See “Incidence of Peptic Ulcer Bleeding in the US Pediatric Population” by Brown et al on page 733.
In this month's issue of JPGN, Brown et al (1) analyzed 2 large databases to estimate the incidence of pediatric peptic ulcer bleeding (PUB) in the United States. According to 2008 data, the authors found that the incidence varied between 0.5 to 0.9/100,000 and 4.4/100,000 individuals, using an inpatient pediatric database (Premier Perspective, Charlotte, NC) and an insurance claims database (MarketScan), respectively. This incidence range translated to a total estimate of 378 to 3250 pediatric PUB cases per year.
Database analyses are 1 effective method of taking a “snapshot” of the population represented in the data. A limitation of analyzing databases is that data may be incomplete or not generalizable to a larger population group. In the present study, database-specific weights were applied to extrapolate the data to represent the total national pediatric population (2,3). Historically, these 2 databases have a strong track record of being able to provide general epidemiological estimates of disease burden and have deduced national incidence of other diseases (4,5). Given that the methodology and data sources which Brown et al use to report pediatric PUB incidence are likely sound, attempting to apply this clinical information in pediatric gastroenterology is another issue.
This question should be evaluated with 3 closely related but separate considerations in mind: public health, health policy, and health disparities. From the public health perspective, diseases with high rates of morbidity and mortality take precedence (6). PUB is a clinical emergency in gastroenterology, and therefore deserves careful thought about the health effects of the patients; however, public health initiatives (eg, universal screening, preventive therapy) need to be weighed against the potential effect on the population as a whole. Typically, it is more difficult to advocate for a public health intervention when general population risk is extremely low; however, there is no epidemiologically worthy threshold for an incidence number when considering a public health intervention.
From a health policy standpoint, evidence-based medicine needs to drive policy making. Specifically, more data are required to understand the health outcomes and economics because they relate to the incidence of pediatric PUB in the United States. A future cross-sectional cohort investigation (7) or a prospective case-control study may be 2 useful study designs providing missing information for clinicians and policy makers on the specific parameters of pediatric PUB. Also, for example, there must be some follow-up thought about how the incidence of pediatric PUB may be influenced by different screening and treatment policies aimed at community-acquired Helicobacter pylori, as Brown et al allude to in the discussion section.
When considering the issue of health disparities, the study population is stratified to subgroups to assess between- and within-group differences. If health disparities are found (eg, much higher risk or life-threatening upper gastrointestinal bleeding in intensive care unit patients with complex chronic disease), then public health and policy interventions can be tailored to reduce the negative health effect on a targeted, at-risk group. This may be a feasible future investigation using the same databases used in the analysis by Brown et al.
In summary, Brown and Colleagues have taken an important first step in enlightening pediatric gastroenterologists and other care providers about how to think about PUB in children. Their study serves as a launching point to pursue more detailed understanding of the disease and lays the groundwork for more clinical applicability.
The author thanks Philip Lavori, PhD, and Kristen Sainani, PhD, in the Department of Health Research and Policy at Stanford University, for helpful discussions in disease epidemiology and biostatistics.
1. Brown K, Lundborg P, Levinson J, et al. Incidence of peptic ulcer bleeding in the US pediatric population. J Pediatr Gastroenterol Nutr
2. Watanabe KK. Projection methodology: national projections from Premier Perspective's hospital inpatient data (1999). Final report. Charlotte, NC: Premier Inc; 2001.
4. Turpin RS, Canada T, Rosenthal V, et al. Bloodstream infections associated with parenteral nutrition preparation methods in the United States: a retrospective, large database analysis. JPEN J Parenter Enteral Nutr
5. Cortes JE, Curns AT, Tate JE, et al. Rotavirus vaccine and health care utilization for diarrhea in U.S. children. N Engl J Med
7. Hudson JI, Pope HG Jr, Glynn RJ. The cross-sectional cohort study: an underutilized design. Epidemiology