Implementation of a 'care bundle' improves the management of patients admitted to hospital with decompensated cirrhosis

Quality measures in pre-liver transplant care by the Practice Metrics Committee of the American Association for the Study of Liver Diseases

The liver transplantation (LT) evaluation and waitlisting process is subject to variations in care that can impede quality. The American Association for the Study of Liver Diseases (AASLD) Practice Metrics Committee (PMC) developed quality measures and patient-reported experience measures along the continuum of pre-LT care to reduce care variation and guide patient-centered care. Following a systematic literature review, candidate pre-LT measures were grouped into 4 phases of care: referral, evaluation and waitlisting, waitlist management, and organ acceptance. A modified Delphi panel with content expertise in hepatology, transplant surgery, psychiatry, transplant infectious disease, palliative care, and social work selected the final set. Candidate patient-reported experience measures spanned domains of cognitive health, emotional health, social well-being, and understanding the LT process. Of the 71 candidate measures, 41 were selected: 9 for referral; 20 for evaluation and waitlisting; 7 for waitlist management; and 5 for organ acceptance. A total of 14 were related to structure, 17 were process measures, and 10 were outcome measures that focused on elements not typically measured in routine care. Among the patient-reported experience measures, candidates of LT rated items from understanding the LT process domain as the most important. The proposed pre-LT measures provide a framework for quality improvement and care standardization among candidates of LT. Select measures apply to various stakeholders such as referring practitioners in the community and LT centers. Clinically meaningful measures that are distinct from those used for regulatory transplant reporting may facilitate local quality improvement initiatives to improve access and quality of care.

Effect of PI3K/AKT/mTOR signaling pathway-based clustered nursing care combined with papaverine injection on vascular inflammation and vascular crisis after replantation of severed fingers

This research aimed to investigate the effect of PI3K (phosphatidylinositol 3-kinase)/AKT (protein kinase B)/mTOR (mammalian target protein of rapamycin) signaling pathway-based clustering care combined with papaverine injection on vascular inflammation and vascular crisis after finger amputation and replantation. 100 patients admitted in General Hospital of Ningxia Medical University from April 2022 to December 2022 for replantation of severed fingers were selected and divided into a control group (n = 50) and an observation group (n = 50) using the randomized grouping principle. The control group received a papaverine injection and general nursing care, the observation group received a papaverine injection and clustered care. The pain score; constipation incidence; replantation finger survival rate; physician, nurse, and patient satisfaction; serum inflammatory factors; vascular crisis parameters; and occurrence of adverse reactions were compared between the two patient groups. Enzyme-linked immunosorbent assay was performed to detect PI3K, AKT, and mTOR protein concentrations in the venous blood of the two groups, and statistical analysis of the data was performed. On postoperative day 7, the pain score and incidence of constipation in the observation group were lower than those in the control group (P < 0.05); the survival rate of reimplanted fingers in the observation group was 88.00%, which was higher than that in the control group 80.00% (P < 0.05); the satisfaction of doctors, nurses, and patients in the observation group was higher than that in the control group; the concentrations of interleukin-1 (IL-1), tumor necrosis factor (TNF-α), blood flow resistance index (RI), and arterial pulsatility index (PI) in the observation group were lower than those in the control group, while the concentration of interleukin-10 (IL-10), vascular diameter, and Vm (mean blood flow velocity) were higher in the observation group than those in the control group; the differences were statistically significant (P < 0.05). The difference in the incidence of adverse reactions between the two groups was not statistically significant (P > 0.05). The concentrations of PI3K, AKT, and mTOR proteins in the observation group were higher than those in the control group (P < 0.05). The concentrations of PI3K, AKT, and mTOR proteins in the observation group were higher than those in the control group (P < 0.05). Overall, these findings suggest that clustered care combined with papaverine injection reduces vascular inflammatory symptoms and vascular crisis in the treatment of severed finger replantation through the PI3K/AKT/mTOR signaling pathway.

