Neighborhood Disparities in Endoscopy Access for Hospitalized Patients with Upper Gastrointestinal Bleeding

Neighborhood Disparities in Endoscopy Access for Hospitalized Patients with Upper Gastrointestinal Bleeding | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Neighborhood Disparities in Endoscopy Access for Hospitalized Patients with Upper Gastrointestinal Bleeding Adedeji Adenusi, Adebolu Adenusi, Olamide Asifat, Hezborn Magacha, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6141853/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction : Acute upper gastrointestinal bleeding (UGIB) is a major gastrointestinal emergency, described as bleeding in areas of GI tract above the ligament of Treitz. It accounts for over 50% of admissions in the US. Studies have highlighted racial disparities in endoscopy, but little is known about the impact of neighborhood level factors on access to therapeutic endoscopy. Methods : We used the National Inpatient Sample data from 2016-2020 to sample patients with a UGIB and assessed endoscopic treatment, weekend admission, socio-demographics, and hospital characteristics. We conducted descriptive analysis, bivariate and multivariate logistic regressions to identify neighborhood disparities in access to endoscopy. Results : A total of 135,795 patients had acute UGIB, of which 22.15% had endoscopic treatment. More than two-thirds of endoscopies performed were in urban teaching hospitals, on weekdays, and in white elderly patients on Medicare. The probability of endoscopy increases in hospitals located in the Midwest (1.29, 1.16-1.44, p < .0001) or Northeast regions (1.19, 1.05-1.33, p = 0.005), but reduces in patients admitted on weekends (0.90, 0.84-0.97, p = 0.004), in rural hospitals (0.46, 0.38-0.56, p< .0001) or urban non-teaching (0.84, 0.76-0.93, p = 0.0009), small or medium bed facilities (0.78, 0.71-0.86, p < .0001), western region hospitals (0.89, 0.79-0.99, p = 0.0352). Conclusion: We identified lower rates of endoscopy on weekends, in rural and urban non-teaching and small or medium sized hospitals. Our findings suggest the need to improve access to endoscopy in underserved regions. Endoscopy Neighborhood disparities Access Upper gastrointestinal bleeding Weekend admission Figures Figure 1 INTRODUCTION Acute Upper gastrointestinal bleeding (AUGIB) is one of the leading digestive emergencies and remains a prime cause of morbidity and mortality. It creates a medico-surgical emergency that rapidly complicates the patient’s prognosis ( 1 ). AUGIB is defined as bleeding originating from a source proximal to the ligament of Treitz which presents with a wide range of clinical severity, ranging from insignificant bleeds to catastrophic hemorrhage ( 2 ). In the United States, AUGIB accounts for more than 250,000 admissions yearly and it is common in men ( 3 ) with an associated 2–10% of deaths ( 4 ). Management protocol of AUGIB according to American Gastroenterological Association (AGA) recommends endoscopic evaluation (esophago-duodenoscopy) within 24 hours of admission. ( 5 ). Therapeutic esophago-gastroduodenoscopy is the standard procedure to identify sources of bleeding and ensure hemostatic treatment of the actively bleeding lesions. This procedure, when done in a timely manner, has been shown to also decrease the risk of further bleeding and the need for surgery ( 6 ). In addition, studies have also observed that early (within 24 hours) endoscopic evaluation in AUGIB has been associated with improved hospital outcomes, reduced mortality and duration of admission compared to those that had endoscopy later ( 7 ). Despite the awareness and provision of guidelines to ensure proper and timely treatment of patients with AUGIB, recent literature found disparities in endoscopic treatment, procedure time and hospital outcomes among those with AUGIB based on their ethnic and racial background as well as insurance status ( 8 ) ( 9 ). The purpose of this study is to identify the impact of Neighborhood level factors on the access to therapeutic endoscopy among hospitalized patients with acute upper gastrointestinal bleeding (AUGIB) METHODS Primary diagnosis and procedure were selected by identifying respective ICD-10 codes for AUGIB and therapeutic endoscopy from the National Inpatient Sample Database (NIS) between 2016-2020. The National Inpatient Sample (NIS) is the largest publicly available inpatient healthcare database in the U.S., representing approximately 20% of community hospitals. It provides nationally weighted estimates of hospital stays, including patient demographics, diagnoses, procedures, and outcomes The inclusion criteria were primary diagnosis of AUGIB, and exclusion criteria was diagnosis of variceal subtype of AUGIB. The main predictor variable is Hospital Region, and the main outcome is Therapeutic upper endoscopy. Other covariates are race and ethnicity, Median household income, primary payer. We controlled for teaching status of hospital, Hospital Bed size, hospital cost, gender, weekend admission and other confounders. This cross-sectional study conducted a weighed descriptive analysis of study characteristics using the variable ‘DISCWT’ (Discharge Weight) to reduce sampling bias in the survey according to NIS Database guidelines. This weight is necessary to ensure that the results of the study are representative of the large population from which the sample was drawn, and to maximize the validity of the results. Statistical analysis involved chi-square tests to estimate the independence of categorical variables, bivariate logistic regression and a backward stepwise approach to multivariate logistic regression analyses were performed to evaluate neighborhood disparities of access to therapeutic endoscopy. Level of significance was set p<0.05. All analyses were conducted with statistical software SAS version 9.4 (SAS Institute Inc., Cary, NC, USA). Ethical Considerations This study used de-identified and publicly accessible inpatient data. Hence, this study is exempted from our institutional review board (IRB) approval. Data Availability The NIS data for the period of study (2016-2020) can be accessed at: https://www.hcup-us.ahrq.gov (11) RESULTS A total of 135,795 (weighted frequency) adults with a primary diagnosis of AUGIB were included in this study of which 22.15% had therapeutic endoscopic treatment and only 26.5% of these endoscopies were performed within 24hrs. More than one-thirds of endoscopies performed were in southern region facilities, urban teaching hospitals, on weekdays, and among white elderly patients on Medicare. The odds of endoscopy treatment increases with age, highest in patients aged > = 65 years (aOR = 5.35, CI:3.33–8.62, p < .0001), hospitals located in the Midwest (1.29, 1.16–1.44, p < .0001) or Northeast regions (1.19, 1.05–1.33, p = 0.005), while lower odds in patients admitted on weekends (0.90, 0.84–0.97, p = 0.004), in rural hospitals (0.46, 0.38–0.56, p < .0001) or urban non-teaching (0.84, 0.76–0.93, p = 0.0009), small or medium bed facilities (0.78, 0.71–0.86, p < .0001), western region hospitals (0.89, 0.79–0.99, p = 0.0352). DISCUSSION In a national inpatient sample, we found risk factors for delayed access to endoscopy for UGIB to