Strategies That Reduce 90-Day Readmissions and Inpatient Costs After Liver Transplantation

Evaluation of Factors Affecting Rehospitalization and Survival After Living Donor Liver Transplantation

BACKGROUND

Complications and comorbidities that may develop after living donor liver transplantation may necessitate rehospitalization after discharge. We aimed to investigate the demographic and clinical factors affecting rehospitalization after discharge.

METHODS

Two hundred seventy patients who underwent living-donor liver transplantation (LDLT) for end-stage liver cirrhosis were included in the study. Patients were divided into two groups as readmission group and others for statistical analysis. Age, gender, body mass index (BMI), model for end-stage liver disease (MELD), Child scores, etiology, blood product transfusion, anhepatic phase, cold ischemia time, operation time, graft-to-recipient weight ratio (GRWR), the type of recipient hepatic artery and hepatic vein utilized in the anastomoses, presence of liver segment 5, segment 8 and inferior accessory hepatic vein, presence of thrombosed, single or reconstructed portal vein, number of bile ducts, use of right, left/left lateral segment graft, postoperative intensive care unit and total hospitalization durations, surgical complications such as leakage/stricture, postoperative portal vein thrombosis, postoperative hepatic vein thrombosis, primary graft dysfunction, intra-abdominal hemorrhage, and postoperative early reoperation were statistically analyzed for readmission. In addition, patients with rehospitalization and others were statistically compared in terms of mortality and survival.

RESULTS

There was no statistical difference among etiologic factors, demographic findings, decompensation findings, comorbidities, perioperative findings, hospital durations, mortality, and survival (P > .05). Only patients with bile leakage/stricture had a statistically higher rehospitalization rate (P = .000).

CONCLUSION

Biliary complications are the most frequent cause of hospital rehospitalization following living donor liver transplantation.

Comprehensive quality initiative leads to immediate postoperative extubation following liver transplant

BACKGROUND

Immediate postoperative extubation (IPE) can reduce perioperative complications and length of stay (LOS), however it is performed variably after liver transplant across institutions and has historically excluded high-risk recipients from consideration. In late 2012, we planned and implemented a single academic institution structured quality improvement (QI) initiative to standardize perioperative care of liver transplant recipients without exceptions. We hypothesized that such an approach would lead to a sustained increase in IPE after primary (PAC) and delayed abdominal closure (DAC).

METHODS

We retrospectively studied 591 patients from 2013 to 2018 who underwent liver transplant after initiative implementation. We evaluated trends in incidence of IPE versus delayed extubation (DE), and reintubation, LOS, and mortality.

RESULTS

Overall, 476/591 (80.5%) recipients underwent PAC (278 IPE, 198 DE) and 115/591 (19.5%) experienced DAC (39 IPE, 76 DE). When comparing data from 2013 to data from 2018, the incidence of IPE increased from 9/67 (13.4%) to 78/90 (86.7%) after PAC and from 1/12 (8.3%) to 16/23 (69.6%) after DAC. For the same years, the incidence of IPE after PAC for recipients with MELD scores ≥30 increased from 0/19 (0%) to 12/17 (70.6%), for recipients who underwent simultaneous liver-kidney transplant increased from 1/8 (12.5%) to 4/5 (80.0%), and for recipients who received massive transfusion (>10 units of packed red blood cells) increased from 0/17 (0%) to 10/13 (76.9%). Reintubation for respiratory considerations <48 h after IPE occurred in 3/278 (1.1%) after PAC and 1/39 (2.6%) after DAC. IPE was associated with decreased intensive care unit (HR of discharge: 1.92; 95% CI: 1.58, 2.33; P < 0.001) and hospital LOS (HR of discharge: 1.45; 95% CI: 1.20, 1.76; P < 0.001) but demonstrated no association with mortality.

CONCLUSION

A structured QI initiative led to sustained high rates of IPE and reduced LOS in all liver transplant recipients, including those classified as high risk.

Definition and Prospective Assessment of Functional Recovery After Liver Transplantation: A New Objective Consensus-Based Metric for Safe Discharge

Standardized discharge criteria are critical to reduce premature discharge and avoid unnecessary hospital stays. No such criteria exist for patients undergoing liver transplantation (LT). To achieve a consensus-based checklist of criteria for safe patient discharge after LT, this mixed-method study included the following: a systematic literature review and expert discussion to draft a first checklist of post-LT discharge criteria, defining patient recovery and indications for hospital discharge (functional recovery); an exploratory online electronic Delphi (e-Delphi) study; a single-center pilot study to test checklist feasibility; and a final e-Delphi study with an extended interdisciplinary expert panel to validate the final checklist. The first round provided a 10-point discharge checklist with 5 patient-centered items derived from discharge criteria after liver surgery and 5 graft-centered items derived from expert discussion. The restricted panel (9 experts) e-Delphi provided 100% consensus after the second round, with slight modifications to the criteria. During the pilot study, 19 of 45 (42.2%) patients included fulfilled the complete checklist (100% of 10 items) after median (IQR) 16 (8-21) days (functional recovery) and a length of stay of 20 (9-24) days. The item with the lowest completion rate was minimum serum tacrolimus level in the target on 2 consecutive blood samples (n = 21; 47%), achieved at 13 (9-15) days. The extended panel (66 experts) e-Delphi provided 95%-98% consensus after the third round, with slight modifications of the criteria. This study provided substantial consensus on discharge criteria after LT. We anticipate that these criteria will be useful in clinical practice to guide patient discharge and increase the comparability of results between future studies.

Validation of the american quality assessment model and performance improvement to the brazilian transplant

Objective:

To validate the quality assessment and performance improvement instrument of US transplant programs to the Brazilian reality.

Method:

Methodological study developed for semantic validation and cultural adaptation of the Quality assessment and Performance Improvement instrument in the following steps: 1) translation; 2) synthesis; 3) back translation; 4) review by expert committee; 5) pretest and 6) content validation. To evaluate the agreement between the five judges, the Kappa coefficient was used and for content validation, the content validation index.

Results:

Kappa coefficient showed the agreement of the judges for semantic, idiomatic, cultural and conceptual equivalences. Content validation index values for relevance and item sequence of at least 0.80 for all blocks.

Conclusion:

The instrument of Quality Evaluation and Performance Improvement of Transplantation Programs proved to be valid and reliable. This instrument will contribute to the development of quality assurance programs for transplant teams in Brazil.