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Ahmed M, Islam M, Gogokhia L, Borz-Baba C, Wakefield D, Jakab SS. Hospital Utilization for Patients With Cirrhosis and Severe Ascites in a Model of Outpatient Paracentesis by Interventional Radiology. Cureus 2023; 15:e51397. [PMID: 38292997 PMCID: PMC10826452 DOI: 10.7759/cureus.51397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Paracentesis is currently performed by interventional radiologists (IR) rather than gastroenterologists/hepatologists or internists. In this model of care, there is usually no evaluation of patients' renal function or adjustment of their medications at the time of paracentesis. The objectives of this study were to analyze hospital utilization and cirrhosis complications within six months of index outpatient paracentesis by IR and to identify potential areas of improvement in care. METHODS This is a retrospective study of patients with cirrhosis and ascites who underwent outpatient paracentesis by IR between October 15, 2015, and October 15, 2018, at a tertiary academic medical center. We collected demographics, data on cirrhosis etiology/complications, laboratory tests, provider notes, outpatient paracentesis dates, emergency department (ED) visits, hospitalizations, and ICU admissions within the following six months post index paracentesis. Associations between categorical predictors and clinical outcomes were analyzed using the chi-square test. Associations between quantitative predictors and clinical outcomes were analyzed using the Wilcoxon rank sum test. RESULTS Our study included 69 unique patients who had at least one outpatient encounter for paracentesis by IR in the study period. Most patients were men (71%), had alcohol-related cirrhosis as primary etiology (53.6%), an average age of 60 years, and an average Model for End-Stage Liver Disease-sodium (MELDNa) score at baseline of 16. Within six months from index paracentesis, 44 patients (64.7%) underwent repeat IR outpatient paracentesis (total 187 paracenteses, 4.25 paracenteses/patient), 43 patients (62.3%) had ER visits (total 118 ER visits, 2.8/patient), 41 patients (59.4%) had hospital admissions (total 88 admissions, 2.2/patient), and 11 patients required ICU admission. Complications of cirrhosis noted during follow-up included hepatic encephalopathy (40.5%), acute kidney injury (38.2%), upper gastrointestinal (UGI) bleeding (16%), and spontaneous bacterial peritonitis (SBP) in 15%. The mortality rate at six months was 20%. On multivariate analysis, the predictive factors for mortality were older age (p = 0.03) and MELDNa score (p = 0.02). Baseline MELDNa was predictive of acute kidney injury (p = 0.02), UGI bleed (p < 0.01), and ICU admission (p < 0.01), but not of SBP, encephalopathy, ED visit, or hospital admissions. Among patients with more than one paracentesis (64%),six patients underwent transjugular portosystemic shunt (TIPS), but there was no documentation of TIPS consideration in 31 patients (70.4%). A total of 20 patients (29%) were waitlisted for liver transplantation. CONCLUSION In this contemporary cohort of patients with cirrhosis undergoing outpatient IR paracentesis, we found a high rate of short-term cirrhosis complications and hospital utilization, while TIPS consideration was very low. Further data are needed to identify specific gaps in care, but IR paracentesis should be integrated within a multidisciplinary management model, with emphasis on early TIPS in eligible patients, as recommended by the current practice guidelines.
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Affiliation(s)
- Mustajab Ahmed
- Internal Medicine, Saint Mary's Hospital, Waterbury, USA
| | - Masuma Islam
- Internal Medicine, Saint Mary's Hospital, Waterbury, USA
| | - Lasha Gogokhia
- Gastroenterology and Hepatology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, USA
| | | | - Dorothy Wakefield
- Statistics, Department of Research, Saint Francis Hospital & Medical Center, Hartford, USA
| | - Sofia S Jakab
- Gastroenterology and Hepatology, Yale School of Medicine, New Haven, USA
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Gorgani F, Esfahani Z, Ghamari SH, Ghasemi E, Azadnajafabad S, Shobeiri P, Mohammadi E, Moghaddam SS, Abbasi-Kangevari M, Fattahi N, Tehrani YS, Farzi Y, Rezaei N, Larijani B, Farzadfar F. Global, regional, and national burden and quality of care index of liver cirrhosis by cause from global burden of disease 1990-2019. J Gastroenterol Hepatol 2023; 38:119-128. [PMID: 36287036 DOI: 10.1111/jgh.16041] [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: 06/29/2022] [Revised: 09/21/2022] [Accepted: 10/17/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND AIM Cirrhosis and other chronic liver diseases are complex disorders with a known burden. Currently health systems have different approaches to dealing with this issue. The objective of this study is to describe the burden attributed to and quality of care for cirrhosis and other chronic liver diseases. METHODS Data of cirrhosis and other chronic liver diseases extracted from Global-Burden-of-Diseases 2019. Four indicators, including mortality to incidence ratio, prevalence to incidence ratio, disability-adjusted-life-years (DALYs) to prevalence ratio, and years-of-life-lost (YLLs) to years-lived-with-disability (YLDs) ratio, were defined and combined by the principal-components-analysis to construct the Quality-of-Care-Index (QCI). RESULTS The global QCI of cirrhosis increased from 71.0 in 1990 to 79.3 in 2019. The QCI showed a favorable situation in higher SDI countries compared with lower SDI countries, with a QCI of 86.8 in high SDI countries and 60.1 in low SDI countries. The highest QCI was found in Western Pacific Region (90.2), and the lowest was for African Region (60.4). Highest QCI belonged to the 50-54 age group (99.5), and the lowest was for the 30.34 age group (70.9). Among underlying causes of cirrhosis, the highest QCI belonged to alcohol use, followed by hepatitis C and NAFLD with QCIs of 86.1, 85.3, and 81.1. CONCLUSIONS There was a considerable variation in the QCI of cirrhosis and other chronic liver diseases. Countries with low QCI, mainly located in developing regions, need organized action to control the burden of cirrhosis and its underlying causes and improve their quality of care.