be weekend admission, rural or urban non-teaching facilities and small and medium size facilities and west region facilities. We did not find an independent association with race or ethnicity when controlling these factors. Prior studies have reported that Black and Hispanic individuals are likely to receive delayed care for UGIB. According to Rodriguez et al. and Abougergi et al. Black and Hispanic participants will usually not get therapeutic endoscopy for AUGIB when compared to the white participants ( 8 , 9 ). Our study suggests that rural residence or urban non-teaching setting may explain the race/ethnicity disparities. Patients admitted to rural and non-teaching facilities were unlikely to get endoscopic treatment compared to those admitted to urban teaching facilities. This could be related to the under-representation of gastrointestinal (GI) specialists in rural based facilities compared to urban based facilities ( 12 ). In addition, the low coverage of Endoscopists in rural and non-teaching facilities could be one of the fallouts of having very few percentage of GI specialty training or programs in the rural and non-teaching facilities, leading to a delay in GI specialist care and contributing to the disparities in GI care. One of the ways we suggest addressing these gaps is by employing GI Hospitalists (GIH) in non-teaching and rural facilities. GIH are specialists who are well trained to evaluate, treat various GI diseases and perform basic GI endoscopy procedures. Schoeppner et al highlighted some benefits of this strategy which are not limited to improved endoscopic care and patient survival ( 13 ). Small and medium-sized facilities were also unlikely to offer therapeutic endoscopy to patients with AUGIB compared to large size facilities (Table 2 ). This could be linked to the limited or absence of endoscopy units in these small bed size hospitals and lesser funding, therefore reduce the facility capacity to perform endoscopic procedures, compared to large size hospitals. We recommend more funding of small and medium bed size hospitals to set up an effective and efficient endoscopy unit. ( 14 ) Table 1 Characteristics of study population with upper gastrointestinal bleeding Variables Therapeutic Endoscopy Weighted Frequencies (%) P-values Yes No Age <.0001 18–24 years 95 (0.321%) 1640 (1.544%) 25–34 years 605 (2.044%) 6320 (5.951%) 35–44 years 1110 (3.7506%) 9245 (8.705%) 45–54 years 1980 (6.6903%) 12605 (11.869%) 55–64 years 5145 (17.385%) 21760 (20.490%) =>65 years 20660 (69.809%) 54630 (51.441%) Insurance < .0001 Medicaid 2530 (8.549%) 17750 (16.714%) Medicare 20870 (70.519%) 59675 (56.191%) Other 735 (2.484%) 3370 (3.173%) Private 4675 (15.797%) 18670 (17.580%) Self-pay 785 (2.653%) 6735 (6.342%) Location/teaching status of hospital < .0001 Rural 1266 (4.258%) 8020 (7.552%) Urban non-teaching 5590 (18.888%) 22040 (20.753%) Urban teaching 22745 (76.854%) 76140 (71.695%) Weekend Admission < .0001 No 23125 (78.138%) 80,255 (75.570%) Yes 6470 (21.862%) 25945 (24.430%) Median household income 0.0022 1st quartile 8855 (29.921%) 34765 (32.735%) 2nd quartile 8595 (29.042%) 28880 (27.194%) 3rd quartile 6680 (22.571%) 23390 (22.024%) 4th quartile 5465 (18.466%) 19165 (18.046%) Sex 0.0002 Female 15745 (53.202%) 59455 (55.984%) Male 13850 (46.798%) 46745 (44.016%) Race/ethnicity < .0001 White 21330 (72.073%) 72215 (67.999%) Black 4970 (16.793%) 18600 (17.514%) Hispanic 2685 (9.073%) 12770 (12.025%) Asian/Pacific Islander 610 (2.061%) 2.462 (2.462%) Total Hospital Cost < .0001 1st quartile 1720 (5.812%) 11715 (11.031%) 2nd quartile 8325 (28.130%) 28160 (26.516%) 3rd quartile 12100 (40.885%) 38410 (36.168%) 4th quartile 7450 (25.173%) 27915 (26.285%) Hospital Bed size < .0001 Small 5965 (20.155%) 23575 (22.199%) Medium 8380 (28.316%) 32980 (31.055%) Large 15250 (51.529%) 49645 (46.749%) Hospital Region < .0001 Northwest 5400 (18.246%) 17305 (16.295%) Midwest 7335 (24.785%) 20380 (19.190%) South 11895 (40.193%) 46210 (43.512%) West 4965 (16.776%) 22305 (21.003%) Procedure Time < .0001 24hrs 21755 (73.509%) 63475 (59.769%) Length of Stay < .0001 3 days 7265 (24.548%) 32180 (30.301%) Table 2 Bivariate and Multivariate Logistic regression of study population and hospital characteristics on access to endoscopy Variables Odds ratio (95%CI) p-values Adjusted odds ratio (95%CI) p-values 25–34 years 1.653 (1.007–2.712) 0.0469 1.649 (0.998–2.725) 0.0510 35–44 years 2.073 (1.281–3.352) 0.0030 1.986 (1.218–3.238) 0.0060 45–54 years 2.712 (1.694–4.341) < .0001 2.449 (1.518–3.952) 0.0002 55–64 years 4.082 (2.560–6.507) < .0001 3.505 (2.184–5.626) 65 years 6.528 (4.109–10.372) < .0001 5.354 (3.327–8.616) < .0001 Black 0.905 (0827-0.989) 0.0285 0.982 (0.895–1.079) 0.7110 Hispanic 0.712 (0.634-0.800) < .0001 0.913 (0.808–1.031) 0.1413 Asian/ Pacific Islander 0.790 (0.625–0.997) 0.0473 0.869 (0.688–1.096) 0.2348 Male 0.894 (0.842–0.949) 0.0002 0.978 (0.920–1.041) 0.4858 Weekend Admission 0.865 (0.808–0.927) < .0001 0.901 (0.840–0.968) 0.0041 1st quartile (Income) 0.893 (0.808–0.988) 0.0275 0.985 (0.885–1.097) 0.7882 2nd quartile (Income) 1.044 (0.947–1.150) 0.3872 1.071 (0.969–1.185) 0.1793 3rd quartile (Income) 1.002 (0.908–1.104) 0.9755 0.997 (0.903–1.101) 0.9595 Medicaid 0.654 (0.532–0.803) < .0001 0.832 (0.674–1.028) 0.0880 Medicare 1.604 (1.330–1.933) < .0001 1.061 (0.876–1.284) 0.5461 Private 1.148 (0.942–1.399) 0.1713 1.208 (0.988–1.477) 0.0661 Self-pay 0.534 (0.418–0.683) < .0001 0.732 (0.569–0.943) 0.0159 Rural hospital 0.766 (0.678–0.864) < .0001 0.463 (0.384–0.557) < .0001 Urban non-teaching hospital 0.941 (0.877–1.009) 0.0862 0.843 (0.763–0.933) 0.0009 Small (Bed size) 0.526 (0.439–0.630) < .0001 0.742 (0.671–0.820) < .0001 Medium (Bed size) 0.849 (0.769–0.938) 0.0013 0.777 (0.706–0.856) < .0001 Northeast 1.212 (1.082–1.358) 0.0009 1.185 (1.053–1.334) 0.0050 Midwest 1.398 (1.254–1.559) < .0001 1.293 (1.159–1.443) < .0001 West 0.865 (0.773–0.967) 0.0110 0.884 (0.789–0.991) 0.0352 *Adjusted odds ratio measures the probability of therapeutic endoscopy after AUGIB Regional disparities in endoscopic treatment were also observed, with facilities in the Northeast and Midwest demonstrating a higher likelihood of performing therapeutic endoscopy while facilities in west region showed lower likelihood performing therapeutic endoscopy (Table 2 ). The disparities may reflect differences in healthcare infrastructure, policy effectiveness, and funding allocation, with Northern and Midwestern regions potentially benefiting from stronger healthcare strategies ( 15 ). These findings imply that there is a need to improve and enhance healthcare delivery systems in the Western region facilities to ensure and provide equitable access to timely and effective endoscopic treatment. Lastly, weekend admission/effects were observed to influence endoscopic care in patients with AUGIB. Those admitted on weekends were unlikely to get endoscopic evaluation and/or treatment. This could be related to the reduced staff strength on weekends compared to weekdays. Our study strengths include (1.) We explored neighborhood disparities in access to endoscopy in AUGIB by utilization of the largest US inpatient database. Few limitations were observed in our study. (1.) This study was