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Swain LA, Godley J, Brahmania M, Abraldes JG, Tang KL, Flemming J, Shaheen AA. Validating new coding algorithms to improve identification of alcohol-associated and nonalcohol-associated cirrhosis hospitalizations in administrative databases. Hepatol Commun 2024; 8:e0469. [PMID: 38896072 PMCID: PMC11186834 DOI: 10.1097/hc9.0000000000000469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/23/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Alcohol (AC) and nonalcohol-associated cirrhosis (NAC) epidemiology studies are limited by available case definitions. We compared the diagnostic accuracy of previous and newly developed case definitions to identify AC and NAC hospitalizations. METHODS We randomly selected 700 hospitalizations from the 2008 to 2022 Canadian Discharge Abstract Database with alcohol-associated and cirrhosis-related International Classification of Diseases 10th revision codes. We compared standard approaches for AC (ie, AC code alone and alcohol use disorder and nonspecific cirrhosis codes together) and NAC (ie, NAC codes alone) case identification to newly developed approaches that combine standard approaches with new code combinations. Using electronic medical record review as the reference standard, we calculated case definition positive and negative predictive values, sensitivity, specificity, and AUROC. RESULTS Electronic medical records were available for 671 admissions; 252 had confirmed AC and 195 NAC. Compared to previous AC definitions, the newly developed algorithm selecting for the AC code, alcohol-associated hepatic failure code, or alcohol use disorder code with a decompensated cirrhosis-related condition or NAC code provided the best overall positive predictive value (91%, 95% CI: 87-95), negative predictive value (89%, CI: 86-92), sensitivity (81%, CI: 76-86), specificity (96%, CI: 93-97), and AUROC (0.88, CI: 0.85-0.91). Comparing all evaluated NAC definitions, high sensitivity (92%, CI: 87-95), specificity (82%, CI: 79-86), negative predictive value (96%, CI: 94-98), AUROC (0.87, CI: 0.84-0.90), but relatively low positive predictive value (68%, CI: 62-74) were obtained by excluding alcohol use disorder codes and using either a NAC code in any diagnostic position or a primary diagnostic code for HCC, unspecified/chronic hepatic failure, esophageal varices without bleeding, or hepatorenal syndrome. CONCLUSIONS New case definitions show enhanced accuracy for identifying hospitalizations for AC and NAC compared to previously used approaches.
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Affiliation(s)
- Liam A. Swain
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jenny Godley
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Sociology, University of Calgary, Calgary, Alberta, Canada
| | - Mayur Brahmania
- Department of Medicine, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Juan G. Abraldes
- Liver Unit, Department of Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Karen L. Tang
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jennifer Flemming
- Department of Medicine and Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Abdel Aziz Shaheen
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Rubin JB, Loeb R, Fenton C, Huang CY, Keyhani S, Seal KH, Lai JC. The burden of significant pain in the cirrhosis population: Risk factors, analgesic use, and impact on health care utilization and clinical outcomes. Hepatol Commun 2024; 8:e0432. [PMID: 38780295 PMCID: PMC11124725 DOI: 10.1097/hc9.0000000000000432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 02/20/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND We aimed to characterize pain and analgesic use in a large contemporary cohort of patients with cirrhosis and to associate pain with unplanned health care utilization and clinical outcomes in this population. METHODS We included all patients with cirrhosis seen in UCSF hepatology clinics from 2013 to 2020. Pain severity and location were determined using documented pain scores at the initial visit; "significant pain" was defined as moderate or severe using established cutoffs. Demographic, clinical, and medication data were abstracted from electronic medical records. Associations between significant pain and our primary outcome of 1-year unplanned health care utilization (ie, emergency department visit or hospitalization) and our secondary outcomes of mortality and liver transplantation were explored in multivariable models. RESULTS Among 5333 patients with cirrhosis, 32% had a nonzero pain score at their initial visit and 25% had significant (ie moderate/severe) pain. Sixty percent of patients with significant pain used ≥1 analgesic; 34% used opioids. Patients with cirrhosis with significant pain had similar Model for End-Stage Liver Disease-Sodium scores (14 vs. 13), but higher rates of decompensation (65% vs. 55%). The most common pain location was the abdomen (44%). Patients with abdominal pain, compared to pain in other locations, were more likely to have decompensation (72% vs. 56%). Significant pain was independently associated with unplanned health care utilization (adjusted odds ratio: 1.3, 95% CI: 1.1-1.5) and mortality (adjusted hazard ratio: 1.4, 95% CI: 1.2-1.6). CONCLUSIONS Pain among patients with cirrhosis is often not well-controlled despite analgesic use, and significant pain is associated with unplanned health care utilization and mortality in this population. Effectively identifying and treating pain are essential in reducing costs and improving quality of life and outcomes among patients with cirrhosis.
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Affiliation(s)
- Jessica B. Rubin
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Department of Medicine, San Francisco VA Health Care System, San Francisco, California, USA
| | - Rebecca Loeb
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Cynthia Fenton
- Division of Hospital Medicine, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Chiung-Yu Huang
- Department of Surgery, University of California-San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Salomeh Keyhani
- Department of Medicine, San Francisco VA Health Care System, San Francisco, California, USA
- Division of General Internal Medicine, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Karen H. Seal
- Department of Medicine, San Francisco VA Health Care System, San Francisco, California, USA
- Division of General Internal Medicine, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
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Hasjim BJ, Huang AA, Paukner M, Polineni P, Harris A, Mohammadi M, Kershaw KN, Banea T, VanWagner LB, Zhao L, Mehrotra S, Ladner DP. Where you live matters: Area deprivation predicts poor survival and liver transplant waitlisting. Am J Transplant 2024; 24:803-817. [PMID: 38346498 PMCID: PMC11070293 DOI: 10.1016/j.ajt.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/25/2024] [Accepted: 02/08/2024] [Indexed: 03/03/2024]
Abstract
Social determinants of health (SDOH) are important predictors of poor clinical outcomes in chronic diseases, but their associations among the general cirrhosis population and liver transplantation (LT) are limited. We conducted a retrospective, multiinstitutional analysis of adult (≥18-years-old) patients with cirrhosis in metropolitan Chicago to determine the associations of poor neighborhood-level SDOH on decompensation complications, mortality, and LT waitlisting. Area deprivation index and covariates extracted from the American Census Survey were aspects of SDOH that were investigated. Among 15 101 patients with cirrhosis, the mean age was 57.2 years; 6414 (42.5%) were women, 6589 (43.6%) were non-Hispanic White, 3652 (24.2%) were non-Hispanic Black, and 2662 (17.6%) were Hispanic. Each quintile increase in area deprivation was associated with poor outcomes in decompensation (sHR [subdistribution hazard ratio] 1.07; 95% CI 1.05-1.10; P < .001), waitlisting (sHR 0.72; 95% CI 0.67-0.76; P < .001), and all-cause mortality (sHR 1.09; 95% CI 1.06-1.12; P < .001). Domains of SDOH associated with a lower likelihood of waitlisting and survival included low income, low education, poor household conditions, and social support (P < .001). Overall, patients with cirrhosis residing in poor neighborhood-level SDOH had higher decompensation, and mortality, and were less likely to be waitlisted for LT. Further exploration of structural barriers toward LT or optimizing health outcomes is warranted.
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Affiliation(s)
- Bima J Hasjim
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA
| | - Alexander A Huang
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA
| | - Mitchell Paukner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA; Division of Biostatistics, Department of Preventive Medicine, Northwestern University, Chicago, Illinois, USA
| | - Praneet Polineni
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA
| | - Alexandra Harris
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA; Institute for Public Health and Medicine (IPHAM), Northwestern University, Chicago, Illinois, USA
| | - Mohsen Mohammadi
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA; Department of Industrial Engineering and Management Sciences, McCormick School of Engineering, Northwestern University, Evanston, Illinois, USA
| | - Kiarri N Kershaw
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA; Division of Epidemiology, Department of Preventive Medicine, Northwestern University, Chicago, Illinois, USA
| | - Therese Banea
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA
| | - Lisa B VanWagner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA; Division of Digestive and Liver Diseases, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lihui Zhao
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA; Division of Biostatistics, Department of Preventive Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sanjay Mehrotra
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA; Department of Industrial Engineering and Management Sciences, McCormick School of Engineering, Northwestern University, Evanston, Illinois, USA
| | - Daniela P Ladner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, Illinois, USA; Division of Organ Transplantation, Department of Surgery, Northwestern University, Chicago, Illinois, USA.
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Elsaid MI, Li N, Firkins SA, Rustgi VK, Paskett ED, Acharya C, Reddy KR, Chiang CW, Mumtaz K. Impacts of glucagon-like peptide-1 receptor agonists on the risk of adverse liver outcomes in patients with metabolic dysfunction-associated steatotic liver disease cirrhosis and type 2 diabetes. Aliment Pharmacol Ther 2024; 59:1096-1110. [PMID: 38538967 DOI: 10.1111/apt.17925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/05/2024] [Accepted: 02/15/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND/AIMS We examined the effects of glucagon-like peptide-1 receptor agonists (GLP-1RAs) initiation on long-term Adverse Liver Outcomes (ALO) in patients with Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) cirrhosis and type 2 diabetes using real-world data from the MarketScan database. METHODS We conducted a retrospective cohort study of patients with MASLD cirrhosis and type 2 diabetes between 2012 and 2020. Cox proportional hazard models examine the association between GLP-1RAs initiation, modelled as time-dependent, and the risk of ALO, a composite endpoint defined by the first occurrence of hepatic decompensation(s), portal hypertension, hepatocellular carcinoma (HCC) or liver transplantation (LT). We used Overlap Propensity Score Weighting (OPSW) to account for confounding. The study included 459 GLP-1RAs and 4837 non-GLP-1RAs patients. RESULTS The non-GLP-1RAs patients presented with 1411 (29%) ALO over 7431.7 person years, while GLP-1RAs patients had 32 (7%) ALO over 586.6 person years - risk rate difference 13.5 (95% CI: 11.4-15.7) per 100 person-years. The OPSW-adjusted risk of ALO was reduced by 36% (hazard ratio [HR]: 0.64; 95% CI: 0.54-0.76) in patients with vs. without GLP-1RAs initiation. GLP-1RAs initiation was associated with significant reductions in the adjusted risk of hepatic decompensation (HR: 0.74; 95% CI: 0.61-0.88), portal hypertension (HR: 0.73; 95% CI: 0.60-0.88), HCC (HR: 0.37; 95% CI: 0.20-0.63) and LT (HR: 0.24; 95% CI: 0.12-0.43). CONCLUSION The use of GLP-1RAs was associated with significant risk reductions in long-term adverse liver outcomes, including hepatic decompensation, portal hypertension, HCC and LT, in MASLD cirrhosis patients with type 2 diabetes.
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Affiliation(s)
- Mohamed I Elsaid
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
- Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
- Department of Internal Medicine, Division of Medical Oncology, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Na Li
- Department of Internal Medicine, Division of Gastroenterology, Hepatology & Nutrition, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Stephen A Firkins
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Vinod K Rustgi
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Center for Liver Diseases and Masses, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Electra D Paskett
- Division of Population Sciences, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
- Department of Internal Medicine, Division of Cancer Prevention and Control, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Chathur Acharya
- Department of Internal Medicine, Division of Gastroenterology, Hepatology & Nutrition, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - K Rajender Reddy
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Chien Wei Chiang
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Khalid Mumtaz
- Department of Internal Medicine, Division of Gastroenterology, Hepatology & Nutrition, College of Medicine, The Ohio State University, Columbus, Ohio, USA
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Horbal SR, Belancourt PX, Zhang P, Holcombe SA, Saini S, Wang SC, Sales AE, Su GL. Independent Associations of Aortic Calcification with Cirrhosis and Liver Related Mortality in Veterans with Chronic Liver Disease. Dig Dis Sci 2024:10.1007/s10620-024-08450-5. [PMID: 38653948 DOI: 10.1007/s10620-024-08450-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 04/12/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Abdominal aortic calcifications (AAC) are incidentally found on medical imaging and useful cardiovascular burden approximations. The Morphomic Aortic Calcification Score (MAC) leverages automated deep learning methods to quantify and score AACs. While associations of AAC and non-alcoholic fatty liver disease (NAFLD) have been described, relationships of AAC with other liver diseases and clinical outcome are sparse. This study's purpose was to evaluate AAC and liver-related death in a cohort of Veterans with chronic liver disease (CLD). METHODS We utilized the VISN 10 CLD cohort, a regional cohort of Veterans with the three forms of CLD: NAFLD, hepatitis C (HCV), alcohol-associated (ETOH), seen between 2008 and 2014, with abdominal CT scans (n = 3604). Associations between MAC and cirrhosis development, liver decompensation, liver-related death, and overall death were evaluated with Cox proportional hazard models. RESULTS The full cohort demonstrated strong associations of MAC and cirrhosis after adjustment: HR 2.13 (95% CI 1.63, 2.78), decompensation HR 2.19 (95% CI 1.60, 3.02), liver-related death HR 2.13 (95% CI 1.46, 3.11), and overall death HR 1.47 (95% CI 1.27, 1.71). These associations seemed to be driven by the non-NAFLD groups for decompensation and liver-related death [HR 2.80 (95% CI 1.52, 5.17; HR 2.34 (95% CI 1.14, 4.83), respectively]. DISCUSSION MAC was strongly and independently associated with cirrhosis, liver decompensation, liver-related death, and overall death. Surprisingly, stratification results demonstrated comparable or stronger associations among those with non-NAFLD etiology. These findings suggest abdominal aortic calcification may predict liver disease severity and clinical outcomes in patients with CLD.