Letter: Shorter duration of intravenous terlipressin for variceal bleeding in patients with cirrhosis-A promising find. Author's reply

This article is linked to Vaishnav et al papers. To view these articles, visit https://doi.org/10.1111/apt.17868 and https://doi.org/10.1111/apt.17976

Regional variations in inpatient decompensated cirrhosis mortality may be associated with access to specialist care: results from a multicentre retrospective study

Introduction

Specialist centres have been developed to deliver high-quality Hepatology care. However, there is geographical inequity in accessing these centres in the United Kingdom (UK). We aimed to assess the impact of these centres on decompensated cirrhosis patient outcomes and understand which patients transfer to specialist centres.

Methods

A UK multicentred retrospective observational study was performed including emergency admissions for patients with decompensated cirrhosis in November 2019. Admissions were grouped by specialist/non-specialist centre designation, National Health Service region and whether a transfer to a more specialist centre occurred or not. Univariable and multivariable comparisons were made.

Results

1224 admissions (1168 patients) from 104 acute hospitals were included in this analysis. Patients at specialist centres were more likely to be managed by a Consultant Gastroenterologist/Hepatologist on a Gastroenterology/Hepatology ward. Only 24 patients were transferred to a more specialist centre. These patients were more likely to be admitted for gastrointestinal bleeding and were not using alcohol. Specialist centres eliminated regional variations in mortality which were present at non-specialist centres. Low specialist Consultant staffing numbers impacted mortality at non-specialist centres (aOR 2.15 (95% CI 1.18 to 4.07)) but not at specialist centres. Hospitals within areas of high prevalence of deprivation were more likely to have lower specialist Consultant staffing numbers.

Conclusions

Specialist Hepatology centres improve patient care and standardise outcomes for patients with decompensated cirrhosis. There is a need to support service development and care delivery at non-specialist centres. Formal referral pathways are required to ensure all patients receive access to specialist interventions.

National study of NAFLD management identifies variation in delivery of care in the UK between 2019 to 2022

Background & Aims

Non-alcoholic fatty liver disease (NAFLD) is associated with liver and cardiovascular morbidity and mortality. Recently published NAFLD Quality Standards include 11 key performance indicators (KPIs) of good clinical care. This national study, endorsed by British Association for the Study of the Liver (BASL) and British Society of Gastroenterology (BSG), aimed to benchmark NAFLD care in UK hospitals against these KPIs.

Methods

This study included all new patients with NAFLD reviewed in the outpatient clinic in the months of March 2019 and March 2022. Participating UK hospitals self-registered for the study through BASL/BSG. KPI outcomes were compared using Fisher's exact or Chi-square tests.

Results

Data from 776 patients with NAFLD attending 34 hospitals (England [25], Scotland [four], Wales [three], Northern Ireland [two]) were collected. A total of 85.3% of hospitals reported established local liver disease assessment pathways, yet only 27.9% of patients with suspected NAFLD had non-invasive fibrosis assessment documented at the point of referral to secondary care. In secondary care, 79.1% of patients had fibrosis assessment. Assessment of cardiometabolic risk factors including obesity, type 2 diabetes, hypertension, and smoking were conducted in 73.2%, 33.0%, 19.3%, and 54.9% of all patients, respectively. There was limited documentation of diet (35.7%) and exercise advice (55.1%). Excluding those on statins, only 9.1% of patients with NAFLD at increased cardiovascular risk (T2DM and/or QRISK-3 >10%) had documented discussion of statin treatment. Significant KPI improvements from 2019 to 2022 were evident in use of non-invasive fibrosis assessment before secondary care referral, statin recommendations, and diet and exercise recommendations.

Conclusions

This national study identified substantial variation in NAFLD management in the UK with clear areas for improvement, particularly fibrosis risk assessment before secondary care referral and management of associated cardiometabolic risk factors.

Impact and implications

This study identified significant variation in the management of NAFLD in the UK. Only 27.9% of patients with suspected NAFLD had non-invasive fibrosis assessment performed to identify those at greater risk of advanced liver disease before specialist referral. Greater emphasis is needed on the management of associated cardiometabolic risk factors in individuals with NAFLD. Hospitals with multidisciplinary NAFLD service provision had higher rates of fibrosis evaluation and assessment and management of cardiometabolic risk than hospitals without multidisciplinary services. Further work is needed to align guideline recommendations and real-world practice in NAFLD care.