a cross-sectional analysis and only demonstrates association not causation. ( 2 ) Our study could not identify the level of education and employment status of the study participants because it was not included in the dataset. In conclusion, neighborhood factors play a key role in influencing access to treatment options in patients with gastrointestinal emergencies like AUGIB. We believe that the awareness of the predictive impacts of Hospital location and characteristics would guide GI specialists, Hospital administrators and policy makers to be proactive by creating accessible endoscopy centers and devise sustainable plans and strategies, to limit these disparities. Declarations Conflict of interest: None declared Funding source: None declared Author Contribution A.A. contributed substantially to the conception, design of the work, acquisition, analysis, and interpretation of data. Drafted and revised the manuscriptA.A. contributed to the study design, drafted and revised the manuscript for important intellectual content.O.A. contributed to the data interpretation, and revised the manuscript critically for important intellectual content;H.M. revised the manuscript critically for important intellectual content;A.S. contributed to the conception, revised the manuscript critically for important intellectual content and approved the version to be published. Data Availability National inpatient sample data that supports our findings are deposited in HCUP DatabaseHealthcare Cost and Utilization Project (HCUP). HCUP NIS Database Documentation. Agency for Healthcare Research and Quality. Published June 2024. Accessed February 9, 2025. www.hcup-us.ahrq.gov/db/nation/nis/nisdbdocumentation.jsp. References Nkurunziza L, Bacha H, Gharbi T, et al. Upper gastrointestinal bleeding: a prospective epidemiological study about 72 cases and review of the literature. Saudi J Med Pharm Sci. 2022;8(7):319–326. Bodh V, Sharma B, Kumar R, et al. Current trends in etiological profile of acute upper gastrointestinal bleeding in Northern India: a retrospective analysis of 5-year endoscopic data. J Dig Endosc. 2021;12(1):31–35. Long, B., & Gottlieb, M. Emergency medicine updates: Upper gastrointestinal bleeding. The American Journal of Emergency Medicine. 2024; 81: 116–123. DOI: 10.1016/j.ajem.2023.09.029 Stanley, A. J., & Laine, L. Management of acute upper gastrointestinal bleeding. BMJ (Clinical Research Edition). 2019; 364: l536. DOI: 10.1136/bmj.l536 Laine, L., Barkun, A. N., Saltzman, J. R., et al. ACG clinical guideline: upper gastrointestinal and ulcer bleeding. The American Journal of Gastroenterology. 2021; 116(5): 899–917. DOI: 10.14309/ajg.0000000000001245 Lau, J. Y., Yu, Y., Tang, R. S., et al. Timing of endoscopy for acute upper gastrointestinal bleeding. New England Journal of Medicine. 2020; 382(14): 1299–1308. DOI: 10.1056/NEJMoa1912482 Weissman S, Aziz M, et al. Relationships of hospitalization outcomes and timing to endoscopy in non-variceal upper gastrointestinal bleeding: A nationwide analysis. World J Gastrointest Endosc. 2023;15:285–296. doi: 10.4253/wjge.v15.i4.285 . Rodriguez, N. J., Zheng, N. S., Mezzacappa, C., et al. Disparities in access to endoscopy for patients with upper gastrointestinal bleeding presenting to emergency departments. Gastroenterology. 2023; 164(7): 1044–1046. DOI: 10.1053/j.gastro.2023.04.029 Abougergi, M. S., Avila, P., & Saltzman, J. R. Impact of insurance status and race on outcomes in nonvariceal upper gastrointestinal hemorrhage: a nationwide analysis. Journal of Clinical Gastroenterology. 2019; 53(1): e12-e18. DOI: 10.1097/MCG.0000000000001047 Macias-Konstantopoulos, W. L., Collins, K. A., Diaz, R., et al. Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity. The Western Journal of Emergency Medicine. 2023; 24(5): 906–918. DOI: 10.5811/westjem.2023.5.59027 Healthcare Cost and Utilization Project (HCUP). HCUP NIS Database Documentation. Agency for Healthcare Research and Quality. Published June 2024. Accessed February 9, 2025. . Aboagye, J. K., Kaiser, H. E., & Hayanga, A. J. Rural-Urban Differences in Access to Specialist Providers of Colorectal Cancer Care in the United States: A Physician Workforce Issue. JAMA Surgery. 2014; 149(6): 537–543. DOI: 10.1001/jamasurg.2013.5063 Schoeppner HL, Miller SL. Developing a gastroenterology hospitalist service. Gastrointest Endosc Clin N Am. 2006;16(4):743–750. American Hospital Association. Fact sheet: Infrastructure investments needed to support access to care in rural areas. AHA. https://www.aha.org/fact-sheets/2021-05-26-fact-sheet-infrastructure-investments-needed-support-access-care-rural . Published May 26, 2021. Accessed February 9, 2025. Miller, C. E., & Vasan, R. S. The southern rural health and mortality penalty: A review of regional health inequities in the United States. Social Science & Medicine. 2021; 268: 113443. DOI: 10.1016/j.socscimed.2020.113443 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6141853","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":423220124,"identity":"873da889-a02d-41c5-a09c-1130f818a4ab","order_by":0,"name":"Adedeji Adenusi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYFCCBAYJBh4JBoYDII6BDZBgbDxAipY0kJYGIrSAAETZYSQ2DsDfnnzwxgcZC3m+473HJH8UnLdb234YaEuNTTQuLRJnniVbzuCRMJx55lyaNI/B7eRtZxKBWo6l5Tbg0nMjx0yah0eCcQOIwQDUYnYAqIWx4TBOLfI38r9J/+GRsN9w/42Z5A+Dc8lm5x/i12JwI4dNGhhiiRtu8JhJ8BgcsDO7QcAWwzPPjC17eCSSZ57JMbbmMUhOMLsBtCUBj1/kjic/vPGzp8627/gZw5s//tjZm51Pf/jgQ40Nbu+DAGMPgp0IVpmATzkY/EAw7QkqHgWjYBSMghEHAHQtZT5WX2ZvAAAAAElFTkSuQmCC","orcid":"","institution":"¹One Brooklyn Heath- Interfaith Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Adedeji","middleName":"","lastName":"Adenusi","suffix":""},{"id":423220125,"identity":"4bb83abb-52aa-4951-98f8-3d836e19323a","order_by":1,"name":"Adebolu Adenusi","email":"","orcid":"","institution":"Lagos State University, Department of Nursing, Lagos, Nigeria","correspondingAuthor":false,"prefix":"","firstName":"Adebolu","middleName":"","lastName":"Adenusi","suffix":""},{"id":423220126,"identity":"3686ffaf-1bef-4249-85ce-de65586085ff","order_by":2,"name":"Olamide Asifat","email":"","orcid":"","institution":"Georgia Southern University","correspondingAuthor":false,"prefix":"","firstName":"Olamide","middleName":"","lastName":"Asifat","suffix":""},{"id":423220127,"identity":"15624d8c-7559-41a9-82c8-93c2dffd50af","order_by":3,"name":"Hezborn Magacha","email":"","orcid":"","institution":"East Tennessee State University, Quillen College of Medicine, TN, USA","correspondingAuthor":false,"prefix":"","firstName":"Hezborn","middleName":"","lastName":"Magacha","suffix":""},{"id":423220128,"identity":"fa9a02c1-4674-41cd-ad1d-b888d0928f49","order_by":4,"name":"Aasma Shaukat","email":"","orcid":"","institution":"Department of Medicine, Division of Gastroenterology, NYU Grossman School of Medicine, USA","correspondingAuthor":false,"prefix":"","firstName":"Aasma","middleName":"","lastName":"Shaukat","suffix":""}],"badges":[],"createdAt":"2025-03-03 01:53:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6141853/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6141853/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":77767125,"identity":"b29d885d-4394-40b2-a840-ea938e486484","added_by":"auto","created_at":"2025-03-05 