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Affiliation(s)
- Steven R Horbal
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
- Morphomics Analysis Group, University of Michigan, Ann Arbor, MI, USA.
| | | | - Peng Zhang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Morphomics Analysis Group, University of Michigan, Ann Arbor, MI, USA
| | - Sven A Holcombe
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Morphomics Analysis Group, University of Michigan, Ann Arbor, MI, USA
| | - Sameer Saini
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Stewart C Wang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Anne E Sales
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, Colombia, MO, USA
| | - Grace L Su
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
- Gastroenterology Section, Ann Arbor VA Healthcare System, Ann Arbor, MI, USA
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Ladner DP, Gmeiner M, Hasjim BJ, Mazumder N, Kang R, Parker E, Stephen J, Polineni P, Chorniy A, Zhao L, VanWagner LB, Ackermann RT, Manski CF. Increasing prevalence of cirrhosis among insured adults in the United States, 2012-2018. PLoS One 2024; 19:e0298887. [PMID: 38408083 PMCID: PMC10896513 DOI: 10.1371/journal.pone.0298887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/31/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Liver cirrhosis is a chronic disease that is known as a "silent killer" and its true prevalence is difficult to describe. It is imperative to accurately characterize the prevalence of cirrhosis because of its increasing healthcare burden. METHODS In this retrospective cohort study, trends in cirrhosis prevalence were evaluated using administrative data from one of the largest national health insurance providers in the US. (2011-2018). Enrolled adult (≥18-years-old) patients with cirrhosis defined by ICD-9 and ICD-10 were included in the study. The primary outcome measured in the study was the prevalence of cirrhosis 2011-2018. RESULTS Among the 371,482 patients with cirrhosis, the mean age was 62.2 (±13.7) years; 53.3% had commercial insurance and 46.4% had Medicare Advantage. The most frequent cirrhosis etiologies were alcohol-related (26.0%), NASH (20.9%) and HCV (20.0%). Mean time of follow-up was 725 (±732.3) days. The observed cirrhosis prevalence was 0.71% in 2018, a 2-fold increase from 2012 (0.34%). The highest prevalence observed was among patients with Medicare Advantage insurance (1.67%) in 2018. Prevalence increased in each US. state, with Southern states having the most rapid rise (2.3-fold). The most significant increases were observed in patients with NASH (3.9-fold) and alcohol-related (2-fold) cirrhosis. CONCLUSION Between 2012-2018, the prevalence of liver cirrhosis doubled among insured patients. Alcohol-related and NASH cirrhosis were the most significant contributors to this increase. Patients living in the South, and those insured by Medicare Advantage also have disproportionately higher prevalence of cirrhosis. Public health interventions are important to mitigate this concerning trajectory of strain to the health system.
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Affiliation(s)
- Daniela P. Ladner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
- Department of Surgery, Division of Organ Transplantation, Northwestern University, Chicago, IL, United States of America
| | - Michael Gmeiner
- Department of Economics, London School of Economics, London, United Kingdom
| | - Bima J. Hasjim
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
| | - Nikhilesh Mazumder
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
- Department of Medicine, Division of Hepatology, University of Michigan, Ann Arbor, MI, United States of America
| | - Raymond Kang
- Institute for Public Health and Medicine (IPHAM), Northwestern University, Chicago, IL, United States of America
| | | | - John Stephen
- Department of Preventive Medicine, Northwestern University, Chicago, IL, United States of America
| | - Praneet Polineni
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
| | - Anna Chorniy
- Department of Medical Social Sciences and Buehler Center for Health Policy and Economics, Northwestern University, Chicago, IL, United States of America
| | - Lihui Zhao
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
- Department of Preventive Medicine, Northwestern University, Chicago, IL, United States of America
| | - Lisa B. VanWagner
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
- Department of Medicine, Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Ronald T. Ackermann
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
- Institute for Public Health and Medicine (IPHAM), Northwestern University, Chicago, IL, United States of America
| | - Charles F. Manski
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Northwestern University, Chicago, IL, United States of America
- Department of Economics and Institute for Policy Research, Northwestern University, Evanston, IL, United States of America
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Faisal N, Lix LM, Walld R, Singer A, Renner E, Singh H, Kosowan L, Mahar A. Identifying patients with diagnosed cirrhosis in administrative health databases: a validation study. CANADIAN LIVER JOURNAL 2024; 7:16-27. [PMID: 38505786 PMCID: PMC10946181 DOI: 10.3138/canlivj-2023-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 06/30/2023] [Indexed: 03/21/2024]
Abstract
Objectives Case ascertainment algorithms were developed and validated to identify people living with cirrhosis in administrative health data in Manitoba, Canada using primary care electronic medical records (EMR) to define the reference standards. Methods We linked provincial administrative health data to primary care EMR data. The validation cohort included 116,675 Manitobans aged >18 years with at least one primary care visit between April 1998 and March 2015. Hospital records, physician billing claims, vital statistics, and prescription drug data were used to develop and test 93 case-finding algorithms. A validated case definition for primary care EMR data was the reference standard. We estimated sensitivity, specificity, positive and negative predictive values (PPV, NPV), Youden's index, area under the receiver operative curve, and their 95% confidence intervals (CIs). Results A total of 116,675 people were in the validation cohort. The prevalence of cirrhosis was 1.4% (n = 1593). Algorithm sensitivity estimates ranged from 32.5% (95% CI 32.2-32.8) to 68.3% (95% CI 68.0-68.9) and PPV from 17.4% (95% CI 17.1-17.6) to 23.4% (95% CI 23.1-23.6). Specificity (95.5-98.2) and NPV (approximately 99%) were high for all algorithms. The algorithms had slightly higher sensitivity estimates among men compared with women, and individuals aged ≥45 years compared to those aged 18-44 years. Conclusion Cirrhosis algorithms applied to administrative health data had moderate validity when a validated case definition for primary care EMRs was the reference standard. This study provides algorithms for identifying diagnosed cirrhosis cases for population-based research and surveillance studies.
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Affiliation(s)
- Nabiha Faisal
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Manitoba Centre of Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Manitoba Centre of Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Randy Walld
- Manitoba Centre of Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alexander Singer
- Department of Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eberhard Renner
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Harminder Singh
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Leanne Kosowan
- Department of Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alyson Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Manitoba Centre of Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
- School of Nursing, Queen's University, Kingston, Ontario, Canada
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Agbalajobi O, Ebhohon E, Amuchi CB, Nzugang EC, Soladoye EO, Babajide O, Adejumo AC. National frequency, trends, and healthcare burden of care fragmentation in readmissions for end-stage liver disease in the USA. Minerva Gastroenterol (Torino) 2023; 69:470-478. [PMID: 38197846 DOI: 10.23736/s2724-5985.22.03232-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND End-stage liver disease (ESLD) patients have frequent readmissions to the same facility or a different hospital (care fragmentation). Care fragmentation results in care delivery from an unfamiliar clinical team or setting, a potential source of suboptimal clinical outcomes. We examined the occurrence, trends, and association between care fragmentation and outcomes during readmissions for ESLD. METHODS From the Nationwide Readmissions Database (January to September 2010-2014), we followed adult (age ≥18 years) hospitalizations for ESLD who were discharged alive for 90 days. During 30- and 90-day readmissions, we calculated the frequency, determinants, and clinical outcomes of care fragmentation (SAS 9.4). RESULTS Of the 67,480 ESLD hospitalizations surviving at discharge from 2010-2014, 35% (23,872) and 52% (35,549) were readmitted in 30- and 90-days respectively. During readmissions, the frequencies of care fragmentation were similar (30-day: 25.4% and 90-day: 25.8%) and remained stable from 2010 to 2014 (P trends>0.5). Similarly, factors associated with care fragmentation were consistent across 30- and 90-day readmissions. These included ages: 18-44 years, liver cancer, receipt of liver transplantation, hepatorenal syndrome, prolonged length of stay, and hospitalization in non-teaching facilities. During 30- and 90-day readmissions, care fragmentation was associated with higher risk of mortality (adjusted mean ratio: 1.13[1.03-1.24] and 1.14 [1.06-1.23]; P values<0.0001), prolonged length of stay (4.6-days vs. 4.1-days and 5.2-days vs. 4.6-days; P values<0.0001), and higher hospital charges ($36,884 vs. $28,932 and $37,354 vs. $30,851; P values<0.0001). CONCLUSIONS Care fragmentation is high among readmissions for ESLD and is associated with poorer outcomes.
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Affiliation(s)
| | - Ebehiwele Ebhohon
- Department of Internal Medicine, Lincoln Medical Center, New York, NY, USA
| | - Chineye B Amuchi
- School of Public Health, Boston University School of Public Health, Boston, MA, USA
| | - Edwige C Nzugang
- Department of Internal Medicine, Beth Israel Lahey Health, Burlington, VT, USA
| | | | - Oyedotun Babajide
- Department of Internal Medicine, Interfaith Medical Center, New York, NY, USA
| | - Adeyinka C Adejumo
- Department of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA -
- Individualized Genomics and Health Program, Johns Hopkins University, Baltimore, MD, USA
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Faisal N, Kosowan L, Zafari H, Zulkernine F, Lix L, Mahar A, Singh H, Renner E, Singer A. Development and validation of a case definition to estimate the prevalence and incidence of cirrhosis in pan-Canadian primary care databases. CANADIAN LIVER JOURNAL 2023; 6:375-387. [PMID: 38152327 PMCID: PMC10751004 DOI: 10.3138/canlivj-2023-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/19/2023] [Indexed: 12/29/2023]
Abstract
Aims To develop and validate case definitions to identify patients with cirrhosis and alcohol-related cirrhosis using primary care electronic medical records (EMRs) and to estimate cirrhosis prevalence and incidence in pan-Canadian primary care databases, between 2011 and 2019. Methods A total of 689,301 adult patients were included with ≥1 visit to a primary care provider within the Canadian Primary Care Sentinel Study Network between January 1, 2017, and December 31, 2018. A subsample of 17,440 patients was used to validate the case definitions. Sensitivity, specificity, predictive values were calculated with their 95% CIs and then determined the population-level prevalence and incidence trends with the most accurate case definition. Results The most accurate case definition included: ≥1 health condition, billing, or encounter diagnosis for International Classification of Diseases, Ninth Revision codes 571.2, 571.5, 789.59, or 571. Sensitivity (84.6; 95% CI 83.1%-86.%), specificity (99.3; 95% CI 99.1%-99.4%), positive predictive values (94.8; 95% CI 93.9%-95.7%), and negative predictive values (97.5; 95% CI 97.3%-97.7%). Application of this definition to the overall population resulted in a crude prevalence estimate of (0.46%; 95% CI 0.45%-0.48%). Annual incidence of patients with a clinical diagnosis of cirrhosis nearly doubled between 2011 (0.05%; 95% CI 0.04%-0.06%) and 2019 to (0.09%; 95% CI 0.08%-0.09%). Conclusions The EMR-based case definition accurately captured patients diagnosed with cirrhosis in primary care. Future work to characterize patients with cirrhosis and their primary care experiences can support improvements in identification and management in primary care settings.
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Affiliation(s)
- Nabiha Faisal
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Leanne Kosowan
- Department of Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Hasan Zafari
- School of Computing, Queen’s University, Kingston, Ontario, Canada
| | | | - Lisa Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alyson Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- School of Nursing, Queen’s University, Kingston, Ontario, Canada
| | - Harminder Singh
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eberhard Renner
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alexander Singer
- Department of Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Chuzi S, Tanaka Y, Bavishi A, Bruce M, Van Wagner LB, Wilcox JE, Ahmad FS, Ladner DP, Lagu T, Khan SS. Association Between End-Stage Liver Disease and Incident Heart Failure in an Integrated Health System. J Gen Intern Med 2023; 38:2445-2452. [PMID: 37095330 PMCID: PMC10465455 DOI: 10.1007/s11606-023-08199-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 04/05/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND End-stage liver disease (ESLD) and heart failure (HF) often coexist and are associated with significant morbidity and mortality. However, the true incidence of HF among patients with ESLD remains understudied. OBJECTIVE This study aims to evaluate the association between ESLD and incident HF in a real-world clinical cohort. DESIGN AND PARTICIPANTS A retrospective electronic health records database analysis of individuals with ESLD and frequency-matched controls without ESLD in a large integrated health system. MAIN MEASURES The primary outcome was incident HF, which was defined by the International Classification of Disease codes and manually adjudicated by physician reviewers. The Kaplan-Meier method was used to estimate the cumulative incidence of HF. Multivariate proportional hazards models adjusted for shared metabolic factors (diabetes, hypertension, chronic kidney disease, coronary heart disease, body mass index) were used to compare the risk of HF in patients with and without ESLD. KEY RESULTS Of 5004 patients (2502 with ESLD and 2502 without ESLD), the median (Q1-Q3) age was 57.0 (55.0-65.0) years, 59% were male, and 18% had diabetes. Over a median (Q1-Q3) follow-up of 2.3 (0.6-6.0) years, 121 incident HF cases occurred. Risk for incident HF was significantly higher for patients with ESLD compared with the non-ESLD group (adjusted HR: 4.67; 95% CI: 2.82-7.75; p < 0.001), with the majority of the ESLD group (70.7%) having HF with preserved ejection fraction (ejection fraction ≥ 50%). CONCLUSION ESLD was significantly associated with a higher risk of incident HF, independent of shared metabolic risk factors, with the predominant phenotype being HF with preserved ejection fraction.
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Affiliation(s)
- Sarah Chuzi
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Yoshihiro Tanaka
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center for Arrhythmia Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Avni Bavishi
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Matthew Bruce
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lisa B Van Wagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, TX, USA
| | - Jane E Wilcox
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Faraz S Ahmad
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Daniela P Ladner
- Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Chicago, IL, USA
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Tara Lagu
- Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sadiya S Khan
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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11
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Simon TG, Wexler DJ, Schneeweiss S, Patorno E. Antidiabetes medication initiation trends in US adults with cirrhosis and type 2 diabetes: A nationwide study. Diabetes Obes Metab 2023; 25:2028-2033. [PMID: 36938914 PMCID: PMC10239316 DOI: 10.1111/dom.15052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/22/2023] [Accepted: 02/26/2023] [Indexed: 03/21/2023]
Affiliation(s)
- Tracey G. Simon
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, MA, USA
- Clinical and Translational Epidemiology Unit (CTEU), Massachusetts General Hospital, Boston, MA, USA
| | - Deborah J. Wexler
- Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, MA, USA
- Diabetes Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, MA, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, MA, USA
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12
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Huang DQ, Terrault NA, Tacke F, Gluud LL, Arrese M, Bugianesi E, Loomba R. Global epidemiology of cirrhosis - aetiology, trends and predictions. Nat Rev Gastroenterol Hepatol 2023; 20:388-398. [PMID: 36977794 PMCID: PMC10043867 DOI: 10.1038/s41575-023-00759-2] [Citation(s) in RCA: 106] [Impact Index Per Article: 106.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 03/30/2023]
Abstract
Cirrhosis is an important cause of morbidity and mortality in people with chronic liver disease worldwide. In 2019, cirrhosis was associated with 2.4% of global deaths. Owing to the rising prevalence of obesity and increased alcohol consumption on the one hand, and improvements in the management of hepatitis B virus and hepatitis C virus infections on the other, the epidemiology and burden of cirrhosis are changing. In this Review, we highlight global trends in the epidemiology of cirrhosis, discuss the contributions of various aetiologies of liver disease, examine projections for the burden of cirrhosis, and suggest future directions to tackle this condition. Although viral hepatitis remains the leading cause of cirrhosis worldwide, the prevalence of non-alcoholic fatty liver disease (NAFLD) and alcohol-associated cirrhosis are rising in several regions of the world. The global number of deaths from cirrhosis increased between 2012 and 2017, but age-standardized death rates (ASDRs) declined. However, the ASDR for NAFLD-associated cirrhosis increased over this period, whereas ASDRs for other aetiologies of cirrhosis declined. The number of deaths from cirrhosis is projected to increase in the next decade. For these reasons, greater efforts are required to facilitate primary prevention, early detection and treatment of liver disease, and to improve access to care.