Outcomes of first emergency admissions for alcohol-related liver disease in England over a 10-year period: retrospective observational cohort study using linked electronic databases

OBJECTIVES

To examine time trends in patient characteristics, care processes and case fatality of first emergency admission for alcohol-related liver disease (ARLD) in England.

DESIGN

National population-based, retrospective observational cohort study.

SETTING

Clinical Practice Research Datalink population of England, 2008/2009 to 2017/2018. First emergency admissions were identified using the Liverpool ARLD algorithm. We applied survival analyses and binary logistic regression to study prognostic trends.

OUTCOME MEASURES

Patient characteristics; 'recent' General Practitioner (GP) consultations and hospital admissions (preceding year); higher level care; deaths in-hospital (including certified cause) and within 365 days. Covariates were age, sex, deprivation status, coding pattern, ARLD stage, non-liver comorbidity, coding for ascites and varices.

RESULTS

17 575 first admissions (mean age: 53 years; 33% women; 32% from most deprived quintile). Almost half had codes suggesting advanced liver disease. In year before admission, only 47% of GP consulters had alcohol-related problems recorded; alcohol-specific diagnostic codes were absent in 24% of recent admission records. Overall, case fatality rate was 15% in-hospital and 34% at 1 year. Case-mix-adjusted odds of in-hospital death reduced by 6% per year (adjusted OR (aOR): 0.94; 95% CI: 0.93 to 0.96) and 4% per year at 365 days (aOR: 0.96; 95% CI: 0.95 to 0.97). Exploratory analyses suggested the possibility of regional inequalities in outcome.

CONCLUSIONS

Despite improving prognosis of first admissions, we found missed opportunities for earlier recognition and intervention in primary and secondary care. In 2017/2018, one in seven were still dying during index admission, rising to one-third within a year. Nationwide efforts are needed to promote earlier detection and intervention, and to minimise avoidable mortality after first emergency presentation. Regional variation requires further investigation.

Quality standards for the management of alcohol-related liver disease: consensus recommendations from the British Association for the Study of the Liver and British Society of Gastroenterology ARLD special interest group

OBJECTIVE

Alcohol-related liver disease (ALD) is the most common cause of liver-related ill health and liver-related deaths in the UK, and deaths from ALD have doubled in the last decade. The management of ALD requires treatment of both liver disease and alcohol use; this necessitates effective and constructive multidisciplinary working. To support this, we have developed quality standard recommendations for the management of ALD, based on evidence and consensus expert opinion, with the aim of improving patient care.

DESIGN

A multidisciplinary group of experts from the British Association for the Study of the Liver and British Society of Gastroenterology ALD Special Interest Group developed the quality standards, with input from the British Liver Trust and patient representatives.

RESULTS

The standards cover three broad themes: the recognition and diagnosis of people with ALD in primary care and the liver outpatient clinic; the management of acutely decompensated ALD including acute alcohol-related hepatitis and the posthospital care of people with advanced liver disease due to ALD. Draft quality standards were initially developed by smaller working groups and then an anonymous modified Delphi voting process was conducted by the entire group to assess the level of agreement with each statement. Statements were included when agreement was 85% or greater. Twenty-four quality standards were produced from this process which support best practice. From the final list of statements, a smaller number of auditable key performance indicators were selected to allow services to benchmark their practice and an audit tool provided.

CONCLUSION

It is hoped that services will review their practice against these recommendations and key performance indicators and institute service development where needed to improve the care of patients with ALD.

Epidemiology, characteristics, and outcomes of patients with acute-on-chronic liver failure in Australia

BACKGROUND AND AIM

Acute-on-chronic liver failure (ACLF) is distinct from acute decompensation (AD) of cirrhosis in its clinical presentation, pathophysiology, and prognosis. There are limited published Australian ACLF data.

