests: John R. Saltzman, MD, Endoscopy Center, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. If you would like to chat with an author of this article, you may contact Dr Saltzman at jsaltzman@partners.org. www.giejournal.org Volume 77, No. 4 : 2013 GASTROINTESTINAL ENDOSCOPY 551
  • 2. ment of patients with ulcer bleeding also recommends that “risk assessment should be performed to stratify patients into higher and lower risk categories, and may assist in initial decisions such as timing of endoscopy, time of discharge, and level of care.”4 Risk stratification on presentation to the emergency department enables rapid and accurate triage as well as appropriate re- source use. This is vital for timely administration of lifesaving therapies to patients and for achieving more appropriate health care expenditure. Several prognostic scores have been created to pre- dict outcomes in UGIB.5-8 The most widely used scores are the Glasgow-Blatchford risk score (GBRS)7 and the Rockall score.8 Derived from a cohort of 1748 patients in the United Kingdom, the GBRS predicts a composite of inpatient mortality, in-hospital rebleeding, endoscopic or surgical intervention, and blood transfusion. The Rockall score is formed from a pre-endoscopic (age, comorbidities, presence of shock) and an endoscopic (the etiology of bleeding and the presence of active bleeding) part. The GBRS, the full Rockall score, and the pre-endoscopic Rockall score have previously been compared in their ability to predict several clinically significant outcomes (the need for hospital-based inter- vention or 30-day mortality, suitability for early dis- charge, likelihood of rebleeding, transfusion, endosur- gical intervention, and death) The GBRS was shown to be consistently equal or superior to the Rockall scores in these studies.9-13 The GBRS, however, has limitations: it is weighted and assigns points to elements in the pa- tient’s medical history, some of which lack a clear def- inition (Table 1). Despite recommendations to incorpo- rate risk stratification scores in UGIB, the GBRS has not been adopted in routine clinical practice. We previously derived and validated a novel score, the AIMS65 score, to predict inpatient mortality.14 We used recursive partitioning in a patient population of 29,222 patients and validated the findings in a second cohort of 32,507 patients in Pennsylvania. The AIMS65 score assigns 1 point for each of the following: albumin level less than 3.0, international normalized ratio greater than 1.5, altered mental status, systolic blood pressure less than 90 mm Hg, and age older than 65 years (Table 1). Compared with existing scores, the AIMS65 score has the advantages of being derived from a large database and not being weighted, which makes it easy to memorize and use. In addition, the AIMS65 score does not rely on the patient’s medical history, but rather on laboratory values routinely obtainable in the emergency department in addition to the patient’s mental status. The primary objective of this study was to revalidate the AIMS65 score as predictor of inpatient mortality in a patient population different from the one in which it was derived. The current study population was drawn from a single teaching tertiary referral center with a higher overall inpatient mortality rate compared with the original validation population. The latter was drawn from 187 hospitals, both teaching and nonteaching, and community and referral centers, with an inpatient mor- tality rate lower than the current study population. In addition to this revalidation, the secondary objective was to compare the AIMS65 score’s performance with that of the GBRS with regard to the primary outcome of mortality and secondary outcomes of (a) a composite clinical endpoint of inpatient mortality and rebleeding and endoscopic, radiologic, or surgical intervention; (b) blood transfusion requirement; (c) intensive care unit (ICU) admission; (d) rebleeding; (e) hospital length of stay; and (f) timing of endoscopy. METHODS Database and patient selection The Research Patient Data Registry at Brigham and Women’s Hospital was used to identify patients who pre- sented to the emergency department with UGIB between 2004 and 2009. The Research Patient Data Registry is a centralized clinical data registry that gathers clinical and laboratory data on each patient admitted to the Partners Healthcare System, which includes Brigham and Women’s Hospital. The initial query was performed by using any ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis codes that indi- cate UGIB (see