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Affiliation(s)
- Daniel Q Huang
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, San Diego, CA, USA
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Norah A Terrault
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, CA, USA
| | - Frank Tacke
- Department of Hepatology & Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Lise Lotte Gluud
- Gastro Unit, Copenhagen University Hospital, Hvidovre, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marco Arrese
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
- Centro de Envejecimiento Y Regeneración (CARE), Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Elisabetta Bugianesi
- Division of Gastroenterology and Hepatology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, San Diego, CA, USA.
- Division of Epidemiology, Department of Family Medicine and Public Health, University of California at San Diego, San Diego, CA, USA.
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Sohal A, Chaudhry H, Kohli I, Arora K, Patel J, Dhillon N, Singh I, Dukovic D, Roytman M. Frailty as a risk-stratification tool in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). J Frailty Sarcopenia Falls 2023; 8:83-93. [PMID: 37275658 PMCID: PMC10233326 DOI: 10.22540/jfsf-08-083] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 06/07/2023] Open
Abstract
Objectives The concept of frailty has gained importance, especially in patients with liver disease. Our study systematically investigated the effect of frailty on post-procedural outcomes in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). Methods We used National Inpatient Sample(NIS) 2016-2019 data to identify patients who underwent TIPS. Hospital frailty risk score (HFRS) was used to classify patients as frail (HFRS>=5) and non-frail (HFRS<5). The relationship between frailty and outcomes such as death, post-procedural shock, non-home discharge, length of stay (LOS), post-procedural LOS, and total hospitalization charges (THC) was assessed. Results A total of 13,700 patients underwent TIPS during 2016-2019. Of them, 5,995 (43.76%) patients were frail, while 7,705 (56.24%) were non-frail. There were no significant differences between the two groups based on age, gender, race, insurance, and income. Frail patients had higher mortality (15.18% vs. 2.07%, p<0.001), a higher incidence of non-home discharge (53.38% vs. 19.08%, p<0.001), a longer overall LOS (12.5 days vs. 3.35,p<0.001), longer post-procedural stay (8.2 days vs. 3.4 days, p<0.001), and higher THC ($240,746.7 vs. $121,763.1, p<0.001) compared to the non-frail patients. On multivariate analysis, frail patients had a statistically significant higher risk of mortality (aOR-3.22, 95% CI-1.98- 5.00, p<0.001). Conclusion Frailty assessment can be beneficial in risk stratification in patients undergoing TIPS.
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Affiliation(s)
- Aalam Sohal
- Department of Hepatology, Liver Institute Northwest, Seattle, USA
| | - Hunza Chaudhry
- Department of Internal Medicine, University of California, San Francisco, Fresno, USA
| | - Isha Kohli
- Department of Public Health, Icahn School of Medicine, Mount Sinai, New York, USA
| | - Kirti Arora
- Dayanand Medical College and Hospital, India
| | - Jay Patel
- Department of Internal Medicine, Orange Park Medical Center, Orange Park, Florida, USA
| | | | | | - Dino Dukovic
- Ross University School of Medicine, Barbados, USA
| | - Marina Roytman
- Department of Gastroenterology and Hepatology, University of California, San Francisco, Fresno, USA
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Arena PJ, Huang K, Löfling L, Bahmanyar S, Mo J, Schachterle SE, Nunes AP, Smits E, Juuti R, Hoti F, Korhonen P, Adelborg K, Sundbøll J, Rasmussen TR, Løkke A, Ehrenstein V. Validation of safety outcomes in routinely collected data: Lessons learned from a multinational postapproval safety study. Pharmacoepidemiol Drug Saf 2023; 32:592-596. [PMID: 36495188 DOI: 10.1002/pds.5582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 11/18/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022]
Abstract
Abstract
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Affiliation(s)
- Patrick J Arena
- Global Medical Epidemiology, Pfizer Inc., New York, New York, USA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Kui Huang
- Global Medical Epidemiology, Pfizer Inc., New York, New York, USA
| | - Lukas Löfling
- Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital SE, Stockholm, Sweden
- Department of Research, Cancer Registry of Norway, Oslo, Norway
| | - Shahram Bahmanyar
- Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital SE, Stockholm, Sweden
| | - Jingping Mo
- Safety Surveillance Research, Pfizer Inc., New York, New York, USA
| | | | - Anthony P Nunes
- Optum Inc., Boston, Massachusetts, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Elisabeth Smits
- PHARMO Institute for Drug Outcomes Research, Utrecht, the Netherlands
| | | | | | | | - Kasper Adelborg
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus N, Denmark
| | - Jens Sundbøll
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus N, Denmark
| | - Torben Riis Rasmussen
- Department of Respiratory Diseases and Allergology, Aarhus University Hospital, Aarhus N, Denmark
| | - Anders Løkke
- Department of Medicine, Little Belt Hospital, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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15
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Simon TG, Schneeweiss S, Wyss R, Lu Z, Bessette LG, York C, Lin KJ. Development and Validation of a Novel Tool to Predict Model for End-Stage Liver Disease (MELD) Scores in Cirrhosis, Using Administrative Datasets. Clin Epidemiol 2023; 15:349-362. [PMID: 36941978 PMCID: PMC10024467 DOI: 10.2147/clep.s387253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/23/2022] [Indexed: 03/18/2023] Open
Abstract
Background The Model for End-Stage Liver Disease (MELD) score predicts disease severity and mortality in cirrhosis. To improve cirrhosis phenotyping in administrative databases lacking laboratory data, we aimed to develop and externally validate claims-based MELD prediction models, using claims data linked to electronic health records (EHR). Methods We included adults with established cirrhosis in two Medicare-linked EHR networks (training and internal validation; 2007-2017), and a Medicaid-linked EHR network (external validation; 2000-2014). Using least absolute shrinkage and selection operator (LASSO) with 5-fold cross-validation, we selected among 146 investigator-specified variables to develop models for predicting continuous MELD and relevant MELD categories (MELD<10, MELD≥15 and MELD≥20), with observed MELD calculated from laboratory data. Regression coefficients for each model were applied to the validation sets to predict patient-level MELD and assess model performance. Results We identified 4501 patients in the Medicare training set (mean age 75.1 years, 18.5% female, mean MELD=13.0), and 2435 patients in the Medicare validation set (mean age: 74.3 years, 31.7% female, mean MELD=12.3). Our final model for predicting continuous MELD included 112 variables, explaining 58% of observed MELD variability; in the Medicare validation set, the area-under-the-receiver operating characteristic curves (AUC) for MELD<10 and MELD≥15 were 0.84 and 0.90, respectively; the AUC for the model predicting MELD≥20 (using 27 variables) was 0.93. Overall, these models correctly classified 77% of patients with MELD<10 (95% CI=0.75-0.78), 85% of patients with MELD≥15 (95% CI=0.84-0.87), and 87% of patients with MELD≥20 (95% CI=0.86-0.88). Results were consistent in the external validation set (n=2240). Conclusion Our MELD prediction tools can be used to improve cirrhosis phenotyping in administrative datasets lacking laboratory data.
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Affiliation(s)
- Tracey G Simon
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard Wyss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Zhigang Lu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Lily G Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Cassandra York
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Kueiyu Joshua Lin
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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16
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Simon TG, Schneeweiss S, Singer DE, Sreedhara SK, Lin KJ. Prescribing Trends of Oral Anticoagulants in US Patients With Cirrhosis and Nonvalvular Atrial Fibrillation. J Am Heart Assoc 2023; 12:e026863. [PMID: 36625307 PMCID: PMC9973619 DOI: 10.1161/jaha.122.026863] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 11/30/2022] [Indexed: 01/11/2023]
Abstract
Background Many patients with cirrhosis have concurrent nonvalvular atrial fibrillation (NVAF). Data are lacking regarding recent oral anticoagulant (OAC) usage trends among US patients with cirrhosis and NVAF. Methods and Results Using MarketScan claims data (2012-2019), we identified patients with cirrhosis and NVAF eligible for OACs (CHA2DS2-VASc score ≥2 [men] or ≥3 [women]). We calculated the yearly proportion of patients prescribed a direct OAC (DOAC), warfarin, or no OAC. We stratified by high-risk features (decompensated cirrhosis, thrombocytopenia, coagulopathy, chronic kidney disease, or end-stage renal disease). Among 32 487 patients (mean age=71.6 years, 38.5% women, 15.1% with decompensated cirrhosis, mean CHA2DS2-VASc=4.2), 44.6% used OACs within 180 days of NVAF diagnosis, including DOACs (20.2%) or warfarin (24.4%). Compared with OAC nonusers, OAC users were less likely to have decompensated cirrhosis (18.6% versus 10.7%), thrombocytopenia (19.5% versus 12.5%), or chronic kidney disease/end-stage renal disease (15.5% versus 14.0%). Between 2012 and 2019, warfarin use decreased by 21.0% (32.0% to 11.0%), whereas DOAC use increased by 30.6% (7.4% to 38.0%), and among all DOACs between 2012 and 2019, apixaban was the most commonly prescribed (46.1%). Warfarin use decreased and DOAC use increased in all subgroups, including in compensated and decompensated cirrhosis, thrombocytopenia, coagulopathy, chronic kidney disease/end-stage renal disease, and across CHA2DS2-VASc categories. Among OAC users (2012-2019), DOAC use increased by 58.9% (18.7% to 77.6%). Among DOAC users, the greatest proportional increase was with apixaban (61.2%; P<0.001). Conclusions Among US patients with cirrhosis and NVAF, DOAC use has increased substantially and surpassed warfarin, including in decompensated cirrhosis. Nevertheless, >55% of patients remain untreated, underscoring the need for clearer treatment guidance.
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Affiliation(s)
- Tracey G. Simon
- Division of Pharmacoepidemiology and PharmacoeconomicsDepartment of Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBostonMA
- Division of Gastroenterology and HepatologyDepartment of Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and PharmacoeconomicsDepartment of Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | - Daniel E. Singer
- Division of General Internal MedicineDepartment of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMA
| | - Sushama Kattinakere Sreedhara
- Division of Pharmacoepidemiology and PharmacoeconomicsDepartment of Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and PharmacoeconomicsDepartment of Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBostonMA
- Division of General Internal MedicineDepartment of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMA
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Serper M, Tapper EB, Kaplan DE, Taddei TH, Mahmud N. Patterns of Care Utilization and Hepatocellular Carcinoma Surveillance: Tracking Care Across the Pandemic. Am J Gastroenterol 2023; 118:294-303. [PMID: 36114778 PMCID: PMC9898115 DOI: 10.14309/ajg.0000000000002011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/09/2022] [Indexed: 02/06/2023]
Abstract
INTRODUCTION We studied longitudinal trends in mortality, outpatient, and inpatient care for cirrhosis in a national cohort in the first 2 years of the coronavirus disease-2019 pandemic. We evaluated trends in hepatocellular carcinoma (HCC) surveillance and factors associated with completion. METHODS Within the national cirrhosis cohort in the Veterans Administration from 2020 to 2021, we captured mortality, outpatient primary care provider, gastroenterology/hepatology (GI/HEP) visits, and hospitalizations. HCC surveillance was computed as percentage of time up to date with surveillance every 6 months (PTUDS). Multivariable models for PTUDS were adjusted for patient demographics, clinical factors, and facility-level variables. RESULTS The total cohort was 68,073; 28,678 were eligible for HCC surveillance. Outpatient primary care provider and GI/HEP appointment rates initially dropped from 30% to 7% with a rebound 1 year into the pandemic and steady subsequent use. Telemedicine monthly visit rates rose from less than 10% to a peak of 20% with a steady gradual decline. Nearly 70% of Veterans were up to date with HCC surveillance before the pandemic with an early pandemic nadir of approximately 50% and 60% PTUDS 2 years into the pandemic. In adjusted models, use of a population-based cirrhosis dashboard (β 8.5, 95% CI 6.9-10.2) and GI/HEP visits both in-person (β 3.2, 95% CI 2.9-3.6) and telemedicine (β 2.1, 95% CI 1.9-2.4) were associated with a higher PTUDS. DISCUSSION Outpatient utilization and HCC surveillance rates have rebounded but remain below at baseline. Population-based approaches and specialty care for cirrhosis were associated with a higher completion of HCC surveillance.
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Affiliation(s)
- Marina Serper
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, USA
- Gastroenterology Section, Ann Arbor Healthcare System, Ann Arbor, VA, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Tamar H. Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Sohal A, Chaudhry H, Dhaliwal A, Singla P, Gupta G, Sharma R, Dukovic D, Prajapati D. Gender differences in esophageal variceal bleeding in the United States. Ann Med 2022; 54:2115-2122. [PMID: 35930410 PMCID: PMC9359179 DOI: 10.1080/07853890.2022.2104920] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND AIMS Esophageal variceal bleeding is a common reason for hospitalization in patients with cirrhosis. The main objective of this study was to analyze the effects of gender differences on outcomes in hospitalizations related to Esophageal variceal bleeding in the United States. METHODS A retrospective observational cohort study was performed using the National Inpatient Sample (NIS) database for all hospitalizations with a discharge diagnosis of esophageal varices with hemorrhage from 2016 to 2019. The primary outcome was in-hospital mortality, while secondary outcomes included rate of early endoscopy (defined as less than 1 day), AKI, blood transfusion, sepsis, ICU admission and TIPS (Transjugular Intrahepatic Portosystemic Shunt). We also compared the length of stay and total hospitalization charges. RESULTS We identified a total of 166,760 patients with variceal bleeding of which 32.7% were females. In-hospital mortality was higher in males, 9.91%, compared to females, 8.31% (adjusted odds ratio (aOR): 0.88, p-value=.008, when adjusted for confounding factors). The odds of undergoing an EGD, length of stay, or total hospitalization charges did not differ between the two groups. Compared to men, women had lower odds of receiving TIPS (aOR = 0.83, p-value=.002). CONCLUSION Women hospitalised with esophageal variceal bleeding are at a lower risk of death compared to males. Further research is needed to elucidate the factors associated with this lower risk.