METHODS

We performed a single-center retrospective cohort study of all adults with cirrhosis admitted with a decompensating event to a liver transplantation (LT) centre between 2015 and 2020. ACLF was defined using the European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) definition while those who did not meet the definition were classified as AD. The primary outcome of interest was 90-day LT-free survival.

RESULTS

A total of 615 patients had 1039 admissions for a decompensating event. On their index admission, 34% (209/615) of patients were classified as ACLF. Median admission model for end-stage liver disease (MELD) and MELD-Na scores were higher in ACLF patients compared with AD (21 vs 17 and 25 vs 20 respectively, both P < 0.001). Both the presence and severity of ACLF (grade ≥ 2) significantly predicted worse LT-free survival compared with patients with AD. The EASL-CLIF ACLF score (CLIF-C ACLF), MELD and MELD-Na scores performed similarly in predicting 90-day mortality. Patients with index ACLF had a higher risk of 28-day mortality (28.1% vs 5.1%, P < 0.001) and shorter times to readmission compared with those with AD.

CONCLUSION

ACLF complicates over a third of hospital admissions for cirrhosis with decompensating events and is associated with a high short-term mortality. The presence and grade of ACLF predicts 90-day mortality and should be identified as those at greatest risk of poor outcome without intervention such as LT.

Admission care bundles for decompensated cirrhosis are poorly utilised across the UK: results from a multi-centre retrospective study

Admission care bundles have been demonstrated to improve clinical outcomes for patients in several settings. Decompensated cirrhosis care bundles have been developed following previous reports demonstrating poor care for inpatients with alcohol-related liver disease (ARLD). We performed a UK multi-centred retrospective observational study to understand how frequently decompensated cirrhosis admission care bundles were utilised, who they were used for and their impact on outcomes. In this study (1,224 admissions, 104 hospitals), we demonstrated that admission care bundle usage was low across the UK (11.44%). They were more likely to be utilised in patients with ARLD or who were jaundiced, and less likely to be used in patients admitted for gastrointestinal bleeding. The admission care bundle improved the standard of alcohol care and requesting initial investigations. However, there were areas where more than 80% compliance was achieved without the use of a care bundle and areas where less than 50% compliance was achieved with the use of a care bundle. Given the low utilisation of care bundles, we were unable to demonstrate an effect on risk-adjusted mortality. Thus, interdisciplinary work is required to develop tools which are widely used and improve care and outcomes for patients with decompensated cirrhosis.

Decompensated cirrhosis: targeted training of acute medical teams to improve quality of care in first 24 hours

BACKGROUND

A quality improvement project in a secondary care centre was initiated to investigate and evaluate the impact of staff education and the use of the British Society of Gastroenterology/British Association for the Study of the Liver cirrhosis care bundle in improving care of patients admitted to hospital with decompensated liver cirrhosis.

METHOD

A staff training programme was implemented, involving around 30 health professionals consisting of consultants, junior doctors, physician associates and nurses from the acute medical unit. A review of electronic documentation and analysis of key clinical parameters, pre- and post-intervention, was carried out.

RESULTS

The data show that the intervention has led to an improvement in patient management and clinical outcomes.

CONCLUSION

This project illustrates that collaboration between hepatology and medical teams, with emphasis on education and training, benefits patients who present to hospital with decompensated liver cirrhosis.

Improved outcomes following the implementation of a decompensated cirrhosis discharge bundle

INTRODUCTION

Mortality from liver disease is increasing and management of decompensated cirrhosis (DC) is inconsistent across the UK. Patients with DC have complex medical needs when discharged from hospital and early readmissions are common. Our aims were: (1) to develop a Decompensated Cirrhosis Discharge Bundle (DCDB) to optimise ongoing care and (2) evaluate the impact of the DCDB.

METHODS

A baseline review of the management of patients with DC was conducted in Newcastle in 2017. The DCCB was developed and implemented in 2018. Impact of the DCDB was evaluated in two cycles, first a paper version (November 2018-October 2019) and then an electronic version (November 2020-March 2021). Key clinical data were collected from the time of discharge.

