Clinical

Oakland score identifies patients with lower GI bleed at low risk for adverse events


 

Background: The Oakland score was initially designed to be used in patients presenting with LGIB in the urgent, emergent, or primary care setting to help predict risk of readmission and determine if outpatient management is feasible. National guidelines in the United Kingdom have recommended use of the Oakland score despite limited external validation for the triage of patients with acute LGIB. This study aimed to externally validate the Oakland score in a large population in the United States and compare the performance at two thresholds.

Dr. Danielle Steker, Division of Hospital Medicine, Northwestern University, Chicago

Dr. Danielle Steker

Study design: Retrospective observational study.

Setting: 140 hospitals across the United States.

Synopsis: In this prognostic study, 38,067 patients were identified retrospectively using ICD-10 codes that were consistent with a diagnosis of LGIB and were admitted to the hospital. The Oakland score consisted of seven variables, including age, sex, prior hospitalization with LGIB, digital rectal exam results, heart rate, systolic blood pressure, and hemoglobin concentration. The primary outcome was safe discharge from the hospital, defined as absence of in-hospital rebleeding, RBC transfusion, therapeutic colonoscopy, mesenteric embolization or laparotomy for bleeding, in-hospital death, or readmission with subsequent LGIB in 28 days. In total, 47.9% of the identified patients experienced no adverse outcomes and were classified as meeting criteria for safe discharge. In addition, 8.7% of patients scored 8 points or fewer with a sensitivity of 98.4% and specificity of 16.0% for safe discharge. A sensitivity of 96% was maintained after increasing the threshold to 10 points or fewer with a specificity of 31.9%, suggesting the threshold can be increased while still maintaining adequate sensitivity. The study suggests that, by using the Oakland score threshold of 8, hospital admission may be avoided in low-risk patients leading to a savings of at least $44.5 million and even more if the threshold is increased to 10. Low specificity does present limitation of the score as some patients considered to be at risk for adverse events may have been safely discharged and managed as an outpatient, avoiding hospitalization.

Bottom line: The Oakland score was externally validated for use in assessing risk of adverse outcomes in patients with LGIB and had a high sensitivity but low specificity for identifying low-risk patients.

Citation: Oakland K et al. External validation of the Oakland score to assess safe hospital discharge among adult patients with acute lower gastrointestinal bleeding in the US. JAMA Netw Open. 2020 Jul 1;3:e209630. doi: 10.1001/jamanetworkopen.2020.9630.

Dr. Steker is a hospitalist at Northwestern Memorial Hospital and instructor of medicine, Feinberg School of Medicine, both in Chicago.

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