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Affiliation(s)
- Aalam Sohal
- Department of Internal Medicine, University of California, Fresno, CA, USA
| | - Hunza Chaudhry
- Department of Internal Medicine, University of California, Fresno, CA, USA
| | - Armaan Dhaliwal
- Department of Internal Medicine, University of Arizona, South Campus-Tucson, AZ, USA
| | - Piyush Singla
- Dayanand Medical College and Hospital, Punjab, India
| | - Gagan Gupta
- Dayanand Medical College and Hospital, Punjab, India
| | | | - Dino Dukovic
- Ross University School of Medicine, Bridgetown, Barbados
| | - Devang Prajapati
- Department of Gastroenterology and Hepatology, University of California, Fresno, CA, USA
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Burkholder DA, Moran IJ, DiBattista JV, Lok AS, Parikh ND, Chen VL. Accuracy of International Classification of Diseases-10 Codes for Cirrhosis and Portal Hypertensive Complications. Dig Dis Sci 2022; 67:3623-3631. [PMID: 34674069 DOI: 10.1007/s10620-021-07282-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/07/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS International Classification of Diseases (ICD)-10 codes may correspond to cirrhosis diagnosis. However, these codes have not been as well studied as ICD-9 codes. We aimed to evaluate the positive predictive value (PPV) and specificity of ICD-10 codes for cirrhosis. METHODS We conducted a single-center retrospective study of patients in Michigan Medicine (Ann Arbor, MI, USA). We evaluated patients with at least one of 28 ICD-10 codes for cirrhosis and randomly selected controls for the presence of cirrhosis and/or portal hypertensive complications. RESULTS Among 1317 patients with at least one ICD-10 code consistent with cirrhosis and/or portal hypertension, 796 had confirmed cirrhosis. After excluding ICD-10 codes found in < 10 patients, we evaluated the PPV of the 19 remaining codes. Of these, 15 had a high PPV for cirrhosis (> 80%), including codes for cirrhosis itself, gastroesophageal varices, hepatic encephalopathy, and other portal hypertensive complications. Specificity of ICD codes for cirrhosis for these 15 codes was high (> 94% for all). PPV and specificity were high across liver disease etiologies. Among patients without portal hypertension, PPVs of ICD-10 codes for cirrhosis were lower but still > 80% for the most common codes. PPVs of most codes for portal hypertensive complications were > 70%. Defining cirrhosis based on the presence of any of the 15 codes resulted in a PPV of 86% and by two different codes, a PPV 94%. CONCLUSIONS ICD-10 codes for cirrhosis can accurately identify patients with cirrhosis with or without portal hypertensive complications.
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Affiliation(s)
- Daniel A Burkholder
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Isabel J Moran
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Jacob V DiBattista
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Anna S Lok
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Vincent L Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
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20
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Association Between Kidney Dysfunction Types and Mortality Among Hospitalized Patients with Cirrhosis. Dig Dis Sci 2022; 67:3426-3435. [PMID: 34292470 PMCID: PMC9568372 DOI: 10.1007/s10620-021-07159-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 07/05/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND AIMS Kidney dysfunction is associated with increased mortality among patients with cirrhosis. We investigated whether kidney dysfunction types [e.g., acute kidney injury (AKI), chronic kidney disease (CKD), and AKI on CKD] were differentially associated with inpatient mortality. METHODS We utilized the nationwide inpatient sample, a nationally representative database, from 2007 to 2014. We included all hospitalizations with previously validated codes for cirrhosis or associated decompensated cirrhosis diagnoses. We defined kidney dysfunction types also from previously validated codes, and we grouped hospitalizations into the following diagnoses: normal, AKI, CKD, and AKI on CKD. Our primary outcome was inpatient mortality. RESULTS There were 1,293,779 hospitalizations with cirrhosis sampled in this study. Of these hospitalizations, 849,193 (66%) had normal kidney function, 176,418 (14%) had AKI, 157,600 (12%) had CKD, and 110,568 (9%) had AKI on CKD. We found that the proportion of hospitalizations with AKI, CKD, and AKI on CKD increased significantly throughout the study period (p < 0.001, test for trend for all). Kidney dysfunction type was differentially associated with inpatient mortality, even after adjustment: as compared to those with CKD, normal kidney function: OR 0.75 [95 CI 0.73-0.78], AKI: OR 2.40 [95 CI 2.32-2.48], and AKI on CKD: OR 1.66 [95 CI 1.60-1.72]. DISCUSSION Using a nationally representative cohort of all hospitalizations with cirrhosis, our study highlights that the burden of kidney dysfunction, especially AKI, among hospitalizations with cirrhosis is rising, and the inclusion of kidney dysfunction type may be an opportunity to improve prognostication.
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21
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International Classification of Diseases Codes are Useful in Identifying Cirrhosis in Administrative Databases. Dig Dis Sci 2022; 67:2107-2122. [PMID: 34091800 DOI: 10.1007/s10620-021-07076-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/24/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Health administrative databases are essential to define patient populations, make socioeconomic predictions, and facilitate medical research and healthcare planning. The accuracy of this data is dependent on valid codes/coding algorithms. AIMS The aim of this study was to systematically identify and summarize the validity of International Classification of Diseases (ICD) codes for identifying patients with cirrhosis in administrative data. METHODS Electronic databases, MEDLINE (via Ovid), EMBASE (via Ovid), the Web of Science, and CINAHL (via EBSCOhost), were searched for validation studies which compared ICD codes related to cirrhosis to a clinical reference standard, and reported statistical measures of performance. RESULTS Fourteen studies were included in the review. There was a large variation in the algorithms used to validate ICD codes to diagnose cirrhosis. Despite the variation, the positive predictive value (PPV) was greater than 84% and the specificity was greater than 75% in the majority of the studies. The negative predictive value (NPV) was lower, but still was associated with values greater than 70% in the majority of studies. Sensitivity data varied significantly with values ranging from 0.27 to 99%. CONCLUSIONS Evaluated ICD codes for cirrhosis, including codes for chronic liver disease, cirrhosis-specific codes, and cirrhosis-related complications, have demonstrated variable sensitivity and reasonable specificity for the identification of cirrhosis. Additional research is needed to maximize the identification of persons with cirrhosis to avoid underestimating the burden of disease.
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22
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Simon TG, Patorno E, Schneeweiss S. Glucagon-Like Peptide-1 Receptor Agonists and Hepatic Decompensation Events in Patients With Cirrhosis and Diabetes. Clin Gastroenterol Hepatol 2022; 20:1382-1393.e19. [PMID: 34256144 PMCID: PMC8743301 DOI: 10.1016/j.cgh.2021.07.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/08/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The study sought to compare the effectiveness of glucagon-like peptide-1 receptor agonists (GLP-1RAs) with dipeptidyl peptidase-4 (DPP-4) inhibitors, sulfonylureas, or sodium-glucose cotransporter-2 (SGLT-2) inhibitors in reducing decompensation events, among patients with cirrhosis and type 2 diabetes. METHODS This population-based, retrospective cohort study included patients with type 2 diabetes and cirrhosis, in a commercial healthcare database (IBM MarketScan). We constructed 3 pairwise, 1:1 propensity score (PS)-matched cohorts of adults initiating GLP-1RAs or a comparator medication (ie, DPP-4 inhibitors [2006-2020], sulfonylurea [2005-2020], or SGLT-2 inhibitors [2013-2020]). Patients were followed in an as-treated approach for decompensation events (ie, ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatic encephalopathy, or esophageal variceal hemorrhage). Within each PS-matched cohort, we estimated hazard ratios (HRs) and 95% confidence intervals (CIs), controlling for >90 baseline characteristics. RESULTS Over 132 days of median follow-up (interquartile range, 73-290 days), PS-matched rates of any decompensation were significantly lower among GLP-1RA initiators, versus DPP-4 inhibitor initiators (105.2 vs 144.0 per 1000 person-years [PY]; HR, 0.68; 95% CI, 0.53-0.88; n = 1431 pairs), and versus sulfonylureas (97.3 vs 144.0 per 1000 PY; HR, 0.64; 95% CI, 0.48-0.84; n = 1246 pairs). Similar, inverse associations were found for individual decompensation events, including ascites, spontaneous bacterial peritonitis, or hepatorenal syndrome (HR, 0.66; 95% CI, 0.45-0.97; and HR, 0.66; 95% CI, 0.46-0.94, respectively); esophageal variceal hemorrhage (HR, 0.62 [95% CI, 0.41-0.92; and HR, 0.59; 95% CI, 0.37-0.92, respectively); and hepatic encephalopathy (HR, 0.76; 95% CI, 0.55-1.06; and HR, 0.60; 95% CI, 0.39-0.92, respectively). Results persisted in subgroups of patients with and without previously decompensated cirrhosis. In contrast, decompensation rates were similar when GLP-1RAs and SGLT-2 inhibitors were directly compared (103.5 vs 112.8 per 1000 PY; HR, 0.89; 95% CI, 0.62-1.28). CONCLUSIONS Among cirrhotic patients with type 2 diabetes, we find high rates of decompensation, consistent with previous reports; these rates were substantially lower among GLP-1RA initiators compared with DPP-4 inhibitors or sulfonylureas.
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Affiliation(s)
- Tracey G. Simon
- Division of Gastroenterology and Hepatology, 55 Fruit Street Wang 5, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA,Clinical and Translational Epidemiology Unit (CTEU), Massachusetts General Hospital, Boston, MA, USA,Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 1620 Tremont St, Suite 3030, Boston, MA, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 1620 Tremont St, Suite 3030, Boston, MA, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 1620 Tremont St, Suite 3030, Boston, MA, USA
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Mahmud N, Asrani SK, Reese PP, Kaplan DE, Taddei TH, Nadim MK, Serper M. Race Adjustment in eGFR Equations Does Not Improve Estimation of Acute Kidney Injury Events in Patients with Cirrhosis. Dig Dis Sci 2022; 67:1399-1408. [PMID: 33761091 PMCID: PMC8460692 DOI: 10.1007/s10620-021-06943-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/06/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Accuracy of glomerular filtration rate estimating (eGFR) equations has significant implications in cirrhosis, potentially guiding simultaneous liver kidney allocation and drug dosing. Most equations adjust for Black race, partially accounted for by reported differences in muscle mass by race. Patients with cirrhosis, however, are prone to sarcopenia which may mitigate such differences. We evaluated the association between baseline eGFR and incident acute kidney injury (AKI) in patients with cirrhosis with and without race adjustment. METHODS We conducted a retrospective national cohort study of veterans with cirrhosis. Baseline eGFR was calculated using multiple eGFR equations including Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), both with and without race adjustment. Poisson regression was used to investigate the association between baseline eGFR and incident AKI events per International Club of Ascites criteria. RESULTS We identified 72,267 patients with cirrhosis, who were 97.3% male, 57.8% white, and 19.7% Black. Over median follow-up 2.78 years (interquartile range 1.22-5.16), lower baseline eGFR by CKD-EPI was significantly associated with higher rates of AKI in adjusted models. For all equations this association was minimally impacted when race adjustment was removed. For example, removal of race adjustment from CKD-EPI resulted in a 0.1% increase in the association between lower eGFR and higher rate of AKI events per 15 mL/min/1.73 m2 change (p < 0.001). CONCLUSIONS Race adjustment in eGFR equations did not enhance AKI risk estimation in patients with cirrhosis. Further study is warranted to assess the impacts of removing race from eGFR equations on clinical outcomes and policy.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 4th Floor, South Pavilion, Philadelphia, PA, 19104, USA.
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Sumeet K Asrani
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX, USA
| | - Peter P Reese
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 4th Floor, South Pavilion, Philadelphia, PA, 19104, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Tamar H Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 4th Floor, South Pavilion, Philadelphia, PA, 19104, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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24
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Rogers JR, Pavisic J, Ta CN, Liu C, Soroush A, Cheung YK, Hripcsak G, Weng C. Leveraging electronic health record data for clinical trial planning by assessing eligibility criteria's impact on patient count and safety. J Biomed Inform 2022; 127:104032. [PMID: 35189334 PMCID: PMC8920749 DOI: 10.1016/j.jbi.2022.104032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To present an approach on using electronic health record (EHR) data that assesses how different eligibility criteria, either individually or in combination, can impact patient count and safety (exemplified by all-cause hospitalization risk) and further assist with criteria selection for prospective clinical trials. MATERIALS AND METHODS Trials in three disease domains - relapsed/refractory (r/r) lymphoma/leukemia; hepatitis C virus (HCV); stages 3 and 4 chronic kidney disease (CKD) - were analyzed as case studies for this approach. For each disease domain, criteria were identified and all criteria combinations were used to create EHR cohorts. Per combination, two values were derived: (1) number of eligible patients meeting the selected criteria; (2) hospitalization risk, measured as the hazard ratio between those that qualified and those that did not. From these values, k-means clustering was applied to derive which criteria combinations maximized patient counts but minimized hospitalization risk. RESULTS Criteria combinations that reduced hospitalization risk without substantial reductions on patient counts were as follows: for r/r lymphoma/leukemia (23 trials; 9 criteria; 623 patients), applying no infection and adequate absolute neutrophil count while forgoing no prior malignancy; for HCV (15; 7; 751), applying no human immunodeficiency virus and no hepatocellular carcinoma while forgoing no decompensated liver disease/cirrhosis; for CKD (10; 9; 23893), applying no congestive heart failure. CONCLUSIONS Within each disease domain, the more drastic effects were generally driven by a few criteria. Similar criteria across different disease domains introduce different changes. Although results are contingent on the trial sample and the EHR data used, this approach demonstrates how EHR data can inform the impact on safety and available patients when exploring different criteria combinations for designing clinical trials.
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Affiliation(s)
- James R. Rogers
- Department of Biomedical Informatics, Columbia University, New York, NY
| | - Jovana Pavisic
- Department of Pediatrics, Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Irving Medical Center, New York, NY
| | - Casey N. Ta
- Department of Biomedical Informatics, Columbia University, New York, NY
| | - Cong Liu
- Department of Biomedical Informatics, Columbia University, New York, NY
| | - Ali Soroush
- Department of Biomedical Informatics, Columbia University, New York, NY,Division of Gastroenterology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | | | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, NY,Medical Informatics Services, New York-Presbyterian Hospital, New York, NY
| | - Chunhua Weng
- Department of Biomedical Informatics, Columbia University, New York, NY, United States.