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Affiliation(s)
- Fateme Gorgani
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Esfahani
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Biostatistics, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Seyyed-Hadi Ghamari
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Erfan Ghasemi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sina Azadnajafabad
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Parnian Shobeiri
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Esmaeil Mohammadi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sahar Saeedi Moghaddam
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Abbasi-Kangevari
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Fattahi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Division of Gastroenterology, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Yeganeh Sharifnejad Tehrani
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Yosef Farzi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Negar Rezaei
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Farshad Farzadfar
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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Nababan SHH, Mansjoer A, Fauzi A, Gani RA. Predictive scoring systems for in-hospital mortality due to acutely decompensated liver cirrhosis in Indonesia. BMC Gastroenterol 2021; 21:392. [PMID: 34670501 PMCID: PMC8529806 DOI: 10.1186/s12876-021-01972-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 10/14/2021] [Indexed: 11/10/2022] Open
Abstract
Background Acutely decompensated liver cirrhosis is associated with high medical costs and negatively affects productivity and quality of life. Data on factors associated with in-hospital mortality due to acutely decompensated liver cirrhosis in Indonesia are scarce. This study aims to identify predictors of in-hospital mortality and develop predictive scoring systems for clinical application in acutely decompensated liver cirrhosis patients. Methods This was a retrospective cohort study using a hospital database of acutely decompensated liver cirrhosis data at Cipto Mangunkusumo National General Hospital, Jakarta (2016–2019). Bivariate and multivariate logistic regression analyses were performed to identify the predictors of in-hospital mortality. Two scoring systems were developed based on the identified predictors. Results A total of 241 patients were analysed; patients were predominantly male (74.3%), had hepatitis B (38.6%), and had Child–Pugh class B or C cirrhosis (40% and 38%, respectively). Gastrointestinal bleeding was observed in 171 patients (70.9%), and 29 patients (12.03%) died during hospitalization. The independent predictors of in-hospital mortality were age (adjusted OR: 1.09 [1.03–1.14]; p = 0.001), bacterial infection (adjusted OR: 6.25 [2.31–16.92]; p < 0.001), total bilirubin level (adjusted OR: 3.01 [1.85–4.89]; p < 0.001) and creatinine level (adjusted OR: 2.70 [1.20–6.05]; p = 0.016). The logistic and additive scoring systems, which were developed based on the identified predictors, had AUROC values of 0.899 and 0.868, respectively. Conclusion The in-hospital mortality rate of acutely decompensated liver cirrhosis in Indonesia is high. We have developed two predictive scoring systems for in-hospital mortality in acutely decompensated liver cirrhosis patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-021-01972-6.
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Affiliation(s)
- Saut Horas H Nababan
- Hepatobiliary Division, Internal Medicine Department, Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia, Jl. Diponegoro No. 71, Jakarta, 10430, Indonesia.