RESULTS

Overall, 192 patients (62% male; median age 55; median model for end-stage liver disease 17; 72% alcohol related) were reviewed in three cycles. At baseline, management was suboptimal, particularly ascites/diuretic management and provision of follow-up for alcohol misuse and 12% of patients had a potentially avoidable readmission within 30 days. After DCDB introduction, care improved across most domains, particularly electrolyte monitoring (p=0.012) and provision of community alcohol follow-up (p=0.026). Potentially preventable readmissions fell to 5% (p=0.055).

CONCLUSIONS

Use of a care bundle for patients with DC can standardise care and improve patient management. If used more widely this could improve outcomes and reduce variability in care for patients with DC.

Prospective study for an independent predictor of prognosis in liver cirrhosis based on the new sarcopenia criteria produced by the Japan Society of Hepatology

AIM

There are limited data from prospective studies showing the clinical usefulness of the new criteria for sarcopenia in liver disease produced by the Japan Society of Hepatology. Therefore, we aimed to evaluate the clinical usefulness of this new criteria for prognosis in cirrhotic patients.

METHODS

This prospective study was performed at six centers. The 300 enrolled patients, aged more than 20 years with liver cirrhosis, were evaluated over a 3-year period for skeletal muscle mass index and grip strength. Sarcopenia was defined according to the Japan Society of Hepatology criteria by grip strength and computed tomography-based skeletal muscle mass index values. We investigated the correlation between sarcopenia and the survival rate of cirrhotic patients.

RESULTS

Among the 300 assessed patients there were 99 (33%) patients with sarcopenia. The number of deaths in the sarcopenia and non-sarcopenia groups was 34 (34.3%) and 38 (18.9%), respectively (p = 0.002). Multivariate analysis confirmed that sarcopenia, decompensated phase, albumin-bilirubin grade, and hepatocellular carcinoma (HCC) stage 3/4 were independent factors correlated with death in patients with liver cirrhosis during the observation period. The interaction between sarcopenia and the presence of HCC was statistically significant (p < 0.001), and the presence of HCC had the highest hazard ratio of 6.665 for deaths in cirrhotic patients when non-sarcopenia and the absence of HCC were used as references.

CONCLUSIONS

The new Japan Society of Hepatology criteria for sarcopenia are accurate predictors of poor prognosis in patients with liver cirrhosis.

Implementation of a care bundle improves the management of patients with non-alcoholic fatty liver disease

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is common and is associated with liver-related and cardiovascular-related morbidity. Our aims were: (1) to review the current management of patients with NAFLD attending hospital clinics in North East England (NEE) and assess the variability in care; (2) develop a NAFLD 'care bundle' to standardise care; (3) to assess the impact of implementation of the NAFLD care bundle.

METHODS

A retrospective review was conducted to determine baseline management of patients with NAFLD attending seven hospitals in NEE. A care bundle for the management of NAFLD was developed including important recommendations from international guidelines. Impact of implementation of the bundle was evaluated prospectively in a single centre.

RESULTS

Baseline management was assessed in 147 patients attending gastroenterology, hepatology and a specialist NAFLD clinic. Overall, there was significant variability in the lifestyle advice given and management of metabolic risk factors, with patients attending an NAFLD clinic significantly more likely to achieve >10% body weight loss and have metabolic risk factors addressed. Following introduction of the NAFLD bundle 50 patients were evaluated. Use of the bundle was associated with significantly better documentation and implementation of most aspects of patient management including management of metabolic risk factors, documented lifestyle advice and provision of NAFLD-specific patient advice booklets.

CONCLUSION

The introduction of an outpatient 'care bundle' led to significant improvements in the assessment and management of patients with NAFLD in the NEE and could help improve and standardise care if used more widely.

Increased cardiovascular risk and reduced quality of life are highly prevalent among individuals with hepatitis C

OBJECTIVE

Hepatitis C virus (HCV) infection is common. Although treatment is effective, with oral antivirals curing >95% of patients, most individuals have comorbidities that persist long term. Therefore, our aim was to determine the prevalence of potentially modifiable health problems in patients with HCV and develop an HCV care bundle to identify and target comorbidities.