10:13:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":9752,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eForrest Plot of Neighborhood level factors, hospital characteristics and weekend effect on access Endoscopy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e*This represents adjusted odd ratios (aOR) distribution of the neighborhood level factors and hospital characteristic on access endoscopy. aOR greater than “1” shows a higher probability to get endoscopy performed, while aOR less than ”1” lowers this probability. Statistical significance (p\u0026lt;0.005) is when the odds ratio confidence interval (CI) does not include “1”\u003c/p\u003e","description":"","filename":"Onlinedrawingimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6141853/v1/e76e2f715b8fdbc396713cc9.png"},{"id":77769460,"identity":"a57e9af8-5905-41b8-80ff-ca3fc1e08d9c","added_by":"auto","created_at":"2025-03-05 10:37:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":977545,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6141853/v1/7b5f0bcc-076a-4ae0-990e-9a61eff1cf53.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Neighborhood Disparities in Endoscopy Access for Hospitalized Patients with Upper Gastrointestinal Bleeding","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAcute Upper gastrointestinal bleeding (AUGIB) is one of the leading digestive emergencies and remains a prime cause of morbidity and mortality. It creates a medico-surgical emergency that rapidly complicates the patient\u0026rsquo;s prognosis (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). AUGIB is defined as bleeding originating from a source proximal to the ligament of Treitz which presents with a wide range of clinical severity, ranging from insignificant bleeds to catastrophic hemorrhage (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In the United States, AUGIB accounts for more than 250,000 admissions yearly and it is common in men (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) with an associated 2\u0026ndash;10% of deaths (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Management protocol of AUGIB according to American Gastroenterological Association (AGA) recommends endoscopic evaluation (esophago-duodenoscopy) within 24 hours of admission. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTherapeutic esophago-gastroduodenoscopy is the standard procedure to identify sources of bleeding and ensure hemostatic treatment of the actively bleeding lesions. This procedure, when done in a timely manner, has been shown to also decrease the risk of further bleeding and the need for surgery (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In addition, studies have also observed that early (within 24 hours) endoscopic evaluation in AUGIB has been associated with improved hospital outcomes, reduced mortality and duration of admission compared to those that had endoscopy later (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the awareness and provision of guidelines to ensure proper and timely treatment of patients with AUGIB, recent literature found disparities in endoscopic treatment, procedure time and hospital outcomes among those with AUGIB based on their ethnic and racial background as well as insurance status (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The purpose of this study is to identify the impact of Neighborhood level factors on the access to therapeutic endoscopy among hospitalized patients with acute upper gastrointestinal bleeding (AUGIB)\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003ePrimary diagnosis and procedure were selected by identifying respective ICD-10 codes for AUGIB and therapeutic endoscopy from the National Inpatient Sample Database (NIS) between 2016-2020. The National Inpatient Sample (NIS) is the largest publicly available inpatient healthcare database in the U.S., representing approximately 20% of community hospitals. It provides nationally weighted estimates of hospital stays, including patient demographics, diagnoses, procedures, and outcomes\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria were primary diagnosis of AUGIB, and exclusion criteria was diagnosis of variceal subtype of AUGIB. The main predictor variable is Hospital Region, and the main outcome is Therapeutic upper endoscopy. Other covariates are race and ethnicity, Median household income, primary payer. We controlled for teaching status of hospital, Hospital Bed size, hospital cost, gender, weekend admission and other confounders. This cross-sectional study conducted a weighed descriptive analysis of study characteristics using the variable \u0026lsquo;DISCWT\u0026rsquo; (Discharge Weight) to reduce sampling bias in the survey according to NIS Database guidelines. This weight is necessary to ensure that the results of the study are representative of the large population from which the sample was drawn, and to maximize the validity of the results.\u0026nbsp;Statistical analysis involved chi-square tests to estimate the independence of categorical variables, bivariate logistic regression and a backward stepwise approach to multivariate logistic regression analyses were performed to evaluate neighborhood disparities of access to therapeutic endoscopy.\u0026nbsp;Level of significance was set p\u0026lt;0.05. All analyses were conducted with statistical software SAS version 9.4\u0026nbsp;(SAS Institute Inc., Cary, NC, USA).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical Considerations\u003c/p\u003e\n\u003cp\u003eThis study used de-identified and publicly accessible inpatient data. Hence, this study is exempted from our institutional review board (IRB) approval.\u003c/p\u003e\n\u003cp\u003eData Availability\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe NIS data for the period of study (2016-2020) can be accessed at: https://www.hcup-us.ahrq.gov (11)\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 135,795 (weighted frequency) adults with a primary diagnosis of AUGIB were included in this study of which 22.15% had therapeutic endoscopic treatment and only 26.5% of these endoscopies were performed within 24hrs. More than one-thirds of endoscopies performed were in southern region facilities, urban teaching hospitals, on weekdays, and among white elderly patients on Medicare. The odds of endoscopy treatment increases with age, highest in patients aged\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;65 years (aOR\u0026thinsp;=\u0026thinsp;5.35, CI:3.33\u0026ndash;8.62, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001), hospitals located in the Midwest (1.29, 1.16\u0026ndash;1.44, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001) or Northeast regions (1.19, 1.05\u0026ndash;1.33, p\u0026thinsp;=\u0026thinsp;0.005), while lower odds in patients admitted on weekends (0.90, 0.84\u0026ndash;0.97, p\u0026thinsp;=\u0026thinsp;0.004), in rural hospitals (0.46, 0.38\u0026ndash;0.56, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001) or urban non-teaching (0.84, 0.76\u0026ndash;0.93, p\u0026thinsp;=\u0026thinsp;0.0009), small or medium bed facilities (0.78, 0.71\u0026ndash;0.86, p\u0026thinsp;\u0026lt;\u0026thinsp;.0001), western region hospitals (0.89, 0.79\u0026ndash;0.99, p\u0026thinsp;=\u0026thinsp;0.0352).