key: cord-300802-2y2oxss4
authors: Kim, Judith; Doyle, John B.; Blackett, John W.; May, Benjamin; Hur, Chin; Lebwohl, Benjamin
title: Effect of the COVID-19 Pandemic on Outcomes for Patients Admitted with Gastrointestinal Bleeding in New York City
date: 2020-05-13
journal: Gastroenterology
DOI: 10.1053/j.gastro.2020.05.031
sha: 
doc_id: 300802
cord_uid: 2y2oxss4

nan

The coronavirus disease 2019 (COVID-19) pandemic has resulted in massive reorganization of hospital operations, with specific implications for patients hospitalized with gastrointestinal bleeding 1, 2 . Guidelines recommend minimizing high-risk aerosol-generating procedures, including upper gastrointestinal endoscopy, and reducing direct patient contact by inpatient consultation services [1] [2] [3] . The impact of these changes on gastrointestinal bleeding, which is the most common gastrointestinal reason for hospitalization in the United States 4 , is unknown.

This study examined the effect of the COVID-19 pandemic on outcomes for patients admitted for gastrointestinal bleeding at two affiliated hospitals in New York City, the epicenter of the COVID-19 pandemic 2 . We sought to assess differences in hospital length of stay for gastrointestinal bleeding before and during the COVID-19 pandemic. We also assessed differences in blood product transfusion requirement and rate of endoscopy performed during hospitalization.

This was a retrospective cohort study of all adults ≥18 years of age admitted with suspected gastrointestinal bleeding from February 1, 2020 to April 24, 2020 at two hospitals in Northern Manhattan affiliated within a single healthcare system (Columbia University Irving Medical Center). The primary exposure was hospital admission date, either preceding or on-or-after March 16, 2020. This was the date on which new COVID-19 policies were put into effect, including stoppage of elective procedures and encouragement of remote (as opposed to inperson) inpatient consultation.

Demographic data, outpatient medications, laboratory findings on admission, inpatient procedures, and outcome data were collected. The primary outcome was hospital length of stay.

Secondary outcomes were transfusions (packed red blood cells, platelets, cryoprecipitate, or fresh frozen plasma) given during hospitalization and performance of inpatient endoscopy. Due to the non-normal distribution of length of stay, and to account for ongoing hospitalization at the time of this analysis, we dichotomized the primary outcome as a length of stay of <5 days vs. ≥5

days, corresponding to the median length of stay in the entire cohort. Multivariable logistic regression models were built to examine the association of primary and secondary outcomes with period of admission (before or during COVID-19 pandemic). This study was approved by the Institutional Review Board of Columbia University Irving Medical Center.

We identified 211 patients admitted with gastrointestinal bleeding between February 1, 2020 and April 24, 2020, with 88 (42%) patients admitted after March 15, 2020. Characteristics of the two cohorts are shown in Table 1 

This study aimed to characterize the impact of massive reorganization to hospital operations during the COVID-19 pandemic on outcomes for patients admitted with gastrointestinal bleeding at two hospitals in New York City. Patients admitted with gastrointestinal bleeding during the pandemic presented with lower hemoglobin and platelet counts and higher INR than those admitted prior to the pandemic. These laboratory differences persisted even when excluding patients with COVID-19, and may reflect patients' reluctance to present to the hospital during the pandemic, or perhaps higher thresholds for hospital admission.

Patients admitted with gastrointestinal bleeding during the pandemic were 2.5 times more likely to have a length of stay ≥ 5 days, even after adjusting for SARS-CoV-2 infection, compared to patients admitted before the pandemic. We are likely underestimating length of stay in the COVID-19 cohort, as 14 patients were still admitted at time of analysis, compared to zero patients in the pre-COVID-19 cohort. This would have a greater impact on our linear regression model than on our logistic regression model (evaluating short versus long hospitalization), since all patients had at least 5 days of follow-up. This may account for the difference in significance between the two models.

Patients admitted during the pandemic had a 2.86-fold higher odds of being transfused while hospitalized, even after adjusting for potential confounders such as admission hemoglobin and platelet counts. These patients also had significantly lower odds of undergoing an endoscopy relative to those admitted before the pandemic. The decrease in inpatient endoscopies, likely due to higher thresholds to perform aerosol-generating procedures, may have contributed to increased length of stay and transfusion requirements for these patients given the lack of endoscopic evaluation.

Our study has limitations. As a retrospective analysis, causal relationships between admission date and outcomes can only be hypothesized. There was also short follow-up time for patients admitted during the COVID-19 pandemic, limiting our ability to measure readmissions for recurrent bleeding as an outcome. This is the first study to evaluate the impact of the COVID-19 pandemic on gastrointestinal bleeding outcomes. Patients admitted during the pandemic, even those without COVID-19, had more concerning laboratory findings on admission, were less likely to undergo inpatient endoscopy, more likely to be transfused, and had increased hospital length of stay. These findings suggest that adapting to the COVID-19 pandemic has downstream deleterious effects on gastrointestinal bleeding management. 

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