Dilution or Decrease in Prevalence and Mortality of Patients With Variceal Bleeding Admitted to the ICU.

To the Editor: We read with great interest the article published in a recent issue of Critical Care Medicine by Majeed et al (1). The authors have done a great job of reporting prevalence and outcome trends in care of patients with variceal bleeding admitted to ICU. We would like to make few points that may be of interest to authors and readers of this article. Majeed et al (1) reported proportion of ICU admissions for variceal bleeding fell significantly from 0.8% in 2005 to 0.4% in 2016 which appears to be largely a result of disproportionate increase in ICU admission of other patients (denominator) hence the proportion declined. Figure 1A suggests very significant and steady increase in nonelective admission of patients without variceal bleeding while almost unchanged admission rate for variceal bleeding. Furthermore, Figure 1B showed that during same period, number of admissions for patients with cirrhosis without variceal bleeding almost doubled. Majeed et al (1) should discuss possibility of larger increase in patients with other diseases admitted to ICU. Majeed et al (1) mentioned that number of hospitals participating in the national database has increased significantly over last decade. Hospital participating only recently may be smaller size and are more likely to be open ICU and more likely to admit relatively less severely sick patients. ICU organization is a significant predictor of admission likelihood and outcomes (2). How the average Acute Physiology and Chronic Health Evaluation (APACHE) III score of patients admitted to ICUs changed during 2005 to 2016? There may be additional variables involved as well; is there a significant change in staffing model for physicians in these ICUs over this period, that is, 24 hours intensivist in-house coverage? Adjustment of these confounding factors may provide better understanding of prevalence and mortality change over this period. They also reported decline in mortality over this time period from 24.6% in 2005 to 15.8% in 2016. This may be the result from large proportion of nonelective admission without variceal bleeding with less severity of disease. Key is the objective plotting of average APACHE III scores during this period. Majeed et al (1) should also mention if there are outpatient endoscopy center in nonhospital setting not participating in the database. Majeed et al (1) excluded; same episode hospital readmission, transfers and patients with unknown outcomes, what was the proportion of these patients? as lost to follow-up patients tends to have worse outcomes. Table 2 in (1) suggests that transfer from another ICU or another hospital was more significant in patients with variceal bleeding versus other nonelective admission (p = 0.0001). American studies reported different outcomes in specialized centers versus nonspecialized centers, but the study by Majeed et al (1) showed similar rates in liver transplant center and nontransplant centers. Is this from difference in patient populations or from similar level of care for transplant center and nontransplant center in Australia and New Zealand? Larger databases like this one provide excellent opportunity to perform well-designed comprehensive studies to understand the trends in the disease prevalence, management, and outcomes. Similar databases are being developed in United Arab Emirates especially in Dubai. We plan to conduct similar studies in our patient populations in near future. The authors have disclosed that they do not have any potential conflicts of interest.