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25
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Shearer JE, Gonzalez JJ, Min T, Parker R, Jones R, Su GL, Tapper EB, Rowe IA. Systematic review: development of a consensus code set to identify cirrhosis in electronic health records. Aliment Pharmacol Ther 2022; 55:645-657. [PMID: 35166399 PMCID: PMC9302659 DOI: 10.1111/apt.16806] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/28/2021] [Accepted: 01/24/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Electronic health records (EHRs) collate longitudinal data that can be used to facilitate large-scale research in patients with cirrhosis. However, there is no consensus code set to define the presence of cirrhosis in EHR. This systematic review aims to evaluate the validity of diagnostic coding in cirrhosis and to synthesise a comprehensive set of ICD-10 codes for future EHR research. METHOD MEDLINE and EMBASE databases were searched for studies that used EHR to identify cirrhosis and cirrhosis-related complications. Validated code sets were summarised, and the performance characteristics were extracted. Citation analysis was done to inform development of a consensus code set. This was then validated in a cohort of patients. RESULTS One thousand six hundred twenty-six records were screened, and 18 studies were identified. The positive predictive value (PPV) was the most frequently reported statistical estimate and was ≥80% in 17/18 studies. Citation analyses showed continued variation in those used in contemporary research practice. Nine codes were identified as those most frequently used in the literature and these formed the consensus code set. This was validated in diverse patient populations from Europe and North America and showed high PPV (83%-89%) and greater sensitivity for the identification of cirrhosis than the most often used code set in the recent literature. CONCLUSION There is variation in code sets used to identify cirrhosis in contemporary research practice. A consensus set has been developed and validated, showing improved performance, and is proposed to align EHR study designs in cirrhosis to facilitate international collaboration and comparisons.
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Affiliation(s)
- Jessica E. Shearer
- Leeds Liver UnitLeeds Teaching Hospitals NHS TrustLeedsUK,Leeds Institute for Data AnalyticsUniversity of LeedsLeedsUK
| | - Juan J. Gonzalez
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA
| | - Thazin Min
- Leeds Liver UnitLeeds Teaching Hospitals NHS TrustLeedsUK
| | - Richard Parker
- Leeds Liver UnitLeeds Teaching Hospitals NHS TrustLeedsUK
| | - Rebecca Jones
- Leeds Liver UnitLeeds Teaching Hospitals NHS TrustLeedsUK
| | - Grace L. Su
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA
| | - Elliot B. Tapper
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA
| | - Ian A. Rowe
- Leeds Liver UnitLeeds Teaching Hospitals NHS TrustLeedsUK,Leeds Institute for Data AnalyticsUniversity of LeedsLeedsUK
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Mahmud N, Goldberg DS, Bittermann T. Best Practices in Large Database Clinical Epidemiology Research in Hepatology: Barriers and Opportunities. Liver Transpl 2022; 28:113-122. [PMID: 34265178 PMCID: PMC8688188 DOI: 10.1002/lt.26231] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 06/10/2021] [Accepted: 06/27/2021] [Indexed: 01/03/2023]
Abstract
With advances in computing and information technology, large health care research databases are becoming increasingly accessible to investigators across the world. These rich, population-level data sources can serve many purposes, such as to generate "real-world evidence," to enhance disease phenotyping, or to identify unmet clinical needs, among others. This is of particular relevance to the study of patients with end-stage liver disease (ESLD), a socioeconomically and clinically heterogeneous population that is frequently under-represented in clinical trials. This review describes the recommended "best practices" in the execution, reporting, and interpretation of large database clinical epidemiology research in hepatology. The advantages and limitations of selected data sources are reviewed, as well as important concepts on data linkages. The appropriate classification of exposures and outcomes is addressed, and the strategies needed to overcome limitations of the data and minimize bias are explained as they pertain to patients with ESLD and/or liver transplantation (LT) recipients. Lastly, selected statistical concepts are reviewed, from model building to analytic decision making and hypothesis testing. The purpose of this review is to provide the practical insights and knowledge needed to ensure successful and impactful research using large clinical databases in the modern era and advance the study of ESLD and LT.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL
| | - Therese Bittermann
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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27
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Patidar KR, Adibuzzaman M, Naved MA, Rodriquez D, Slaven JE, Grama A, Desai AP, Gomez EV, Ghabril MS, Nephew L, Samala NR, Anderson M, Chalasani NP, Orman ES. Practice patterns and outcomes associated with intravenous albumin in patients with cirrhosis and acute kidney injury. Liver Int 2022; 42:187-198. [PMID: 34779104 DOI: 10.1111/liv.15096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/30/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Guidelines recommend albumin as the plasma-expander of choice for acute kidney injury (AKI) in cirrhosis. However, the impact of these recommendations on patient outcomes remains unclear. We aimed to determine the practice-patterns and outcomes associated with albumin use in a large, nationwide-US cohort of hospitalized cirrhotics with AKI. METHODS A retrospective cohort study was performed in hospitalized cirrhotics with AKI using Cerner-Health-Facts database from January 2009 to March 2018. 6786 were included for analysis on albumin-practice-patterns, and 4126 had available outcomes data. Propensity-score-adjusted model was used to determine the association between albumin use, AKI-recovery and in-hospital survival. RESULTS Median age was 61-years (60% male, 70% white), median serum-creatinine was 1.8 mg/dL and median Model for End-stage Liver Disease Sodium (MELD-Na) score was 24. Albumin was given to 35% of patients, of which 50% received albumin within 48-hours of AKI-onset, and 17% received appropriate weight-based dosing. Albumin was used more frequently in patients with advanced complications of cirrhosis, higher MELD-Na scores and patients admitted to urban-teaching hospitals. After propensity-matching and multivariable adjustment, albumin use was not associated with AKI-recovery (odds ratio [OR] 0.70, 95% confidence-interval [CI]: 0.59-1.07, P = .130) or in-hospital survival (OR 0.76 [95% CI: 0.46-1.25], P = .280), compared with crystalloids. Findings were unchanged in subgroup analyses of patients with varying cirrhosis complications and disease severity. CONCLUSIONS USA hospitalized patients with cirrhosis and AKI frequently do not receive intravenous albumin, and albumin use was not associated with improved clinical outcomes. Prospective randomised trials are direly needed to evaluate the impact of albumin in cirrhotics with AKI.
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Affiliation(s)
- Kavish R Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mohammad Adibuzzaman
- Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Mobasshir A Naved
- Department of Computer Science, Purdue University, West Lafayette, Indiana, USA
| | - Dylan Rodriquez
- Department of Computer Science, Purdue University, West Lafayette, Indiana, USA
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ananth Grama
- Department of Computer Science, Purdue University, West Lafayette, Indiana, USA
| | - Archita P Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eduardo V Gomez
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Niharika R Samala
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Melissa Anderson
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Naga P Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eric S Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Hypoglycemia is an early, independent predictor of bacteremia and in-hospital death in patients with cirrhosis. Eur J Gastroenterol Hepatol 2021; 33:e693-e699. [PMID: 34074985 PMCID: PMC8669667 DOI: 10.1097/meg.0000000000002218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS Bacteremia is a common cause of death in patients with cirrhosis and early antimicrobial therapy can be life-saving. Severe liver disease impairs glucose metabolism such that hypoglycemia may be a presenting sign of infection in patients with cirrhosis. We explored this association using granular retrospective data. METHODS We conducted a case-control analysis from 1 January 2008 to 31 December 17 in the University of Pennsylvania Health System. We identified the first blood culture results from all cirrhosis hospitalizations and obtained detailed vital sign and laboratory data in the 24-72 h prior to culture results. We used multivariable logistic regression to develop models predicting blood culture positivity and in-hospital mortality. We repeated these analyses restricted to normothermic individuals. Restricted cubic splines were used to model nonlinearity in the glucose variable. RESULTS We identified 1274 cirrhosis admissions with blood culture results (52.7% positive). In adjusted models, minimum glucose 24-72 h prior to blood culture result date was a significant predictor of blood culture positivity. In particular, glucose levels below 100 mg/dL significantly increased the probability of subsequent positive blood culture (e.g. odds ratio 1.89 for 50 mg/dL vs. 100 mg/dL, P = 0.004). This relationship persisted when restricting the cohort to normothermic individuals. Glucose levels <100 mg/dL in patients with bacteremia were also positively associated with in-hospital mortality. CONCLUSIONS Early hypoglycemia is predictive of subsequently documented bacteremia and in-hospital mortality in patients with cirrhosis, even among normothermic individuals. In patients without other overt signs of infection, low glucose values may serve as an additional data point to justify early antibiosis.
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Brahmania M, Alotaibi A, Mooney O, Rush B. Treatment in disproportionately minority hospitals is associated with an increased mortality in end-stage liver disease. Eur J Gastroenterol Hepatol 2021; 33:1408-1413. [PMID: 32796359 DOI: 10.1097/meg.0000000000001860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Racial and ethnic disparities are a barrier in delivery of healthcare across the USA. Care for minority patients tends to be clustered into a small number of providers at minority hospitals, which has been associated with worse clinical outcomes in several conditions. However, the outcomes of treatment in patients with end-stage liver disease (ESLD) at predominately minority hospitals are unknown. We investigated the burden of the problem. METHODS We utilized the nationwide in-patient sample (NIS) to conduct a retrospective nationwide cohort analysis. All patients >18 years of age admitted with ESLD were included in the analysis. A multivariate logistic regression model was used to study the mortality rate among patients with ESLD treated at minority hospitals compared to nonminority hospitals. RESULTS A total of 53 281 467 hospitalizations from the 2008 to 2014 NIS were analyzed. There were 163 470 patients with ESLD that met inclusion criteria. In-hospital mortality rates for all races were 8.0 and 8.1% in black and Hispanic minority hospitals, respectively, compared to 7.3% in nonminority hospitals (P < 0.01). On multivariate analysis, treatment of ESLD in black and Hispanic minority hospitals was associated with 11% [odds ratio (OR), 1.11; 95% confidence interval (CI), 1.03-1.20; P < 0.01] and 22% (OR, 1.22; 95% CI, 1.09-1.37; P < 0.01) increased odds of death, respectively, compared to treatment in nonminority hospitals regardless of patient's race. CONCLUSION Patients with ESLD treated at minority hospitals are faced with an increased mortality rate regardless of patient's race. This study highlights another quality gap that needs improvement to affect overall survival among patients with ESLD.
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Affiliation(s)
- Mayur Brahmania
- Department of Medicine, Division of Gastroenterology, Western University, London Health Sciences Center, London, Ontario, Canada
| | - Ammar Alotaibi
- Department of Medicine, Division of Gastroenterology, Western University, London Health Sciences Center, London, Ontario, Canada
- Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Owen Mooney
- Department of Medicine, Division of Critical Care, Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Barret Rush
- Department of Medicine, Division of Critical Care, Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada
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Campbell DJT, Campbell DB, Ogundeji Y, Au F, Beall R, Ronksley PE, Quinn AE, Manns BJ, Hemmelgarn BR, Tonelli M, Spackman E. First-line pharmacotherapy for incident type 2 diabetes: Prescription patterns, adherence and associated costs. Diabet Med 2021; 38:e14622. [PMID: 34133781 DOI: 10.1111/dme.14622] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/15/2021] [Indexed: 01/01/2023]
Abstract
AIMS To use real-world prescription data from Alberta, Canada to: (a) describe the prescribing patterns for initial pharmacotherapy for those with newly diagnosed uncomplicated type 2 diabetes; (b) describe medication-taking behaviours (adherence and persistence) in the first year after initiating pharmacotherapy; and (c) explore healthcare system costs associated with prescribing patterns. METHODS We employed a retrospective cohort design using linked administrative datasets from 2012 to 2017 to define a cohort of those with uncomplicated incident diabetes. We summarized the initial prescription patterns, adherence and costs (healthcare and pharmaceutical) over the first year after initiation of pharmacotherapy. Using multivariable regression, we determined the association of these outcomes with various sociodemographic characteristics. RESULTS The majority of individuals for whom metformin was indicated as first-line therapy received a prescription for metformin monotherapy (89%). Older individuals, those with higher baseline A1C and those with no comorbidities, were most likely to be started on non-metformin agents. Adherence with the initially prescribed regimen was suboptimal overall, with nearly half (48%) being non-adherent over the first year. One-third of those who started metformin discontinued it in the first 3 months. Those started on non-metformin agents had roughly twice the healthcare costs, and five to seven times higher medication costs, compared to those started on metformin, in the first year after starting therapy. CONCLUSIONS With the addition of new classes of medications, healthcare providers who look after those with type 2 diabetes have more pharmaceutical options than ever. Most individuals continue to be prescribed metformin monotherapy. However, adherence is suboptimal, and drops off considerably within the first 3 months.
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Affiliation(s)
- David J T Campbell
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Dennis B Campbell
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Yewande Ogundeji
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Flora Au
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Reed Beall
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Amity E Quinn
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Braden J Manns
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Brenda R Hemmelgarn
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Marcello Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Eldon Spackman
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Chen Q, Cherry DR, Nalawade V, Qiao EM, Kumar A, Lowy AM, Simpson DR, Murphy JD. Clinical Data Prediction Model to Identify Patients With Early-Stage Pancreatic Cancer. JCO Clin Cancer Inform 2021; 5:279-287. [PMID: 33739856 DOI: 10.1200/cci.20.00137] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Pancreatic cancer is an aggressive malignancy with patients often experiencing nonspecific symptoms before diagnosis. This study evaluates a machine learning approach to help identify patients with early-stage pancreatic cancer from clinical data within electronic health records (EHRs). MATERIALS AND METHODS From the Optum deidentified EHR data set, we identified early-stage (n = 3,322) and late-stage (n = 25,908) pancreatic cancer cases over 40 years of age diagnosed between 2009 and 2017. Patients with early-stage pancreatic cancer were matched to noncancer controls (1:16 match). We constructed a prediction model using eXtreme Gradient Boosting (XGBoost) to identify early-stage patients on the basis of 18,220 features within the EHR including diagnoses, procedures, information within clinical notes, and medications. Model accuracy was assessed with sensitivity, specificity, positive predictive value, and the area under the curve. RESULTS The final predictive model included 582 predictive features from the EHR, including 248 (42.5%) physician note elements, 146 (25.0%) procedure codes, 91 (15.6%) diagnosis codes, 89 (15.3%) medications, and 9 (1.5%) demographic features. The final model area under the curve was 0.84. Choosing a model cut point with a sensitivity of 60% and specificity of 90% would enable early detection of 58% late-stage patients with a median of 24 months before their actual diagnosis. CONCLUSION Prediction models using EHR data show promise in the early detection of pancreatic cancer. Although widespread use of this approach on an unselected population would produce high rates of false-positive tests, this technique may be rapidly impactful if deployed among high-risk patients or paired with other imaging or biomarker screening tools.