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn a national inpatient sample, we found risk factors for delayed access to endoscopy for UGIB to be weekend admission, rural or urban non-teaching facilities and small and medium size facilities and west region facilities. We did not find an independent association with race or ethnicity when controlling these factors. Prior studies have reported that Black and Hispanic individuals are likely to receive delayed care for UGIB. According to Rodriguez et al. and Abougergi et al. Black and Hispanic participants will usually not get therapeutic endoscopy for AUGIB when compared to the white participants (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur study suggests that rural residence or urban non-teaching setting may explain the race/ethnicity disparities. Patients admitted to rural and non-teaching facilities were unlikely to get endoscopic treatment compared to those admitted to urban teaching facilities. This could be related to the under-representation of gastrointestinal (GI) specialists in rural based facilities compared to urban based facilities (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In addition, the low coverage of Endoscopists in rural and non-teaching facilities could be one of the fallouts of having very few percentage of GI specialty training or programs in the rural and non-teaching facilities, leading to a delay in GI specialist care and contributing to the disparities in GI care. One of the ways we suggest addressing these gaps is by employing GI Hospitalists (GIH) in non-teaching and rural facilities. GIH are specialists who are well trained to evaluate, treat various GI diseases and perform basic GI endoscopy procedures. Schoeppner et al highlighted some benefits of this strategy which are not limited to improved endoscopic care and patient survival (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSmall and medium-sized facilities were also unlikely to offer therapeutic endoscopy to patients with AUGIB compared to large size facilities (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This could be linked to the limited or absence of endoscopy units in these small bed size hospitals and lesser funding, therefore reduce the facility capacity to perform endoscopic procedures, compared to large size hospitals. We recommend more funding of small and medium bed size hospitals to set up an effective and efficient endoscopy unit. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of study population with upper gastrointestinal bleeding\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eTherapeutic Endoscopy\u003c/p\u003e \u003cp\u003eWeighted Frequencies (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-values\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;24 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95 (0.321%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1640 (1.544%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;34 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e605 (2.044%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6320 (5.951%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026ndash;44 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1110 (3.7506%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9245 (8.705%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45\u0026ndash;54 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1980 (6.6903%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12605 (11.869%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e55\u0026ndash;64 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5145 (17.385%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21760 (20.490%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e=\u0026gt;65 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20660 (69.809%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54630 (51.441%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInsurance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedicaid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2530 (8.549%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17750 (16.714%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedicare\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20870 (70.519%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59675 (56.191%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e735 (2.484%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3370 (3.173%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4675 (15.797%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18670 (17.580%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-pay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e785 (2.653%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6735 (6.342%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocation/teaching status of hospital\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1266 (4.258%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8020 (7.552%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban non-teaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5590 (18.888%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22040 (20.753%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban teaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22745 (76.854%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76140 (71.695%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeekend Admission\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23125 (78.138%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80,255 (75.570%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6470 (21.862%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25945 (24.430%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedian household income\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1st quartile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8855 (29.921%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34765 (32.735%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2nd quartile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8595 (29.042%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28880 (27.194%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3rd quartile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6680 (22.571%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23390 (22.024%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4th quartile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5465 (18.466%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19165 (18.046%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15745 (53.202%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59455 (55.984%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13850 (46.798%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46745 (44.016%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace/ethnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21330 (72.073%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72215 (67.999%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4970 (16.793%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18600 (17.514%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2685 (9.073%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12770 (12.025%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian/Pacific Islander\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e610 (2.061%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.462 (2.462%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Hospital Cost\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1st quartile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1720 (5.812%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11715 (11.031%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2nd quartile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8325 (28.130%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28160 (26.516%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3rd quartile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12100 (40.885%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38410 (36.168%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4th quartile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7450 (25.173%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27915 (26.285%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospital Bed size\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5965 (20.155%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23575 (22.199%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8380 (28.316%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32980 (31.055%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15250 (51.529%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49645 (46.749%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospital Region\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorthwest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5400 (18.246%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17305 (16.295%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMidwest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7335 (24.785%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20380 (19.190%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11895 (40.193%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46210 (43.512%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4965 (16.776%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22305 (21.003%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProcedure Time\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;=24hrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7840 (26.491%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42725 (40.231%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;24hrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21755 (73.509%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63475 (59.769%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength of Stay\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22330 (75.452%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74020 (69.698%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e=\u0026gt;3 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7265 (24.548%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32180 (30.301%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBivariate and Multivariate Logistic regression of study population and hospital characteristics on access to endoscopy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOdds ratio (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-values\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjusted odds ratio (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-values\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e25\u0026ndash;34 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.653 (1.007\u0026ndash;2.712)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0469\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.649 (0.998\u0026ndash;2.725)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0510\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e35\u0026ndash;44 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.073 (1.281\u0026ndash;3.352)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0030\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.986 (1.218\u0026ndash;3.238)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0060\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e45\u0026ndash;54 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.712 (1.694\u0026ndash;4.341)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.449 (1.518\u0026ndash;3.952)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e55\u0026ndash;64 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.082 (2.560\u0026ndash;6.507)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.505 (2.184\u0026ndash;5.626)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e=\u0026gt;65 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.528 (4.109\u0026ndash;10.372)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.354 (3.327\u0026ndash;8.616)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlack\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.905 (0827-0.989)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0285\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.982 (0.895\u0026ndash;1.079)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.7110\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHispanic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.712 (0.634-0.800)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.913 (0.808\u0026ndash;1.031)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.1413\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAsian/ Pacific Islander\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.790 (0.625\u0026ndash;0.997)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0473\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.869 (0.688\u0026ndash;1.096)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.2348\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.894 (0.842\u0026ndash;0.949)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.978 (0.920\u0026ndash;1.041)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.4858\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeekend Admission\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.865 (0.808\u0026ndash;0.927)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.901 (0.840\u0026ndash;0.968)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0041\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1st quartile (Income)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.893 (0.808\u0026ndash;0.988)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0275\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.985 (0.885\u0026ndash;1.097)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.7882\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2nd quartile (Income)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.044 (0.947\u0026ndash;1.150)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.3872\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.071 (0.969\u0026ndash;1.185)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.1793\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3rd quartile (Income)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.002 (0.908\u0026ndash;1.104)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.9755\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.997 (0.903\u0026ndash;1.101)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.9595\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedicaid\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.654 (0.532\u0026ndash;0.803)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.832 (0.674\u0026ndash;1.028)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0880\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedicare\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.604 (1.330\u0026ndash;1.933)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.061 (0.876\u0026ndash;1.284)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.5461\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrivate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.148 (0.942\u0026ndash;1.399)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.1713\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.208 (0.988\u0026ndash;1.477)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.0661\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelf-pay\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.534 (0.418\u0026ndash;0.683)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.732 (0.569\u0026ndash;0.943)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0159\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRural hospital\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.766 (0.678\u0026ndash;0.864)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.463 (0.384\u0026ndash;0.557)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUrban non-teaching hospital\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.941 (0.877\u0026ndash;1.009)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0862\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.843 (0.763\u0026ndash;0.933)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSmall (Bed size)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.526 (0.439\u0026ndash;0.630)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.742 (0.671\u0026ndash;0.820)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedium (Bed size)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.849 (0.769\u0026ndash;0.938)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.777 (0.706\u0026ndash;0.856)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNortheast\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.212 (1.082\u0026ndash;1.358)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.185 (1.053\u0026ndash;1.334)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0050\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMidwest\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.398 (1.254\u0026ndash;1.559)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.293 (1.159\u0026ndash;1.443)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWest\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.865 (0.773\u0026ndash;0.967)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.884 (0.789\u0026ndash;0.991)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0352\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Adjusted odds ratio measures the probability of therapeutic endoscopy after AUGIB\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegional disparities in endoscopic treatment were also observed, with facilities in the Northeast and Midwest demonstrating a higher likelihood of performing therapeutic endoscopy while facilities in west region showed lower likelihood performing therapeutic endoscopy (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The disparities may reflect differences in healthcare infrastructure, policy effectiveness, and funding allocation, with Northern and Midwestern regions potentially benefiting from stronger healthcare strategies (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). These findings imply that there is a need to improve and enhance healthcare delivery systems in the Western region facilities to ensure and provide equitable access to timely and effective endoscopic treatment. Lastly, weekend admission/effects were observed to influence endoscopic care in patients with AUGIB. Those admitted on weekends were unlikely to get endoscopic evaluation and/or treatment. This could be related to the reduced staff strength on weekends compared to weekdays.\u003c/p\u003e \u003cp\u003eOur study strengths include (1.) We explored neighborhood disparities in access to endoscopy in AUGIB by utilization of the largest US inpatient database. Few limitations were observed in our study. (1.) This study was a cross-sectional analysis and only demonstrates association not causation. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Our study could not identify the level of education and employment status of the study participants because it was not included in the dataset.\u003c/p\u003e \u003cp\u003eIn conclusion, neighborhood factors play a key role in influencing access to treatment options in patients with gastrointestinal emergencies like AUGIB. We believe that the awareness of the predictive impacts of Hospital location and characteristics would guide GI specialists, Hospital administrators and policy makers to be proactive by creating accessible endoscopy centers and devise sustainable plans and strategies, to limit these disparities.\u003c/p\u003e"},{"header":"Declarations","content":" \u003ch2\u003eConflict of interest:\u003c/h2\u003e \u003cp\u003eNone declared\u003c/p\u003e \u003ch2\u003eFunding source:\u003c/h2\u003e \u003cp\u003eNone declared\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.A. contributed substantially to the conception, design of the work, acquisition, analysis, and interpretation of data. Drafted and revised the manuscriptA.A. contributed to the study design, drafted and revised the manuscript for important intellectual content.O.A. contributed to the data interpretation, and revised the manuscript critically for important intellectual content;H.M. revised the manuscript critically for important intellectual content;A.S. contributed to the conception, revised the manuscript critically for important intellectual content and approved the version to be published.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eNational inpatient sample data that supports our findings are deposited in HCUP DatabaseHealthcare Cost and Utilization Project (HCUP). HCUP NIS Database Documentation. Agency for Healthcare Research and Quality. Published June 2024. Accessed February 9, 2025. www.hcup-us.ahrq.gov/db/nation/nis/nisdbdocumentation.jsp.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNkurunziza L, Bacha H, Gharbi T, et al. Upper gastrointestinal bleeding: a prospective epidemiological study about 72 cases and review of the literature. Saudi J Med Pharm Sci. 2022;8(7):319\u0026ndash;326.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBodh V, Sharma B, Kumar R, et al. Current trends in etiological profile of acute upper gastrointestinal bleeding in Northern India: a retrospective analysis of 5-year endoscopic data. J Dig Endosc. 