Online Appendix available at www. giejournal.org). The search was then limited to patients with a primary diagnosis of UGIB. Patients were excluded if the emergency department data required for calculation of the AIMS65 score or the GBRS were incomplete. Two independent auditors (B.H.H., N.L.K.) reviewed each pa- tient’s medical record, including discharge summaries, ad- mission and progress notes, laboratory values, and endos- copy reports to confirm the presence of UGIB. A third auditor (J.R.S.) resolved disagreements when necessary. If an eligible patient was admitted more than once during the study period, only the earliest visit was included in the analysis. The study was approved by the Partners Health- care System Institutional Review Board on August 20, 2009. Take-home Message ● The AIMS65 score and Glasgow-Blatchford risk score are similar in predicting elements useful in triage decisions (rebleeding) and resource use (intensive care unit admission, hospital length of stay, and time to endoscopy). ● Because the AIMS65 score is easy to calculate and only uses data available on initial presentation, its routine use might assist in initial decisions such as level of care and timing of endoscopy for patients with upper GI bleeding. AIMS65 predicts outcomes in upper GI bleeding Hyett et al 552 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 4 : 2013 www.giejournal.org
  • 3. Data collection and outcome ascertainment For each patient, the following data were collected through manual chart review: age, sex, medical history, albumin level, international normalized ratio, blood urea nitrogen, hemoglobin, systolic blood pressure, pulse, mental status, presence of melena or syncope, and medication use, including oral or intravenous pro- ton pump inhibitor therapy. For patients with multiple laboratory tests or vital signs collected in the emergency department, the most abnormal values were recorded. A patient was considered to have a change in mental status if the Glasgow Coma Scale score on presentation was less than 14 or a designation of disoriented, leth- argy, stupor, or coma was written in the chart by a physician.14 Outcomes were ascertained through chart review. The primary outcome was inpatient mortality. The secondary outcomes were (a) a composite endpoint of inpatient mortality, in-hospital rebleeding, and endo- scopic, radiologic, or surgical intervention; (b) blood transfusion requirement; (c) intensive care unit (ICU) admission; (d) rebleeding; (e) hospital length of stay; and (f) timing of endoscopy. The exposures of interest were the AIMS65 score and the GBRS (Table 1). Receiver-operating characteristic curves were con- structed to assess the relationship between each score and the occurrence of the primary and secondary out- comes. For inpatient mortality and inpatient rebleeding, a cutoff point was chosen that maximizes the sum of the sensitivity and the specificity for each score. Patients were considered to be in the low-risk group for each score if they fell below the cutoff point or in the high- risk group otherwise.15-17 TABLE 1. Comparison of the AIMS65 and the Glasgow-Blatchford scores AIMS65 Score Glasgow-Blatchford Risk Score Risk factor Score Risk factor Score Albumin Ͻ3.0 mg/dL 1 BUN, mg/dL INR Ͼ1.5 1 Ն18.2 to Ͻ22.4 2 Altered mental status 1 Ն22.4 to Ͻ28.0 3 SBP Ͻ90 mm Hg 1 Ն28.0 to Ͻ70.0 4 Age Ͼ65 y 1 Ն70.0 6 Maximum score 5 Hemoglobin, men g/dL Ն12.0 to Ͻ13.0 1 Ն10.0 to Ͻ12.0 3 Ͻ10.0 6 Hemoglobin, women g/dL Ն10.0 to Ͻ12.0 1 Ͻ10.0 6 SBP, mm Hg 100-109 1 90-99 2 Ͻ90 3 Other markers Heart rate Ն100 bpm bpmbbpmbpm 1 Melena 1 Syncope 2 Hepatic diseases 2 Heart failure 2 Maximum score 23 BUN, Blood urea nitrogen; INR, international normalized ratio; SBP, systolic blood pressure; bpm, beats per minute. Hyett et al AIMS65 predicts outcomes in upper GI bleeding www.giejournal.org Volume 77, No. 4 : 2013 GASTROINTESTINAL ENDOSCOPY 553