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Affiliation(s)
- Qinyu Chen
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Daniel R Cherry
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,School of Medicine, University of California San Diego, La Jolla, CA
| | - Vinit Nalawade
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Edmund M Qiao
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,School of Medicine, University of California San Diego, La Jolla, CA
| | - Abhishek Kumar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,School of Medicine, University of California San Diego, La Jolla, CA
| | - Andrew M Lowy
- Department of Surgery, University of California San Diego, La Jolla, CA
| | - Daniel R Simpson
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.,School of Medicine, University of California San Diego, La Jolla, CA
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Mazumder NR, Simpson D, Atiemo K, Jackson K, Zhao L, Daud A, Kho A, Gabra LG, Caicedo JC, Levitsky J, Ladner DP. Black Patients With Cirrhosis Have Higher Mortality and Lower Transplant Rates: Results From a Metropolitan Cohort Study. Hepatology 2021; 74:926-936. [PMID: 34128254 DOI: 10.1002/hep.31742] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 11/30/2020] [Accepted: 01/19/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS Estimates of racial disparity in cirrhosis have been limited by lack of large-scale, longitudinal data, which track patients from diagnosis to death and/or transplant. APPROACH AND RESULTS We analyzed a large, metropolitan, population-based electronic health record data set from seven large health systems linked to the state death registry and the national transplant database. Multivariate competing risk analyses, adjusted for sex, age, insurance status, Elixhauser score, etiology of cirrhosis, HCC, portal hypertensive complication, and Model for End-Stage Liver Disease-Sodium (MELD-Na), examined the relationship between race, transplant, and cause of death as defined by blinded death certificate review. During the study period, 11,277 patients met inclusion criteria, of whom 2,498 (22.2%) identified as Black. Compared to White patients, Black patients had similar age, sex, MELD-Na, and proportion of alcohol-associated liver disease, but higher comorbidity burden, lower rates of private insurance, and lower rates of portal hypertensive complications. Compared to White patients, Black patients had the highest rate all-cause mortality and non-liver-related death and were less likely to be listed or transplanted (P < 0.001 for all). In multivariate competing risk analysis, Black patients had a 26% increased hazard of liver-related death (subdistribution HR, 1.26; 95% CI, [1.15-1.38]; P < 0.001). CONCLUSIONS Black patients with cirrhosis have discordant outcomes. Further research is needed to determine how to address these real disparities in the field of hepatology.
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Affiliation(s)
- Nikhilesh R Mazumder
- Department of Gastroenterology and HepatologyNorthwestern University Feinberg School of MedicineChicagoIL.,Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL
| | - Dinee Simpson
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Division of TransplantDepartment of SurgeryNorthwestern MedicineChicagoIL
| | - Kofi Atiemo
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Tulane Abdominal Transplant InstituteDepartment of SurgeryTulane University School of MedicineNew OrleansLA
| | - Kathryn Jackson
- Institute for Public Health and Medicine-Center for Health Information PartnershipsNorthwestern University, Feinberg School of MedicineChicagoIL
| | - Lihui Zhao
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Department of Preventative MedicineNorthwestern University Feinberg School of MedicineChicagoIL
| | - Amna Daud
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL
| | - Abel Kho
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Institute for Public Health and Medicine-Center for Health Information PartnershipsNorthwestern University, Feinberg School of MedicineChicagoIL
| | - Lauren G Gabra
- Feinberg School of MedicineNorthwestern University Feinberg School of MedicineChicagoIL
| | - Juan C Caicedo
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Division of TransplantDepartment of SurgeryNorthwestern MedicineChicagoIL
| | - Josh Levitsky
- Department of Gastroenterology and HepatologyNorthwestern University Feinberg School of MedicineChicagoIL.,Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL
| | - Daniela P Ladner
- Comprehensive Transplant CenterNorthwestern University Feinberg School of MedicineNorthwestern University Transplant Outcomes Research Collaborative (NUTORC)ChicagoIL.,Division of TransplantDepartment of SurgeryNorthwestern MedicineChicagoIL
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Hagström H, Adams LA, Allen AM, Byrne CD, Chang Y, Grønbæk H, Ismail M, Jepsen P, Kanwal F, Kramer J, Lazarus JV, Long MT, Loomba R, Newsome PN, Rowe IA, Ryu S, Schattenberg JM, Serper M, Sheron N, Simon TG, Tapper EB, Wild S, Wai-Sun Wong V, Yilmaz Y, Zelber-Sagi S, Åberg F. Administrative Coding in Electronic Health Care Record-Based Research of NAFLD: An Expert Panel Consensus Statement. Hepatology 2021; 74:474-482. [PMID: 33486773 PMCID: PMC8515502 DOI: 10.1002/hep.31726] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/11/2020] [Accepted: 01/15/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Electronic health record (EHR)-based research allows the capture of large amounts of data, which is necessary in NAFLD, where the risk of clinical liver outcomes is generally low. The lack of consensus on which International Classification of Diseases (ICD) codes should be used as exposures and outcomes limits comparability and generalizability of results across studies. We aimed to establish consensus among a panel of experts on ICD codes that could become the reference standard and provide guidance around common methodological issues. APPROACH AND RESULTS Researchers with an interest in EHR-based NAFLD research were invited to collectively define which administrative codes are most appropriate for documenting exposures and outcomes. We used a modified Delphi approach to reach consensus on several commonly encountered methodological challenges in the field. After two rounds of revision, a high level of agreement (>67%) was reached on all items considered. Full consensus was achieved on a comprehensive list of administrative codes to be considered for inclusion and exclusion criteria in defining exposures and outcomes in EHR-based NAFLD research. We also provide suggestions on how to approach commonly encountered methodological issues and identify areas for future research. CONCLUSIONS This expert panel consensus statement can help harmonize and improve generalizability of EHR-based NAFLD research.
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Affiliation(s)
- Hannes Hagström
- Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Leon A Adams
- Medical School, University of Western Australia, Perth Australia
| | - Alina M. Allen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Christopher D. Byrne
- Nutrition and Metabolism, Faculty of Medicine, University of Southampton, UK
- Southampton National Institute for Health Research Biomedical Research Centre, University Hospital Southampton, Southampton General Hospital, Tremona Road, Southampton, UK
| | - Yoosoo Chang
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Henning Grønbæk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Mona Ismail
- Division of Gastroenterology, Department of Internal Medicine, King Fahad Hospital of the University, Al-Khobar, Saudi Arabia
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Fasiha Kanwal
- Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston TX, USA
| | - Jennifer Kramer
- Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston TX, USA
| | - Jeffrey V. Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Michelle T. Long
- Department of Medicine, Section of Gastroenterology, Boston University School of Medicine, Boston, MA, USA
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology and Epidemiology, University of California at San Diego, La Jolla, California, USA
| | - Philip N. Newsome
- National Institute for Health Research Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, UK
| | - Ian A. Rowe
- Leeds Institute for Medical Research, University of Leeds, UK
| | - Seungho Ryu
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Jörn M. Schattenberg
- Metabolic Liver Research Program, I. Department of Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Tracey G. Simon
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, USA
| | - Sarah Wild
- Usher Institute, University of Edinburgh, UK
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Yusuf Yilmaz
- Liver Research Unit, Institute of Gastroenterology, Marmara University, Turkey
- Department of Gastroenterology, School of Medicine, Marmara University, Istanbul, Turkey
| | | | - Fredrik Åberg
- Transplantation and Liver Surgery Clinic, Helsinki University Hospital, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
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Nonalcoholic Fatty Liver Disease Risk Factors Affect Liver-Related Outcomes After Direct-Acting Antiviral Treatment for Hepatitis C. Dig Dis Sci 2021; 66:2394-2406. [PMID: 32654086 PMCID: PMC7854862 DOI: 10.1007/s10620-020-06457-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/28/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION In hepatitis C (HCV) patients, obesity and/or diabetes may increase the risk of liver-related outcomes. We aimed to determine whether diabetes and/or obesity are associated with adverse outcomes in direct-acting antiviral (DAA)-treated HCV patients. METHODS We conducted a retrospective study of 33,003 HCV-infected, DAA-treated Veterans between 2013 and 2015. Body mass index was used to categorize patients into underweight (< 18.5 kg/m2), normal weight (18.5 to < 25 kg/m2), overweight (25 to < 30 kg/m2), obesity I (30 to < 35 kg/m2), and obesity II-III (> 35 kg/m2). Diabetes was defined by ICD-9/10 codes in association with hemoglobin A1c > 6.5% or medication prescriptions. Patients were followed from 180 days post-DAA initiation until 2/14/2019 to assess for development of cirrhosis, decompensations, hepatocellular carcinoma (HCC), and death. Multivariable Cox proportional hazards regression models were used to determine the association between diabetes and/or obesity and outcomes. RESULTS During a mean follow-up of 3 years, 10.1% patients died, 5.0% were newly diagnosed with cirrhosis, 4.7% had a decompensation and 4.0% developed HCC. Diabetes was associated with an increased risk of mortality (AHR = 1.25, 95% CI 1.10-1.42), cirrhosis (AHR = 1.31, 95% CI 1.16-1.48), decompensation (AHR = 1.74, 95% CI 1.31-2.31), and HCC (AHR = 1.32, 95% CI 1.01-1.72) among patients without baseline cirrhosis. Compared to normal-weight persons, obese persons had a higher risk of cirrhosis, but overweight and obese persons had lower risk of mortality and HCC. CONCLUSIONS In this large DAA-treated Veterans cohort, pre-DAA diabetes increases mortality and liver-related events independent of SVR. Continued vigilance is warranted in patients with diabetes despite SVR. Elevated BMI categories appear to have improved outcomes, although further studies are needed to understand those associations.
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Rogers JR, Hripcsak G, Cheung YK, Weng C. Clinical comparison between trial participants and potentially eligible patients using electronic health record data: A generalizability assessment method. J Biomed Inform 2021; 119:103822. [PMID: 34044156 DOI: 10.1016/j.jbi.2021.103822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To present a generalizability assessment method that compares baseline clinical characteristics of trial participants (TP) to potentially eligible (PE) patients as presented in their electronic health record (EHR) data while controlling for clinical setting and recruitment period. METHODS For each clinical trial, a clinical event was defined to identify patients of interest using available EHR data from one clinical setting during the trial's recruitment timeframe. The trial's eligibility criteria were then applied and patients were separated into two mutually exclusive groups: (1) TP, which were patients that participated in the trial per trial enrollment data; (2) PE, the remaining patients. The primary outcome was standardized differences in clinical characteristics between TP and PE per trial. A standardized difference was considered prominent if its absolute value was greater than or equal to 0.1. The secondary outcome was the difference in mean propensity scores (PS) between TP and PE per trial, in which the PS represented prediction for a patient to be in the trial. Three diverse trials were selected for illustration: one focused on hepatitis C virus (HCV) patients receiving a liver transplantation; one focused on leukemia patients and lymphoma patients; and one focused on appendicitis patients. RESULTS For the HCV trial, 43 TP and 83 PE were found, with 61 characteristics evaluated. Prominent differences were found among 69% of characteristics, with a mean PS difference of 0.13. For the leukemia/lymphoma trial, 23 TP and 23 PE were found, with 39 characteristics evaluated. Prominent differences were found among 82% of characteristics, with a mean PS difference of 0.76. For the appendicitis trial, 123 TP and 242 PE were found, with 52 characteristics evaluated. Prominent differences were found among 52% of characteristics, with a mean PS difference of 0.15. CONCLUSIONS Differences in clinical characteristics were observed between TP and PE among all three trials. In two of the three trials, not all of the differences necessarily compromised trial generalizability and subsets of PE could be considered similar to their corresponding TP. In the remaining trial, lack of generalizability appeared present, but may be a result of other factors such as small sample size or site recruitment strategy. These inconsistent findings suggest eligibility criteria alone are sometimes insufficient in defining a target group to generalize to. With caveats in limited scalability, EHR data quality, and lack of patient perspective on trial participation, this generalizability assessment method that incorporates control for temporality and clinical setting promise to better pinpoint clinical patterns and trial considerations.
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Affiliation(s)
- James R Rogers
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, NY, United States; Medical Informatics Services, New York-Presbyterian Hospital, New York, NY, United States
| | - Ying Kuen Cheung
- Department of Biostatistics, Columbia University, New York, NY, United States
| | - Chunhua Weng
- Department of Biomedical Informatics, Columbia University, New York, NY, United States.
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Mahmud N, Kaplan DE, Taddei TH, Goldberg DS. Frailty Is a Risk Factor for Postoperative Mortality in Patients With Cirrhosis Undergoing Diverse Major Surgeries. Liver Transpl 2021; 27:699-710. [PMID: 33226691 PMCID: PMC8517916 DOI: 10.1002/lt.25953] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/28/2020] [Accepted: 11/14/2020] [Indexed: 02/06/2023]
Abstract
With a rising burden of cirrhosis surgeries, understanding risk factors for postoperative mortality is more salient than ever. The role of baseline frailty has not been assessed in this context. We evaluated the association between patient frailty and postoperative risk among diverse patients with cirrhosis and determined if frailty improves prognostication of cirrhosis surgical risk scores. This was a retrospective cohort study of U.S. veterans with cirrhosis identified between 2008 and 2016 who underwent nontransplant major surgery. Frailty was ascertained using the Hospital Frailty Risk Score (HFRS). Cox regression analysis was used to investigate the impact of patient frailty on postoperative mortality. Logistic regression was used to identify incremental changes in discrimination for postoperative mortality when frailty was added to the risk prediction models, including the Model for End-Stage Liver Disease (MELD), MELD-sodium (MELD-Na), Child-Turcotte-Pugh (CTP), Mayo Risk Score (MRS), and Veterans Outcomes and Costs Associated With Liver Disease (VOCAL)-Penn. A total of 804 cirrhosis surgeries were identified. The majority of patients (48.5%) had high-risk frailty at baseline (HFRS >15). In adjusted Cox regression models, categories of increasing frailty scores were associated with poorer postoperative survival. For example, intermediate-risk frailty (HFRS 5-15) conferred a 1.77-fold increased hazard relative to low-risk frailty (HFRS, <5; 95% confidence interval [CI], 1.06-2.95; P = 0.03). High-risk frailty demonstrated a similarly increased hazard (hazard ratio, 1.74; 95% CI, 1.05-2.88; P = 0.03), suggesting a threshold effect of frailty on postoperative mortality. The incorporation of frailty improved discrimination of MELD, MELD-Na, and CTP for postoperative mortality, but did not do so for the MRS or VOCAL-Penn score. Patient frailty was an additional important predictor of cirrhosis surgical risk. The incorporation of preoperative frailty assessments may help to risk stratify patients, especially in settings where the MELD-Na and CTP are commonly applied.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA,Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL
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Mahmud N, Kaplan DE, Goldberg DS, Taddei TH, Serper M. Changes in Hepatocellular Carcinoma Surveillance and Risk Factors for Noncompletion in the Veterans Health Administration Cohort During the Coronavirus Disease 2019 Pandemic. Gastroenterology 2021; 160:2162-2164.e3. [PMID: 33434604 PMCID: PMC8142896 DOI: 10.1053/j.gastro.2021.01.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/28/2020] [Accepted: 01/07/2021] [Indexed: 02/06/2023]
Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania,Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania,Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
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Rosenblatt R, Atteberry P, Tafesh Z, Ravikumar A, Crawford CV, Lucero C, Jesudian AB, Brown RS, Kumar S, Fortune BE. Uncontrolled diabetes mellitus increases risk of infection in patients with advanced cirrhosis. Dig Liver Dis 2021; 53:445-451. [PMID: 33153928 DOI: 10.1016/j.dld.2020.10.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/24/2020] [Accepted: 10/18/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Diabetes mellitus (DM) is common in patients with cirrhosis and is associated with increased risk of infection. AIM To analyze the impact of uncontrolled DM on infection and mortality among inpatients with advanced cirrhosis. METHODS This study utilized the Nationwide Inpatient Sample from 1998 to 2014. We defined advanced cirrhosis using a validated ICD-9-CM algorithm requiring a diagnosis of cirrhosis and clinically significant portal hypertension or decompensation. The primary outcome was bacterial infection. Secondary outcomes included inpatient mortality stratified by elderly age (age≥70). Multivariable logistic regression analyzed outcomes. RESULTS 906,559 (29.2%) patients had DM and 109,694 (12.1%) were uncontrolled. Patients who had uncontrolled DM were younger, had less ascites, but more encephalopathy. Bacterial infection prevalence was more common in uncontrolled DM (34.2% vs. 28.4%, OR 1.33, 95% CI 1.29-1.37, p<0.001). Although uncontrolled DM was not associated with mortality, when stratified by age, elderly patients with uncontrolled DM had a significantly higher risk of inpatient mortality (OR 1.62, 95% CI 1.46-1.81). CONCLUSIONS Uncontrolled DM is associated with increased risk of infection, and when combined with elderly age is associated with increased risk of inpatient mortality. Glycemic control is a modifiable target to improve morbidity and mortality in patients with advanced cirrhosis.