DESIGN

Cross-sectional, observational single-centre study that recruited consecutive patients with HCV from our viral hepatitis clinics. Data were collected on cardiovascular (CV) risk factors, lifestyle behaviours, anthropometry and health-related quality of life (HRQoL). QRISK 3 was used to predict 10-year CV event risk.

RESULTS

100 patients were recruited (67% male, 93% white, median age 52 years (range 24-80); 71% were treated for HCV; 34% had cirrhosis; 14% had diabetes; 61% had hypertension; 31% had metabolic syndrome; and 54% were smokers). The median 10-year CV event risk was 8.3% (range 0.3%-63%). 45% had a predicted 10-year CV event risk of >10%. Only 10% of individuals were treated with statins and 27% with antihypertensives. 92% had a predicted 'heart age' greater than their chronological age (median difference +7 (-4 to +26) years). HRQoL was reduced in all SF36v2 domains in the cohort. Factors independently associated with HRQoL included cirrhosis, metabolic syndrome, history of mental health disorder, sedentary behaviour and HCV viraemia.

CONCLUSION

A large proportion of patients with HCV presented with increased risk of CV events, and rates of smoking and sedentary behaviour were high, while prescribing of primary prophylaxis was infrequent. HRQoL was also reduced in the cohort. A 'care bundle' was developed to provide a structured approach to treating potentially modifiable health problems.

Reducing variation in hospital mortality for alcohol-related liver disease in North West England

BACKGROUND

Variations in emergency care quality for alcohol-related liver disease (ARLD) have been highlighted.

AIM

To determine whether introduction of a regional quality improvement (QI) programme was associated with a reduction in potentially avoidable inpatient mortality.

METHOD

Retrospective observational cohort study using hospital administrative data spanning a 1-year period before (2014/2015) and 3 years after a QI initiative at seven acute hospitals in North West England. The intervention included serial audit of a bundle of process metrics. An algorithm was developed to identify index ("first") emergency admissions for ARLD (n = 3887). We created a standardised mortality ratio (SMR) to compare relative mortality and regression models to examine risk-adjusted odds of death.

RESULTS

In 2014/2015, three of seven hospitals had an SMR above the upper control limit ("outliers"). Adjusted odds of death for patients admitted to outlier hospitals was higher than non-outliers (OR 2.13, 95% CI 1.32-3.44, P = 0.002). Following the QI programme there was a step-wise reduction in outliers (none in 2017/2018). Odds of death was 67% lower in 2017/2018 compared to 2014/2015 at original outlier hospitals, but unchanged at other hospitals. Process audit performance of outliers was worse than non-outliers at baseline, but improved after intervention.

CONCLUSIONS

There was a reduction in unexplained variation in hospital mortality following the QI intervention. This challenges the pessimism that is prevalent for achieving better outcomes for patients with ARLD. Notwithstanding the limitations of an uncontrolled observational study, these data provide hope that co-ordinated efforts to drive adoption of evidence-based practice can save lives.

Providing effective inpatient care for cirrhosis by improving utilization of national guidelines

BACKGROUND

Over the past 10 years, cirrhosis incidence has increased dramatically, with a 59% increase in the need for treatment of disease complications. Cirrhosis treatment complexity and cost have increased substantially, and cirrhosis deaths are increasing by 10.5% yearly.

LOCAL PROBLEM

A review of 29 cirrhosis admissions revealed that guideline criteria were only addressed 66% of the time on 10 key cirrhosis issues. After identifying gaps in care, the project aimed to improve right care for cirrhosis by 20% within 90 days by using a guideline-based checklist and chart audit process.

METHODS

The quality improvement (QI) initiative used four Plan-Do-Study-Act cycles. Cycles included tests of change for the checklist, patient engagement, chart audit, and team participation.

INTERVENTIONS

A guideline-based cirrhosis checklist focused on providing right care for cirrhosis patient admissions. Patient engagement was addressed with a shared decision-making tool. To monitor data, a chart audit was created. Team engagement included biweekly QI meetings with an agenda and a postmeeting survey.