  • 4. Statistical analysis The area under the receiver-operating characteristic curve (AUROC) was calculated for each score and bino- mial outcome, with exact binomial confidence intervals. AUROCs were tested for equality by using the Delong ␹2 test. The concordance between the scoring systems and various continuous outcomes were compared by using Somer’s D statistic. Comparisons between the low- and high-risk groups within each score were performed by using the Fisher exact test. All P values were 2 sided, with the value .05 considered to be the threshold for statistical significance. The data analysis was performed by using STATA, version 12.0 (StataCorp, College Station, Tex). RESULTS Patient characteristics There were 5252 patients with any ICD-9-CM code indicating a diagnosis of UGIB in the Partners network, of whom 325 patients were treated at our institution and had UGIB as the main diagnosis (retrospectively determined at the end of the admission). Complete records were avail- able for 278 of the 325 patients. These patients comprised the study cohort. Table 2 shows the patient characteristics. Fifty-four percent of the patients were male; 10 patients had UGIB as inpatients. The median age was 63 years (range 50-77 years). Inpatient mortality The overall mortality was 6.5%. Inpatient mortality in- creased with increasing AIMS65 score. There were no deaths among patients with an AIMS65 score of 0. For AIMS65 scores of 1, 2, 3, 4, and 5, mortality was 0.9%, 7.4%, 42.9%, 75.0%, and 100.0%, respectively (Fig. 1). The AUROC for AIMS65 score predicting mortality was 0.93 (range 0.89-0.96) (Fig. 2). The AIMS65 score was superior to GBRS for predicting mortality (AUROC, 0.93 vs 0.71; P Ͻ .01), even after patients were stratified according to their level of care: 0.90 (range 0.81-0.96) and 0.54 (range 0.43-0.66), respectively, P Ͻ .01 for patients in the ICU and 0.89 (range 0.84-0.93) and 0.64 (range 0.57-0.70), respec- tively, P ϭ .01 for patients out of the ICU. The cutoff point that maximized the sum of the sensi- tivity and the specificity was 2 for the AIMS65 score (sen- sitivity, 0.94; specificity, 0.76; total, 1.70) and 10 for the GBRS (sensitivity, 0.83; specificity, 0.48; total, 1.32). Mor- tality for patients with a low-risk AIMS65 score was 0.5% TABLE 2. Patient characteristics Overall 278 100% Male 150 54.0% Medical history Liver cirrhosis 9 3.2% Peptic ulcer disease 47 16.9% Gastritis 24 8.6% Esophagitis 9 3.2% Duodenitis 6 2.2% GERD 41 14.7% Myocardial infarction 46 16.5% Peripheral vascular disease 22 7.9% Cerebrovascular disease 23 8.3% Diabetes mellitus 73 26.3% Any malignancy 81 29.1% Leukemia and lymphoma 10 3.6% Renal disease 21 7.6% Previous endoscopy 100 36.0% Medications Selective serotonin reuptake inhibitors 30 10.8% Nonsteroidal anti-inflammatory drugs 124 44.6% Steroids 18 6.5% Clopidogrel 26 9.4% Warfarin 45 16.2% Proton pump inhibitors 258 92.8% Score components Age at admission, y 63 (50-70) Albumin 3.5 (3.1-3.9) International normalized ratio 1.1 (1.0-1.4) Mental status change 22 7.9% Systolic blood pressure 112 (93-133) Hematochezia 16 5.8% Hematemesis 145 52.2% Hemoglobin 9.4 (7.7-11.7) Pulse 91 (76-108) Melena 176 63.3% Blood urea nitrogen 33 (21-48) Syncope 33 11.9% TABLE 2. Continued Liver disease 27 9.7% Congestive heart failure 34 12.2% Proportions are presented as percentage. Continuous variables are presented as median (interquartile range). AIMS65 predicts outcomes in upper GI bleeding Hyett et al 554 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 4 : 2013 www.giejournal.org
  • 5. and was 21% for patients with a high-risk AIMS65 score (P Ͻ .01). Mortality for patients with a low-risk GBRS was 2% and 10% for patients with a high-risk GBRS (P ϭ .01). Composite endpoint of significant clinical outcomes Ninety-eight patients (35.2%) experienced 1 or more components of the composite endpoint: 18 died (6.5%), 14 rebled (5.0%), 72 required endoscopic therapy (25.9%), 4 required radiologic intervention (1.4%), and 5 required surgical intervention (1.8%). When comparing the AUROCs of the AIMS65 score and GBRS for the com- posite clinical endpoint, we found that the AIMS65 score was similar to the GBRS, with AUROCs of 0.62 (range 0.56-0.68) and 0.68 (range 0.62-0.73), respectively (P ϭ .13). Rebleeding, blood transfusion requirement, and ICU admission The AIMS65 score and the GBRS had similar AUROCs for rebleeding (0.63 [range 0.57-0.69] and 0.63 [0.57-0.69], respectively, P ϭ .97) and for ICU admission (0.69 [range 0.63-0.74] and 0.63 [0.57-0.69], respectively, P ϭ 0.35). However, the GBRS was superior to the AIMS65 for pre- dicting the need for and the number of packed red blood cell (PRBC) transfusions (0.85 [range 0.80-0.89] and 0.65 [range 0.59-0.70], respectively; P Ͻ .01 for need for PRBC transfusion and 0.49 [range 0.42-0.57] and 0.22 [range 0.13- 0.30], respectively, P Ͻ .01 for number for PRBCs transfused). For inpatient rebleeding, the cutoff point that maxi- mized the sum of the sensitivity and the specificity was 2 for the AIMS65 score (sensitivity, 0.57; specificity, 0.73; total, 1.30) and 12 for the GBRS (sensitivity, 0.57; specific- ity, 0.67; total, 1.24). Rebleeding in patients with a low-risk AIMS65 score was 3% and 