2021;12(1):31\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLong, B., \u0026amp; Gottlieb, M. Emergency medicine updates: Upper gastrointestinal bleeding. The American Journal of Emergency Medicine. 2024; 81: 116\u0026ndash;123. 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DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.14309/ajg.0000000000001245\u003c/span\u003e\u003cspan address=\"10.14309/ajg.0000000000001245\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLau, J. Y., Yu, Y., Tang, R. S., et al. Timing of endoscopy for acute upper gastrointestinal bleeding. New England Journal of Medicine. 2020; 382(14): 1299\u0026ndash;1308. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMoa1912482\u003c/span\u003e\u003cspan address=\"10.1056/NEJMoa1912482\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeissman S, Aziz M, et al. Relationships of hospitalization outcomes and timing to endoscopy in non-variceal upper gastrointestinal bleeding: A nationwide analysis. World J Gastrointest Endosc. 2023;15:285\u0026ndash;296. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4253/wjge.v15.i4.285\u003c/span\u003e\u003cspan address=\"10.4253/wjge.v15.i4.285\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodriguez, N. J., Zheng, N. S., Mezzacappa, C., et al. Disparities in access to endoscopy for patients with upper gastrointestinal bleeding presenting to emergency departments. Gastroenterology. 2023; 164(7): 1044\u0026ndash;1046. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/j.gastro.2023.04.029\u003c/span\u003e\u003cspan address=\"10.1053/j.gastro.2023.04.029\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbougergi, M. S., Avila, P., \u0026amp; Saltzman, J. R. Impact of insurance status and race on outcomes in nonvariceal upper gastrointestinal hemorrhage: a nationwide analysis. Journal of Clinical Gastroenterology. 2019; 53(1): e12-e18. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/MCG.0000000000001047\u003c/span\u003e\u003cspan address=\"10.1097/MCG.0000000000001047\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacias-Konstantopoulos, W. L., Collins, K. A., Diaz, R., et al. Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity. The Western Journal of Emergency Medicine. 2023; 24(5): 906\u0026ndash;918. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5811/westjem.2023.5.59027\u003c/span\u003e\u003cspan address=\"10.5811/westjem.2023.5.59027\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHealthcare Cost and Utilization Project (HCUP). HCUP NIS Database Documentation. Agency for Healthcare Research and Quality. Published June 2024. Accessed February 9, 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003c/span\u003e\u003cspan address=\"http://www.hcup-us.ahrq.gov/db/nation/nis/nisdbdocumentation.jsp\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAboagye, J. K., Kaiser, H. E., \u0026amp; Hayanga, A. J. Rural-Urban Differences in Access to Specialist Providers of Colorectal Cancer Care in the United States: A Physician Workforce Issue. JAMA Surgery. 2014; 149(6): 537\u0026ndash;543. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamasurg.2013.5063\u003c/span\u003e\u003cspan address=\"10.1001/jamasurg.2013.5063\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchoeppner HL, Miller SL. Developing a gastroenterology hospitalist service. Gastrointest Endosc Clin N Am. 2006;16(4):743\u0026ndash;750.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Hospital Association. Fact sheet: Infrastructure investments needed to support access to care in rural areas. AHA. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.aha.org/fact-sheets/2021-05-26-fact-sheet-infrastructure-investments-needed-support-access-care-rural\u003c/span\u003e\u003cspan address=\"https://www.aha.org/fact-sheets/2021-05-26-fact-sheet-infrastructure-investments-needed-support-access-care-rural\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published May 26, 2021. Accessed February 9, 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller, C. E., \u0026amp; Vasan, R. S. The southern rural health and mortality penalty: A review of regional health inequities in the United States. Social Science \u0026amp; Medicine. 2021; 268: 113443. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.socscimed.2020.113443\u003c/span\u003e\u003cspan address=\"10.1016/j.socscimed.2020.113443\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Endoscopy, Neighborhood disparities, Access, Upper gastrointestinal bleeding, Weekend admission","lastPublishedDoi":"10.21203/rs.3.rs-6141853/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6141853/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: Acute upper gastrointestinal bleeding (UGIB) is a major gastrointestinal emergency, described as bleeding in areas of GI tract above the ligament of Treitz. It accounts for over 50% of admissions in the US. Studies have highlighted racial disparities in endoscopy, but little is known about the impact of neighborhood level factors on access to therapeutic endoscopy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: We used the National Inpatient Sample data from 2016-2020 to sample patients with a UGIB and assessed endoscopic treatment, weekend admission, socio-demographics, and hospital characteristics. We conducted descriptive analysis, bivariate and multivariate logistic regressions to identify neighborhood disparities in access to endoscopy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: A total of 135,795 patients had acute UGIB, of which 22.15% had endoscopic treatment. More than two-thirds of endoscopies performed were in urban teaching hospitals, on weekdays, and in white elderly patients on Medicare. The probability of endoscopy increases in hospitals located in the Midwest (1.29, 1.16-1.44, p \u0026lt; .0001) or Northeast regions (1.19, 1.05-1.33, p = 0.005), but reduces in patients admitted on weekends (0.90, 0.84-0.97, p = 0.004), in rural hospitals (0.46, 0.38-0.56, p\u0026lt; .0001) or urban non-teaching (0.84, 0.76-0.93, p = 0.0009), small or medium bed facilities (0.78, 0.71-0.86, p \u0026lt; .0001), western region hospitals (0.89, 0.79-0.99, p = 0.0352).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e We identified lower rates of endoscopy on weekends, in rural and urban non-teaching and small or medium sized hospitals. Our findings suggest the need to improve access to endoscopy in underserved regions.\u003c/p\u003e","manuscriptTitle":"Neighborhood Disparities in Endoscopy Access for Hospitalized Patients with Upper Gastrointestinal Bleeding","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-05 10:13:41","doi":"10.21203/rs.3.rs-6141853/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4589db5d-33a0-4136-87cf-f882220313db","owner":[],"postedDate":"March 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-05T10:13:43+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-05 10:13:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6141853","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6141853","identity":"rs-6141853","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}