RESULTS

The project aim was achieved, improving cirrhosis guideline-based care by 22%, while utilization of the guideline-based checklist rose to 100%. Moreover, 96% of patients approached for shared decision making agreed to participate, and the chart audit was completed on all patients. Team engagement and satisfaction remained high throughout the cycles.

CONCLUSIONS

The project team used an evidence-based approach to effectively improve inpatient care for cirrhosis. Engaging providers and patients with this approach led to high patient and team participation and improved project outcomes.

British Society of Gastroenterology (BSG)-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding

Medical care bundles improve standards of care and patient outcomes. Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency which has been consistently associated with suboptimal care. We aimed to develop a multisociety care bundle centred on the early management of AUGIB. Commissioned by the British Society of Gastroenterology (BSG), a UK multisociety task force was assembled to produce an evidence-based and consensus-based care bundle detailing key interventions to be performed within 24 hours of presentation with AUGIB. A modified Delphi process was conducted with stakeholder representation from BSG, Association of Upper Gastrointestinal Surgeons, Society for Acute Medicine and the National Blood Transfusion Service of the UK. A formal literature search was conducted and international AUGIB guidelines reviewed. Evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluation tool and statements were formulated and subjected to anonymous electronic voting to achieve consensus. Accepted statements were eligible for incorporation into the final bundle after a separate round of voting. The final version of the care bundle was reviewed by the BSG Clinical Services and Standards Committee and approved by all stakeholder groups. Consensus was reached on 19 statements; these culminated in 14 corresponding care bundle items, contained within 6 management domains: Recognition, Resuscitation, Risk assessment, Rx (Treatment), Refer and Review. A multisociety care bundle for AUGIB has been developed to facilitate timely delivery of evidence-based interventions and drive quality improvement and patient outcomes in AUGIB.

Cost-effectiveness of integrating gut microbiota analysis into hospitalisation prediction in cirrhosis

BACKGROUND

Admissions in cirrhosis are expensive and often unpredictable based on purely clinical variables. Admissions could be related to complications associated with gut microbial changes, which can improve prognostication. However, the cost-effectiveness is unclear.

AIMS

Determine cost-effectiveness of adding gut microbiota analysis to clinical parameters in prediction and subsequent reduction of admissions in cirrhosis.

METHODS

Using a Markov model of 1000 cirrhosis patients over 90 days, we modeled microbiota testing using 16srRNA ($250/sample), low-depth ($350/sample) and high-depth ($650/sample) metagenomics added to standard-of-care (SOC) for prevention of admissions using standard outcome costs and rates of development. We generated quality of life years (QALY) and Incremental cost-effectiveness ratios (ICER) for the base scenarios and performed sensitivity analyses by varying costs for outcomes (transplant, death, admission) and admission rates (40%, range 25%-60%).

RESULTS

Using fixed costs of outcomes and outcome rates, microbiota analysis was cost-saving ($47K-$97K) at $250 and $350/sample if admissions were reduced by 5%over SOC and >10% with $650/sample. When costs of LT, death and admissions were varied, these cost-savings remained robust provided there was >2.1% reduction (range 1.3%-3.2%) for $250/sample, >2.9% (range 1.8%-4.4%) for $350/sample and >5.4% (range 3.3%-8.2%) for $650/sample. These cost-savings remained robust even when the assumed admission rate was varied for all sample cost values.

CONCLUSIONS

Gut microbiota analysis is cost-effective for predicting and potentially preventing 90-day admissions in cirrhosis over current standard of care. This cost-saving remained robust even after sensitivity analyses that varied the background admission rates.

Patient pathway: the ideal approach

Hepatic encephalopathy (HE) can be a devastating complication of cirrhosis, affecting patients and their families. Multidisciplinary community and specialist teams must work together with patients and their families to recognise HE, identify and treat problems early, and minimise time spent unwell or in hospital. Primary care provides an ideal setting for patient education and reinforcement of the salient points on self-care. In the acute setting, the use of care pathways can ensure that the critical aspects of pharmacological, dietetic and supportive care are offered in a timely fashion to reduce morbidity and mortality. This article discusses strategies that can be used in primary and secondary care to help teams deliver excellent practice in HE management.