10% for patients with a high-risk AIMS65 score (P ϭ .03). Rebleeding in patients with a low-risk GBRS was 3% and 8% for patients with a high-risk GBRS (P ϭ .08). Hospital length of stay and time to endoscopy Both the AIMS65 score and GBRS could predict length of stay and time to endoscopy, with higher scores predict- ing shorter time to endoscopy (Ϫ0.12 [range Ϫ0.23 to Ϫ0.01] and Ϫ0.21 [range Ϫ0.33 to Ϫ0.1] days, respec- tively) and longer length of stay (0.15 [range 0.06-0.23] and 0.17 [range 0.07-0.26], respectively). However, there was no difference between the 2 scores in predicting either of the outcomes (P ϭ .151 and P ϭ .67, respectively). DISCUSSION This study confirms that the AIMS65 score accurately predicts inpatient mortality in patients with UGIB. In ad- dition, the AIMS65 score was superior to the GBRS for predicting inpatient and in and out of ICU mortality, whereas the GBRS is superior to the AIMS65 score for predicting PRBC transfusion. The 2 scores had similar predictive ability when a composite clinical endpoint of inpatient mortality, rebleeding, and endoscopic, radio- logic, or surgical intervention was considered as well as hospital length of stay, time to endoscopy, rebleeding, and ICU admission. Finally, the appropriate cutoffs for GBRS risk group stratification seem to be 10 or more for inpatient mortality and 12 or more for inpatient rebleeding, whereas they are 2 and more for the AIMS65 score. International consensus statements and ACG practice guidelines emphasize use of prognostic scales in the care of patients with UGIB to help guide management. How- ever, studies have shown that actual patient management for several medical conditions varies by geographic region and hospital characteristics.18-20 Use of a score such as AIMS65 may help standardize practice because it is an Figure 1. Inpatient mortality rate by AIMS65 score. Inpatient mortality increased with increasing AIMS65 scores. Figure 2. Receiver-operating characteristic curves (AUROCs) for the AIMS65 and Glasgow-Blatchford risk scores as predictors of inpatient mortality. AUROCs for the AIMS65 score was superior to the Glasgow- Blatchford risk score for predicting inpatient mortality from upper GI bleeding. Hyett et al AIMS65 predicts outcomes in upper GI bleeding www.giejournal.org Volume 77, No. 4 : 2013 GASTROINTESTINAL ENDOSCOPY 555
  • 6. easy-to-calculate, nonweighted score that relies on ele- ments readily obtainable in the emergency department. We sought to validate the AIMS65 score in a patient pop- ulation that differed from the original study’s validation cohort and to compare it directly with the best known and most comparable risk score in the literature, the GBRS, which also does not rely on endoscopic findings for cal- culation. Our results indicate that not only does the AIMS65 score perform as well in a tertiary referral center as it did in the initial validation patient population that in- cluded multiple types of hospitals,14 but that it is also superior or equal to the GBRS with regard to many clini- cally relevant outcomes except blood transfusion. Use of either AIMS65 score or GBRS may also aid with triage of patients with UGIB. In fact, although the AUROC for the AIMS65 was higher than that for the GBRS in predicting ICU admission, this difference was not statisti- cally significant. However, the AIMS65 score’s superiority in predicting mortality both in and out of the ICU, in addition to its equivalence with the GBRS in predicting the need for intervention, makes it an attractive triage tool. Predicting resource use in addition to prognosis is becom- ing increasingly important in the current health care envi- ronment. Both the AIMS65 score and the GBRS equally predict important aspects of the process of care and re- source use, including length of stay, ICU admission, and timing of endoscopy. Previous studies have used a GBRS score of 2 or more to classify patients into high- and low-risk groups.18-20 Although those are useful for the purpose of determining which patient can potentially be managed in an outpatient setting, we demonstrate that a more appropriate cutoff may be 10 and more for mortality and 12 or more for rebleeding. Because our study was not designed to test this hypothesis and because it might lack the appropriate power to do so, more research is needed to validate those cutoffs before their use in clinical practice. Those cutoffs are 2 or more for the AIMS65 score for both outcomes. We directly compared the AIMS65 score and the GBRS. Our results show that the AIMS65 score is superior to the