| | - Arif Mansjoer
- Clinical Epidemiology Unit, Internal Medicine Department, Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia, Jl. Diponegoro No.71, Jakarta, 10430, Indonesia
| | - Achmad Fauzi
- Gastroenterology Division, Internal Medicine Department, Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia, Jl. Diponegoro No.71, Jakarta, 10430, Indonesia
| | - Rino A Gani
- Hepatobiliary Division, Internal Medicine Department, Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia, Jl. Diponegoro No. 71, Jakarta, 10430, Indonesia
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Carrier P, Debette-Gratien M, Jacques J, Loustaud-Ratti V. Cirrhotic patients and older people. World J Hepatol 2019; 11:663-677. [PMID: 31598192 PMCID: PMC6783402 DOI: 10.4254/wjh.v11.i9.663] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/18/2019] [Accepted: 07/16/2019] [Indexed: 02/06/2023] Open
Abstract
The global population is aging, and so the number of older cirrhotic patients is increasing. Older patients are characterised by a risk of frailty and comorbidities, and age is a risk factor for mortality in cirrhotic patients. The incidence of non-alcoholic fatty liver disease as an aetiology of cirrhosis is increasing, while that of chronic viral hepatitis is decreasing. Also, cirrhosis is frequently idiopathic. The management of portal hypertension in older cirrhotic patients is similar to that in younger patients, despite the greater risk of treatment-related adverse events of the former. The prevalence of hepatocellular carcinoma increases with age, but its treatment is unaffected. Liver transplantation is generally recommended for patients < 70 years of age. Despite the increasing prevalence of cirrhosis in older people, little data are available and few recommendations have been proposed. This review suggests that comorbidities have a considerable impact on older cirrhotic patients.
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Affiliation(s)
- Paul Carrier
- Fédération d’Hépatologie, Centre Hospitalier Universitaire Dupuytren de Limoges, Limoges 87042, France
- Faculté de Médecine et de Pharmacie de Limoges, Rue Docteur Marcland, Limoges 87042, France
| | - Marilyne Debette-Gratien
- Fédération d’Hépatologie, Centre Hospitalier Universitaire Dupuytren de Limoges, Limoges 87042, France
- Faculté de Médecine et de Pharmacie de Limoges, Rue Docteur Marcland, Limoges 87042, France
| | - Jérémie Jacques
- Service de Gastroentérologie, Centre Hospitalier Universitaire Dupuytren de Limoges, Limoges 87042, France
| | - Véronique Loustaud-Ratti
- Fédération d’Hépatologie, Centre Hospitalier Universitaire Dupuytren de Limoges, Limoges 87042, France
- Faculté de Médecine et de Pharmacie de Limoges, Rue Docteur Marcland, Limoges 87042, France.
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Lavekar A, Raje D, Sadar A, Manohar T, Manjari KS, Satyanarayana PT. Predictors of Three-month Hospital Readmissions and Mortality in Patients with Cirrhosis of Liver. Euroasian J Hepatogastroenterol 2019; 9:71-77. [PMID: 32117694 PMCID: PMC7047310 DOI: 10.5005/jp-journals-10018-1302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The rate of readmission to the hospital and mortality within 3 months is used as a quality measure for hospitalized patients with advanced liver disease; however, the topic has not been studied adequately under Indian context. MATERIALS AND METHODS This study was a longitudinal study conducted from March 2017 to March 2018. Patients admitted with liver cirrhosis at inpatient hepatology service in Tertiary Health Care Centre, Mysore, India, were included for the study. A total of 232 patients were studied and their demographic, clinical, biochemical parameters along with readmission status and outcomes within 3 months of observation were recorded. The effect of these factors on readmission and mortality was studied through multivariate logistic regression. RESULTS The risk of readmission within 3 months was significantly associated with the presence of hydrothorax, hepatorenal syndrome (HRS), and portal vein thrombosis (PVT). Maddrey's discriminant function (DF), model for end-stage liver disease (MELD) score, and the Child-Turcotte-Pugh (CTP) C grade also significantly increased the odds of readmission. The area under curve (AUC) for DF and MELD were 0.927 and 0.928, respectively. Both DF and MELD significantly increased the odds of mortality. CONCLUSION The present study revealed that the parameters such as MELD and DF score and complications such as hydrothorax, HRS, and PVT are the most predictive indicators of cirrhosis complication to ascertain the rate of readmission and mortality within 3 months of patient discharge. HOW TO CITE THIS ARTICLE Lavekar A, Raje D, Sadar A, et al. Predictors of Three-month Hospital Readmissions and Mortality in Patients with Cirrhosis of Liver. Euroasian J Hepato-Gastroenterol 2019;9(2):71-77.
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Affiliation(s)
- Anurag Lavekar
- Department of Gastroenterology and Hepatology, JSS Medical College and Hospital, Mysore, Karnataka, India
| | - Dhananjay Raje
- Department of Biostatistics, Data Analysis Group, MDS Bio Analytics Private Limited, Nagpur, Maharashtra, India
| | - Aarsha Sadar
- Department of Gastroenterology and Hepatology, JSS Medical College and Hospital, Mysore, Karnataka, India
| | - Tanuja Manohar
- Department of General Medicine, NKP Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Nagpur, Maharashtra, India
| | - Kavutharapu Sri Manjari
- Department of Genetics and Biotechnology, University College for Women, Koti, Hyderabad, Telangana, India
| | - Pradeep T Satyanarayana
- Department of Community Medicine, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India
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