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Affiliation(s)
- Russell Rosenblatt
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, United States.
| | - Preston Atteberry
- NewYork Presbyterian Hospital, Department of Medicine, New York, NY, United States
| | - Zaid Tafesh
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, United States
| | | | - Carl V Crawford
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, United States
| | - Catherine Lucero
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, United States
| | - Arun B Jesudian
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, United States
| | - Robert S Brown
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, United States
| | - Sonal Kumar
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, United States
| | - Brett E Fortune
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York, NY, United States
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Brahmania M, Wiskar K, Walley KR, Celi LA, Rush B. Lower household income is associated with an increased risk of hospital readmission in patients with decompensated cirrhosis. J Gastroenterol Hepatol 2021; 36:1088-1094. [PMID: 32562577 PMCID: PMC8063220 DOI: 10.1111/jgh.15153] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 06/01/2020] [Accepted: 06/08/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIM The impact of household income, a surrogate of socioeconomic status, on hospital readmission rates for patients with decompensated cirrhosis has not been well characterized. METHODS The Nationwide Readmission Database from 2012 to 2014 was used to study the association of lower median household income on 30-, 90-, and 180-day hospital readmission rates for patients with decompensated cirrhosis. RESULTS From the 42 679 001 hospital admissions contained in the sample, there were 82 598 patients with decompensated cirrhosis who survived a hospital admission in the first 6 months of the year. During a uniform 6-month follow-up period, 25 914 (31.4%), 39 928 (48.3%), and 47 496 (57.5%) patients were readmitted at 30, 90, and 180 days, respectively. After controlling for demographic and clinical confounders, patients residing in the three lowest income quartiles were significantly more likely to be readmitted at 30 days than those in the fourth quartile (first quartile, odds ratio [OR] 1.32 [95% confidence interval, CI, 1.17-1.47, P < 0.01]; second quartile, OR 1.25 [95% CI 1.13-1.38, P < 0.01]; and third quartile, OR 1.08 [95% CI 0.97-1.20, P = 0.07]). The association between lower socioeconomic status and the higher risk of readmissions persisted at 90 days (first quartile, OR 1.21 [95% CI 1.14-1.30, P < 0.01]) and 180 days (first quartile, OR 1.32 [95% CI 1.20-1.44, P < 0.01]). CONCLUSION Patients with decompensated cirrhosis residing in the lowest income quartile had a 32% higher odds of hospital readmissions at 30, 90, and 180 days compared with those in the highest income quartile.
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Affiliation(s)
- Mayur Brahmania
- Department of Medicine, Division of Gastroenterology, London Health Sciences Center, Western University, London, Ontario
| | - Katie Wiskar
- Department of Medicine, Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia
| | - Keith R Walley
- Department of Medicine, Division of Critical Care Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia,,Center for Heart Lung Innovation (HLI), University of British Columbia, Vancouver, British Columbia
| | - Leo A Celi
- Department of Medicine, Division of Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, Massachusetts, USA
| | - Barret Rush
- Department of Internal Medicine, Division of Critical Care Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Juliao-Baños F, Kock J, Arrubla M, Calixto O, Camargo J, Cruz L, Hurtado J, Clavijo A, Donado J, Schwartz S, Abreu MT, Damas OM. Trends in the epidemiology of inflammatory bowel disease in Colombia by demographics and region using a nationally representative claims database and characterization of inflammatory bowel disease phenotype in a case series of Colombian patients. Medicine (Baltimore) 2021; 100:e24729. [PMID: 33607817 PMCID: PMC7899864 DOI: 10.1097/md.0000000000024729] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 01/18/2021] [Indexed: 01/05/2023] Open
Abstract
The incidence of inflammatory bowel disease (IBD) is on the rise in Latin America. The aims of this study were to examine epidemiologic trends of IBD in Colombia by demographics, region, urbanicity, and to describe the IBD phenotype in a large well-characterized Colombian cohort.We used a national database of 33 million adults encompassing 97.6% of the Colombian population in order to obtain epidemiologic trends of IBD using International Classification of Diseases 10codes for adults with ulcerative colitis (UC) and Crohn disease (CD). We calculated the incidence and prevalence of UC and CD from 2010-2017 and examined epidemiologic trends by urbanicity, demographics, and region. We then examined the IBD phenotype (using Montreal Classification), prevalence of IBD-related surgeries, and types of IBD-medications prescribed to adult patients attending a regional IBD clinic in Medellin, Colombia between 2001 and 2017.The incidence of UC increased from 5.59/100,000 in 2010 to 6.3/100,000 in 2017 (relative risk [RR] 1.12, confidence interval (CI) (1.09-1.18), P < .0001). While CD incidence did not increase, the prevalence increased within this period. The Andes region had the highest incidence of IBD (5.56/100,000 in 2017). IBD was seen less in rural regions in Colombia (RR=.95, CI (0.92-0.97), p < .01). An increased risk of IBD was present in women, even after adjusting for age and diagnosis year (RR 1.06 (1.02-1.08), P = .0003). The highest IBD risk occurred in patients 40 to 59 years of age. In the clinic cohort, there were 649 IBD patients: 73.7% UC and 24.5% CD. Mean age of diagnosis in CD was 41.0 years and 39.9 years in UC. UC patients developed mostly pancolitis (43%). CD patients developed mostly ileocolonic disease and greater than a third of patients had an inflammatory, non-fistulizing phenotype (37.7%). A total of 16.7% of CD patients had perianal disease. CD patients received more biologics than UC patients (odds ratio: 3.20, 95% CI 2.19-4.69 P < .001).Using both a national representative sample and a regional clinic cohort, we find that UC is more common in Colombia and is on the rise in urban regions; especially occurring in an older age cohort when compared to Western countries. Future studies are warranted to understand evolving environmental factors explaining this rise.
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Affiliation(s)
| | - Joshua Kock
- Takeda Pharmaceuticals, Medical Department, Bogotá
- Department of Medicine, Universidad de La Sabana, Chía
| | - Mateo Arrubla
- Department of Internal Medicine, Pontificia Bolivariana University, Medellin
| | - Omar Calixto
- Department of Internal Medicine. Nueva Granada Militar University. Bogotá
| | | | - Lina Cruz
- General Medicine. Medellin Clinic, Medellin Colombia
| | - Juan Hurtado
- Department of Internal Medicine. Universidad de Antioquia
| | - Absalon Clavijo
- Department of Internal Medicine, Pontificia Bolivariana University, Medellin
| | - Jorge Donado
- Department of Internal Medicine, Pontificia Bolivariana University, Medellin
- Department of Epidemiology. Pablo Tobón Uribe Hospital
| | - Seth Schwartz
- Division of Public Health Sciences, University of Miami Miller School of Medicine and Departments of Kinesiology, Health Education, and Educational Psychology, College of Education, University of Texas at Austin
| | - Maria T. Abreu
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami FL USA
| | - Oriana M. Damas
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami FL USA
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Mahmud N, Asrani SK, Kaplan DE, Ogola GO, Taddei TH, Kamath PS, Serper M. The Predictive Role of Model for End-Stage Liver Disease-Lactate and Lactate Clearance for In-Hospital Mortality Among a National Cirrhosis Cohort. Liver Transpl 2021; 27:177-189. [PMID: 37160007 PMCID: PMC7880877 DOI: 10.1002/lt.25913] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/28/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023]
Abstract
The burden of cirrhosis hospitalizations is increasing. The admission Model for End-Stage Liver Disease-lactate (MELD-lactate) was recently demonstrated to be a superior predictor of in-hospital mortality compared with MELD in limited cohorts. We identified specific classes of hospitalizations where MELD-lactate may be especially useful and evaluated the predictive role of lactate clearance. This was a retrospective cohort study of 1036 cirrhosis hospitalizations for gastrointestinal bleeding, infection, or other portal hypertension-related indications in the Veterans Health Administration where MELD-lactate was measured on admission. Performance characteristics for in-hospital mortality were compared between MELD-lactate and MELD/MELD-sodium (MELD-Na), with stratified analyses of MELD categories (≤15, >15 to <25, ≥25) and reason for admission. We also incorporated day 3 lactate levels into modeling and tested for an interaction between day 1 MELD-lactate and day 3 lactate clearance. MELD-lactate had superior discrimination for in-hospital mortality compared with MELD or MELD-Na (area under the curve [AUC] 0.789 versus 0.776 versus 0.760, respectively; P < 0.001) and superior calibration. MELD-lactate had higher discrimination among hospitalizations with MELD ≤15 (AUC 0.763 versus 0.608 for MELD, global P = 0.01) and hospitalizations for infection (AUC 0.791 versus 0.674 for MELD, global P < 0.001). We found a significant interaction between day 1 MELD-lactate and day 3 lactate clearance; heat maps were created as clinical tools to risk-stratify patients based on these clinical data. MELD-lactate had significantly superior performance in predicting in-hospital mortality among patients hospitalized for infection and/or with MELD ≤15 when compared with MELD or MELD-Na. Incorporating day 3 lactate clearance may further improve prognostication.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sumeet K. Asrani
- Baylor University Medical Center, Baylor Scott and White, Dallas, Texas
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | | | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | | | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
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Cheung K, Mailman JF, Crawford JJ, Karvellas CJ, Sy E. Trends and outcomes of mechanically ventilated cirrhotic patients in the United States from 2005–2014. J Intensive Care Soc 2021; 23:139-149. [DOI: 10.1177/1751143720985293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Purpose Cirrhotic patients in organ failure are frequently admitted to intensive care units (ICUs) to receive invasive mechanical ventilation (IMV). We evaluated the trends of hospitalizations, in-hospital mortality, hospital costs, and hospital length of stay (LOS) of IMV patients with cirrhosis. Methods We analyzed the United States National Inpatient Sample from 2005–2014. We selected discharges of IMV adult (≥18 years) patients with cirrhosis using the International Classification of Diseases, 9th Edition , Clinical Modification codes. Trends were assessed using linear regression and joinpoint regression. Results Between 2005 and 2014, there were approximately 9,441,605 hospitalizations of IMV adult patients, of which 4.7% had cirrhosis. There was an increasing trend in the total number of IMV cirrhotic patient hospitalizations (annual percent change [APC] 7.0%, 95% confidence interval [CI] 6.4%; 7.6%, Ptrend < 0.001). The in-hospital case-fatality ratio declined between 2005–2011 (APC –2.9%, 95% CI, –3.4%; –2.4%, Ptrend < 0.001); however, it remained similar between 2011–2014 ( Ptrend = 0.58). The total annual hospital costs of all IMV cirrhotic patients increased from approximately $1.2 billion USD in 2005 to $2.7 billion USD in 2014 ( Ptrend < 0.001). The mean hospital costs per patient and mean LOS declined between 2005 and 2014 ( Ptrend < 0.001 and Ptrend = 0.01 respectively). Conclusions The total number of hospitalizations and total annual costs of IMV patients with cirrhosis have been increasing over time. However, past hesitancy around admitting cirrhotic patients to the ICU may need to be tempered by the improving mortality trends in this patient population.
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Affiliation(s)
- Kyle Cheung
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jonathan F Mailman
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Department of Critical Care, Regina General Hospital, Regina, Saskatchewan, Canada
- Department of Pharmacy Services, Regina General Hospital, Regina, Saskatchewan, Canada
| | | | - Constantine J Karvellas
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Eric Sy
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Department of Critical Care, Regina General Hospital, Regina, Saskatchewan, Canada
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Shah S, Goldberg DS, Kaplan DE, Sundaram V, Taddei TH, Mahmud N. Patient Frailty Is Independently Associated With the Risk of Hospitalization for Acute-on-Chronic Liver Failure. Liver Transpl 2021; 27:16-26. [PMID: 32946660 PMCID: PMC8249075 DOI: 10.1002/lt.25896] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/12/2020] [Accepted: 08/24/2020] [Indexed: 12/17/2022]
Abstract
There is significant interest in identifying risk factors associated with acute-on-chronic liver failure (ACLF). In transplant candidates, frailty predicts wait-list mortality and posttransplant outcomes. However, the impact of frailty on ACLF development and mortality is unknown. This was a retrospective study of US veterans with cirrhosis identified between 2008 and 2016. First hospitalizations were characterized as ACLF or non-ACLF admissions. Prehospitalization patient frailty was ascertained using a validated score based on administrative coding data. We used logistic regression to investigate the impact of an increasing frailty score on the odds of ACLF hospitalization and short-term ACLF mortality. Cox regression was used to analyze the association between frailty and longterm survival from hospitalization. We identified 16,561 cirrhosis hospitalizations over a median follow-up of 4.19 years (interquartile range, 2.47-6.34 years). In adjusted models, increasing frailty score was associated with significantly increased odds of ACLF hospitalization versus non-ACLF hospitalization (odds ratio, 1.03 per point; 95% CI 1.02-1.03; P < 0.001). By contrast, frailty score was not associated with ACLF 28- or 90-day mortality (P = 0.13 and P = 0.33, respectively). In an adjusted Cox analysis of all hospitalizations, increasing frailty scores were associated with poorer longterm survival from the time of hospitalization (hazard ratio, 1.02 per 5 points; 95% confidence interval, 1.01-1.03; P = 0.004). Frailty increases the likelihood of ACLF hospitalization among patients with cirrhosis, but it does not impact short-term ACLF mortality. These findings have implications for clinicians caring for frail outpatients with cirrhosis, including tailored follow-up, risk mitigation strategies, and possible expedited transplant evaluation.