GBRS for predicting inpatient mortality, whereas the GBRS was superior for predicting PRBC transfusion. This is not surprising because the AIMS65 score was derived to pre- dict inpatient mortality, whereas PRBC transfusion was part of the composite outcome for which the GBRS was derived. We also compared the performance or the 2 scores for predicting the composite endpoint of clinically meaningful outcomes: inpatient mortality, rebleeding, and endoscopic, radiologic, or surgical intervention. The 2 scores did not differ in predicting this composite endpoint. We chose this endpoint because it includes meaningful clinical outcomes that could aid with patient triage. The composite clinical endpoint is similar to the one used in the original derivation and validation of the GBRS.7 Blatchford et al7 used inpatient mortality, in-hospital re- bleeding, endoscopic or surgical intervention, need for blood transfusion, and a significant decrease in the hemat- ocrit as a composite endpoint that predicted the need for intervention. Radiologic intervention was not included originally, likely because it was not widely available at that time. We did not include blood transfusion because the need for a blood transfusion does not necessarily indicate the need for an intervention or a high-risk outcome. For similar reasons and because it was not clearly defined in the GBRS derivation and validation study, we did not include a significant drop in hematocrit in the composite clinical endpoint used in this study. A prospective study comparing the AIMS65 score and the GBRS in predicting clinically significant endpoints or usefulness in triage is needed. Several features of our study support the generalizabil- ity of our findings. First, inclusion criteria were few and simple. All adults with a confirmed UGIB were included. Second, the only exclusion criterion was the unavailability of data to calculate both risk scores. Only 15% of patients were excluded, and although it is conceivable that patients with incomplete data behaved differently from those with complete data, this percentage is similar to the lost-to- follow-up rates in most randomized, controlled trials. Certain limitations in the study’s design and methods should be pointed out. First, the study was retrospective, and thus exposure measurement and outcome ascertain- ment were based on existing clinical records. However, we reviewed individual charts and used a standardized collection tool to minimize variability. In addition, 2 inde- pendent reviewers examined each chart, with discrepan- cies resolved by a third reviewer when needed. Second, because our study is retrospective, different clinicians de- termined and recorded the exposures used to calculate the AIMS65 score and the GBRS in a nonstandardized fashion. Fortunately, 4 of the 5 components of the AIMS65 score are objective values. The only subjective component is altered mental status, which was recorded for most pa- tients by using the Glasgow Coma Scale, a standardized and widely used scale in emergency departments. The Glasgow Coma Scale score was directly recorded from the initial assessment documented in the chart of patients who bled on presentation to the emergency department. The score was inferred from the charts of the patients who bled after presentation to the emergency department. This might have introduced a degree of subjectivity in the score determination. However, only 10 patients (Ͻ4% of the study population) bled after presentation to the emer- gency department. The definitions of the medical history elements that are part of the GBRS score were more diffi- cult to standardize. We used the definition Blatchford et al used in their original work: the presence of those elements in the medical chart. Third, the lack of difference between the 2 scores in predicting the composite clinical endpoint and the difference in ICU admission rate between the high- and low-risk GBRS groups could have been due to a true equivalence or to too few patients to detect a differ- AIMS65 predicts outcomes in upper GI bleeding Hyett et al 556 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 4 : 2013 www.giejournal.org
