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Background: Among patients with nonvalvular atrial fibrillation (NVAF) who have sustained an upper gastrointestinal bleed (UGIB), the benefits and harms of oral anticoagulation change over time. Early resumption of anticoagulation increases recurrent bleeding, while delayed resumption exposes patients to a higher risk of ischemic stroke. We therefore set out to estimate the expected benefit of resuming anticoagulation as a function of time after UGIB among patients with NVAF., Methods: We created a decision-analytic model estimating discounted quality-adjusted life-years when patients with NVAF resume anticoagulation on each day following UGIB. We simulated from a health system perspective over a lifelong time horizon., Results: Peak utility for warfarin was achieved by resumption 41 days after hemostasis from the index UGIB. Resumption between days 32 and 51 produced greater than 99.9% of the peak utility. Peak utility for apixaban was achieved by resumption 32 days after the index UGIB. Resumption between days 21 and 47 produced greater than 99.9% of the peak utility. Of input parameters, results were most sensitive to underlying stroke risk. Specifically, across the range of CHA 2 DS 2 -Vasc scores, the optimal day of resumption varied by around 11 days for patients resuming warfarin and by around 15 days for patients resuming apixaban. Results were less sensitive to underlying risk of rebleeding., Conclusions: For patients with NVAF following UGIB, warfarin is optimally restarted approximately six weeks following hemostasis, and apixaban is optimally restarted approximately one month following hemostasis. Modest changes to this timing based on probability of thromboembolic stroke are reasonable.

Introduction: Inadequate bowel preparation (IBP) is a common problem in hospitalized patients; however, little is known about how to prevent IBP. In a large, multihospital system, we evaluated the association between modifiable factors and IBP rate., Methods: We reviewed data from adult (≥18 years) inpatients undergoing colonoscopy between January 2011 and June 2017. Colonoscopies performed in the intensive care unit or lacking descriptions of bowel preparation quality were excluded. Multivariate logistic regression analysis was performed to identify factors associated with IBP. A counterfactual analysis was performed to assess the potential contribution of modifiable factors to IBP., Results: Of 8,819 patients that were included (median age of 64 years; 50.5% female), 51% had IBP. Patients with IBP stayed in the hospital one day longer than those with adequate bowel preparation (P < .001). Modifiable factors associated with IBP include opiate use within three days of colonoscopy (OR, 1.31; 95% CI, 1.18, 1.45), colonoscopy performed after 12:00 pm (OR, 1.25; 95% CI, 1.1, 1.41), and solid diet the day before colonoscopy (OR, 1.37; 95% CI, 1.18, 1.59). In the counterfactual analysis, if all patients avoided these three conditions, adjusted IBP rates were reduced by 5.6%., Conclusions: Among hospitalized patients undergoing colonoscopy, IBP rates are high and associated with an increased length of stay. Avoiding opiates before colonoscopy, performing colonoscopy before noon, and maintaining patients on a liquid diet or nil per os might significantly reduce IBP rates.