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Affiliation(s)
- Shivani Shah
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - David E. Kaplan
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Vinay Sundaram
- Division of Gastroenterology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Nadim Mahmud
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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The Use of Administrative Data to Investigate the Population Burden of Hepatic Encephalopathy. J Clin Med 2020; 9:jcm9113620. [PMID: 33182743 PMCID: PMC7696713 DOI: 10.3390/jcm9113620] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/13/2022] Open
Abstract
Hepatic encephalopathy (HE) is a devastating complication of cirrhosis with an increasing footprint in global public health. Although the condition is defined using a careful history and examination, we cannot accurately measure the true impact of HE relying on data collected exclusively from clinical studies. For this reason, administrative data sources are necessary to study the population burden of HE. Administrative data is generated with each health care encounter to account for health care resource utilization and is extracted into a dataset for the secondary purpose of research. In order to utilize such data for valid analysis, several pitfalls must be avoided—specifically, selecting the particular database capable of meeting the needs of the study’s aims, paying careful attention to the limits of each given database, and ensuring validity of case definition for HE specific to the dataset. In this review, we summarize the types of data available for and the results of administrative data studies of HE.
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Mazumder NR, Celaj S, Atiemo K, Daud A, Jackson KL, Kho A, Levitsky J, Ladner DP. Liver-related mortality is similar among men and women with cirrhosis. J Hepatol 2020; 73:1072-1081. [PMID: 32344052 PMCID: PMC7572539 DOI: 10.1016/j.jhep.2020.04.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 04/08/2020] [Accepted: 04/13/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Sex-based differences are known to significantly contribute to outcomes in patients with chronic liver diseases; however, the role of patient sex in cirrhosis is unclear. We aimed to study the relationship between patient sex and cirrhosis. METHODS We analyzed a cohort of 20,045 patients with cirrhosis using a Chicago-wide electronic health record database that was linked with the United Network for Organ Sharing and cause of death data from the state death registry. Adjusted Cox survival analyses and competing risk analyses were performed to obtain subdistribution hazard ratios (HRs) for liver-related cause of death. RESULTS Female and male patients had similar age, racial distribution, insurance status, and comorbidity status by Elixhauser score. Females had higher rates of cholestatic liver disease (17.1% vs. 6.2%, p <0.001) and non-alcoholic steatohepatitis (29.8% vs. 21.2%, p <0.001) than males. They were less likely to have portal hypertensive complications and had lower peak MELD-Na scores during follow-up. Female sex was associated with a decreased hazard of all-cause mortality (adjusted HR 0.85; 95% CI 0.80-0.90). This effect was attenuated when liver-related mortality was examined (subdistribution HR 0.93; 95% CI 0.87-1.00). No significant difference was noted for women who were 'ever-listed' in competing risk analyses for either all-cause mortality (subdistribution HR 1.09; 95% CI 0.88-1.35) or liver-related death (subdistribution HR 1.12; 95% CI 0.87-1.43), despite lower rates of listing (7.5% vs. 9.8%; p <0.001) and transplant (3.5% vs. 5.2%; p <0.001). CONCLUSIONS In this longitudinal study of patients with cirrhosis, female sex was associated with a survival advantage likely driven by lower rates of non-liver-related death. Women were not at an increased risk of liver-related death despite lower rates of listing and transplantation. LAY SUMMARY Patient sex is an important contributor in many chronic diseases, including cirrhosis. Prior studies have suggested that female sex is associated with worse outcomes. We analyzed a cohort of 20,045 patients with cirrhosis using a Chicago-wide electronic health record database. Using multivariate competing risk analyses, we found that female sex in cirrhosis is actually associated with a lower risk of all-cause mortality and has no association with liver-related mortality. Our findings are novel because we show that women with cirrhosis have a similar risk of liver-related death as their male counterparts, despite lower rates of listing and transplantation.
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Affiliation(s)
- Nikhilesh R Mazumder
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Stela Celaj
- Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kofi Atiemo
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Amna Daud
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Kathryn L Jackson
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Chicago, IL
| | - Abel Kho
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Chicago, IL
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL; Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Daniela P Ladner
- Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Healthcare Studies, Institute for Public Health and Medicine, Chicago, IL.
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Antithymocyte Globulin Versus Interleukin-2 Receptor Antagonist in Kidney Transplant Recipients With Hepatitis C Virus. Transplantation 2020; 104:1294-1303. [PMID: 32433232 DOI: 10.1097/tp.0000000000002959] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Hepatitis C virus-positive (HCV+) kidney transplant (KT) recipients are at increased risks of rejection and graft failure. The optimal induction agent for this population remains controversial, particularly regarding concerns that antithymocyte globulin (ATG) might increase HCV-related complications. METHODS Using Scientific Registry of Transplant Recipients and Medicare claims data, we studied 6780 HCV+ and 139 681 HCV- KT recipients in 1999-2016 who received ATG or interleukin-2 receptor antagonist (IL2RA) for induction. We first examined the association of recipient HCV status with receiving ATG (versus IL2RA) using multilevel logistic regression. Then, we studied the association of ATG (versus IL2RA) with KT outcomes (rejection, graft failure, and death) and hepatic complications (liver transplant registration and cirrhosis) among HCV+ recipients using logistic and Cox regression. RESULTS HCV+ recipients were less likely to receive ATG than HCV- recipients (living donor, adjusted odds ratio [aOR] = 0.640.770.91; deceased donor, aOR = 0.710.810.92). In contrast, HCV+ recipients who received ATG were at lower risk of acute rejection compared to those who received IL2RA (1-y crude incidence = 11.6% versus 12.6%; aOR = 0.680.820.99). There was no significant difference in the risks of graft failure (adjusted hazard ratio [aHR] = 0.861.001.17), death (aHR = 0.850.951.07), liver transplant registration (aHR = 0.580.971.61), and cirrhosis (aHR = 0.730.921.16). CONCLUSIONS Our findings suggest that ATG, as compared to IL2RA, may lower the risk of acute rejection without increasing hepatic complications in HCV+ KT recipients. Given the higher rates of acute rejection in this population, ATG appears to be safe and reasonable for HCV+ recipients.
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Khan MZ, Khan MU, Munir MB, Khan SU, Osman M, Balla S. Contemporary trends and outcomes in aortic valve replacement in patients with end-stage liver disease. Catheter Cardiovasc Interv 2020; 96:947-955. [PMID: 32129573 DOI: 10.1002/ccd.28834] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/16/2020] [Accepted: 02/25/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Even in high-risk trials pertaining to transcatheter aortic valve replacement (TAVR), patients with end-stage liver disease (ESLD) have been under-represented. We sought to study this population group from a large national United States population database. METHODS We used National Inpatient Sample (NIS) database from January 2005 to August 2015. Patients with ESLD were extracted using Goldberg's algorithm. Propensity match analysis was done for comparative analysis between surgical aortic valve replacement (SAVR) and TAVR groups. Logistic regression analysis was used for predictors of in-hospital mortality. RESULTS Out of 309,959 ESLD patients, 1,375 underwent aortic valve replacement and 1,199 patients were included in our study. Mean age was 66.1 (SD, 9.1) years. In matched data, the in-hospital mortality was 5.5% in TAVR group when compared to 19.4% in SAVR group. Ventilator use (16.1 vs. 27.2%, p < .01), tracheostomy (<4 vs. 7.2%, p < .01), and vasopressin use (0 vs. 7.4%, p < .01) were utilized less in TAVR group as compared to SAVR group. The proportion of TAVR has increased from almost zero in 2011 to 51.3% in 2015. Mean cost for hospital stay has increased in SAVR group (from 254,427$ in 2005 to 321,791$ in 2015, p < .01). Similarly, a large decrease in length of stay has been observed for TAVR group (14.5 days in 2011 to 5.4 days in 2015, p < .01). TAVR (odds ratios [OR]: 0.42, 95% confidence interval [CI]: 0.20-0.87, p = .02) was associated with lower in-hospital mortality. CONCLUSION TAVR was associated with lower in-hospital mortality, morbidity, and resource utilization in high-risk ESLD patients.
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Affiliation(s)
- Muhammad Z Khan
- Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Muhammad U Khan
- Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Muhammad Bilal Munir
- Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia, USA.,Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California, USA
| | - Safi U Khan
- Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Mohammed Osman
- Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia, USA
| | - Sudarshan Balla
- Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia, USA
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48
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Bengtsson B, Askling J, Ludvigsson JF, Hagström H. Validity of administrative codes associated with cirrhosis in Sweden. Scand J Gastroenterol 2020; 55:1205-1210. [PMID: 32960654 DOI: 10.1080/00365521.2020.1820566] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Although cirrhosisis a major cause of liver-related mortality globally, validation studies of the administrative coding for diagnoses associated with cirrhosis are scarce. We aimed to determine the validity of the International Classification of Diseases, 10th revision (ICD-10) codes corresponding to cirrhosis and its complications in the Swedish National Patient Register (NPR). METHODS We randomly selected 750 patients with ICD codes for either alcohol-related cirrhosis (K70.3), unspecified cirrhosis (K74.6) oesophageal varices (I85.0/I85.9), hepatocellular carcinoma (HCC, C22.0) or ascites (R18.9) registered in the NPR from 72 healthcare centres in 2000-2016. Hospitalisation events and outpatient visits in specialised care were included. Positive predictive values (PPVs) were calculated using the information in the patient charts as the gold standard. RESULTS Complete data were obtained for 630 (of 750) patients (84%). For alcohol-related cirrhosis, 126/136 cases were correctly coded, corresponding to a PPV of 93% (95% confidence interval, 95%CI: 87-96). The PPV for cirrhosis with unspecified aetiology was 91% (121/133, 95%CI: 85-95) and 96% for oesophageal varices (118/123, 95%CI: 91-99). The PPV was lower for HCC, 84% (91/109, 95%CI: 75-90). The PPV for liver-related ascites was low, 43% (56/129, 95%CI: 35-52), as this category often consisted of non-hepatic ascites. When combining the ascites code with a code for chronic liver disease, the PPV for liver-related ascites increased to 93% (50/54, 95%CI: 82-98). CONCLUSIONS The validity of ICD-10 codes for cirrhosis, oesophageal varices and HCC is high. However, coding for ascites should be combined with a code of chronic liver disease to have an acceptable validity.
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Affiliation(s)
- Bonnie Bengtsson
- Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden.,Unit of Gastroenterology and Rheumatology, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Johan Askling
- Rheumatology, Theme Inflammation and Infection, Karolinska University Hospital, Stockholm, Sweden.,Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatrics, Örebro University Hospital, Örebro, Sweden.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK.,Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Hannes Hagström
- Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden.,Unit of Gastroenterology and Rheumatology, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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49
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Kaplan DE, Medvedeva E, Serper M. Care quality and outcomes among US veterans with chronic hepatitis B in the hepatitis C direct-acting antiviral era. J Viral Hepat 2020; 27:1082-1092. [PMID: 32484991 DOI: 10.1111/jvh.13340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/09/2020] [Accepted: 05/10/2020] [Indexed: 12/14/2022]
Abstract
Adherence to guideline-recommended hepatitis B virus (HBV) care is suboptimal. We hypothesized that national hepatitis C eradication efforts during the era from 2015 to 2017 would improve the quality of care for cHBV given increased recognition and specialty referrals for liver disease. The study described herein is a retrospective cohort study of veterans with at least one positive HBsAg (HBsAg+) result from 1 January 2003 to 31 December 2017 using the VA Corporate Data Warehouse (CDW) analysed by era (2003-2004, 2005-2009, 2010-2014, 2015-2017). Relevant covariates such as HCV co-infection, demographics, cirrhosis and baseline laboratory testing were obtained through previously validated approaches. We evaluated completion of process measures within 2 years of the index HBsAg + result: specialty care referral; testing of ALT, HBV-DNA, HBeAg and anti-HBe; testing for co-infection and/or vaccination for HAV, HCV, HDV and HIV; and hepatocellular carcinoma (HCC) surveillance among those meeting criteria. We also measured use of antiviral therapy in appropriate candidates (ALT ≥ 2 × ULN, HBV-DNA ≥ 2000 IU/mL). Of the 16 673 individuals with HBsAg + test results, 9,521 were confirmed as chronic HBV. Era-related (Era 3:2010-2014 vs Era 4:2015-2017) increases in guideline-recommended process measures included the following: outpatient visits with GI/ID specialists (78%-89%), HBV-DNA testing (73%-79%), HDV testing (27%-35%), appropriate HBV antiviral utilization (55%-70%) and HCC surveillance (40%-43%); all P < .0001. In the subset of HBV/HCV-co-infected patients, HCV DAA therapy was associated with a trend towards improved overall survival. In conclusion, the overall quality of care for HBV has significantly improved in the era of widespread HCV DAA therapy in an integrated health system possibly due to increased recognition and referral for liver disease.
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Affiliation(s)
- David E Kaplan
- Gastroenterology Section, Philadelphia VA Medical Center, Philadelphia, Pennsylvania, USA.,Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Elina Medvedeva
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Marina Serper
- Gastroenterology Section, Philadelphia VA Medical Center, Philadelphia, Pennsylvania, USA.,Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania, USA.,Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Mahmud N, Hubbard RA, Kaplan DE, Serper M. Declining Cirrhosis Hospitalizations in the Wake of the COVID-19 Pandemic: A National Cohort Study. Gastroenterology 2020; 159:1134-1136.e3. [PMID: 32387493 PMCID: PMC7200325 DOI: 10.1053/j.gastro.2020.05.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 05/01/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Rebecca A. Hubbard
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David E. Kaplan
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Marina Serper
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania,Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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