  • 7. ence. Fourth, the primary outcome was inpatient mortality rather than 30-day mortality because the AIMS65 score was derived to predict inpatient mortality and because our database recorded inpatient mortality. Finally, the study population was that of a teaching referral tertiary-care center, which may make it difficult to extrapolate the results to other types of institutions, especially nonteach- ing, community-based hospitals. However, we previously demonstrated that the AIMS65 score performs well in a cohort of patients gathered from hospitals with varied characteristics.14 CONCLUSIONS In this study, we validate the AIMS65 score as a predic- tor of inpatient mortality in a different patient population from that used in the original derivation study, with com- parable results. We have also demonstrated that the AIMS65 score is superior to the GBRS in predicting inpa- tient mortality, whereas the GBRS is superior to the AIMS65 score in predicting PRBC transfusion. In addition, we show that both scores are equivalent in predict- ing several clinically useful outcomes including hospital length of stay, time to endoscopy, rebleeding, and ICU admission. Finally, the appropriate cutoffs for GBRS risk group stratification seem to be 10 or more for inpatient mortality and 12 or more for inpatient rebleeding, whereas the cutoffs are 2 or more for the AIMS65 score. Further prospective studies that compare the AIMS65 score with other risk scores in patients with UGIB are warranted. REFERENCES 1. Terdiman JP. Update on upper gastrointestinal bleeding. Basing treat- ment decisions on patients’ risk level. Postgrad Med 1998;103:43,7,51- 2,58-9. 2. vanLeerdamME,VreeburgEM,RauwsEA,etal.AcuteupperGIbleeding: did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000. Am J Gastroen- terol 2003;98:1494-9. 3. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recom- mendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010;152:101-13. 4. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012;107:345-60; quiz 361. 5. SaeedZA,WinchesterCB,MichaletzPA,etal.Ascoringsystemtopredict rebleeding after endoscopic therapy of non-variceal upper gastrointes- tinal hemorrhage. Am J Gastroenterol 1993;88:1842-9. 6. Hay JA, Lyubashevsky E, Elashoff J, et al. Upper gastrointestinal hemor- rhage clinical guideline: determining the optimal hospital length of stay. Am J Med 1996;100:313-22. 7. Blatchford O, Murray W, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000;356: 1318-21. 8. Rockall TA, Logan RF, Devlin HB, et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996;38:316-21. 9. Laursen SB, Hansen JM, Schaffalitzky de Muckadell OB. The Glasgow Blatchford score is the most accurate assessment of patients with upper gastrointestinal hemorrhage. Clin Gastroenterol Hepatol 2012;10: 1130-5. 10. Stanley AJ, Dalton HR, Blatchford O, et al. Multicentre comparison of the Glasgow Blatchford and Rockall Scores in the prediction of clinical end- points after upper gastrointestinal haemorrhage. Aliment Pharmacol Ther 2011;34:470-5. 11. Pang SH, Ching JY, Lau JY, et al. Comparing the Blatchford and pre- endoscopic Rockall score in predicting the need for endoscopic therapy in patients with upper GI hemorrhage. Gastrointest Endosc 2010;71: 1134-40. 12. Stanley AJ, Ashley D, Dalton HR, et al. Outpatient management of pa- tients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Lancet 2009;373:42-7. 13. Chen IC, Hung MS, Chiu TF, et al. Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointesti- nal tract bleeding. Am J Emerg Med 2007;25:774-9. 14. Saltzman JR, Tabak YP, Hyett BH, et al. A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding. Gastrointest Endosc 2011;74:1215-24. 15. Joo MJ, Lee TA, Weiss KB. Geographic variation of spirometry use in newly diagnosed COPD. Chest 2008;134:38-45. 16. Kumar A, Fonarow GC, Eagle KA, et al. Regional and practice variation in adherence to guideline recommendations for secondary and primary prevention among outpatients with atherothrombosis or risk factors in the United States: a report from the REACH Registry. Crit Path Cardiol 2009;8:104-11. 17. Powell TM, Thompsen JP, Virgo KS, et al. Geographic variation in patient surveillance after radical prostatectomy. Ann Surg Oncol 2000;7:339-45. 18. Adams BD, McHugh KJA, Bryson SA, et al. The law of unintended conse- quences: the joint commission regulations and the digital rectal exam- ination. Ann Emerg Med 2008;51:197-201. 19. Le Jeune IR, Gordon AL, Farrugia D, et al. Safe discharge of patients with low-riskuppergastrointestinalbleeding(UGIB):cantheuseofGlasgow- Blatchford Bleeding Score be extended? Acute Med 2011;10:176-81. 20. Stephens JR, Hare NC, Warshow U, et al. Management of minor upper gastrointestinal haemorrhage in the community using the Glasgow Blatchford Score. Eur J Gastroenterol Hepatol 2009;21:1340-6. Hyett et al AIMS65 predicts outcomes in upper GI bleeding www.giejournal.org Volume 77, No. 4 : 2013 GASTROINTESTINAL ENDOSCOPY 557