Reducing recurrent hospital admissions in patients with decompensated cirrhosis

Recurrent admissions to hospital are a major issue for people living with decompensated cirrhosis, particularly those who develop chronic hepatic encephalopathy, a condition that leads to significantly impaired quality of life for patients and their family caregivers. Such patients have high health-care use costs but recent data have shown how the appropriate use of effective medical therapy can significantly reduce hospital admissions, length of stay and unplanned readmissions. Redesigning clinical services to optimize access to specialist care and improving the education and support of patients and their carers can further help to reduce the burden of this disease.

Management of decompensated cirrhosis

Decompensated cirrhosis is a common reason for admission to the acute medical unit, and such patients typically have complex medical needs and are at high risk of in-hospital death. It is therefore vital that these patients receive appropriate investigations and management as early as possible in their patient journey. Typical presenting clinical features include jaundice, ascites, hepatic encephalopathy, hepato-renal syndrome or variceal haemorrhage. A careful history, examination and investigations can help identify the precipitating cause (infections, gastrointestinal bleeding, high alcohol intake / alcohol-related hepatitis or drug-induced liver injury), so appropriate treatment can be given. A 'care bundle' that has been endorsed by the British Society of Gastroenterology is available to help guide the management of patients with decompensated cirrhosis for the first 24 hours and ensure all aspects are addressed. Specific management of complications, such as infections, gastrointestinal bleeding, hepatic encephalopathy and hepatorenal syndrome, are discussed.

Management of decompensated cirrhosis

Decompensated cirrhosis is a common reason for admission to the acute medical unit, and such patients typically have complex medical needs and are at high risk of in-hospital death. It is therefore vital that these patients receive appropriate investigations and management as early as possible in their patient journey. Typical presenting clinical features include jaundice, ascites, hepatic encephalopathy, hepato-renal syndrome or variceal haemorrhage. A careful history, examination and investigations can help identify the precipitating cause (infections, gastrointestinal bleeding, high alcohol intake / alcohol-related hepatitis or drug-induced liver injury), so appropriate treatment can be given. A 'care bundle' that has been endorsed by the British Society of Gastroenterology is available to help guide the management of patients with decompensated cirrhosis for the first 24 hours and ensure all aspects are addressed. Specific management of complications, such as infections, gastrointestinal bleeding, hepatic encephalopathy and hepatorenal syndrome, are discussed.

Survival from alcoholic hepatitis has not improved over time

PURPOSE/BACKGROUND

We aimed to describe changes in survival in alcoholic hepatitis (AH) over time by examining published data.

METHODS

A systematic literature search of Ovid Embase and PubMed was undertaken using the MESH terms 'hepatitis, alcoholic' to identify randomised controlled trials (RCT) and observational studies (OS) in alcoholic hepatitis. Data were extracted from included studies regarding 28-day, 90-day, 180-day mortality, as well as biochemical and clinical data.

RESULTS

After review of the literature search results, 77 studies published between 1971 and 2016 were analysed, which included data from a total of 8,184 patients. Overall mortality from AH was 26% at 28 days, 29% at 90 days and 44% at 180 days after admission. No changes in mortality over time were observed in univariable analysis at 28 days or 90 days after admission (Pearson correlation r -0.216, p = 0.098, and r 0.121 p = 0.503 respectively). A small but statistically significant increase in mortality was seen in 180-day mortality (r 0.461 p = 0.036). However, after meta-regression to adjust for other factors associated with mortality at each time point, no changes in mortality were seen. Sub-group analysis did not reveal any changes in mortality over time in different study types, or when only biopsy-proven or severe disease were considered.

CONCLUSION

There has been no improvement in mortality from AH. This is not explained by changes in severity of disease. This emphasises the urgent need for effective treatments for this alcoholic hepatitis.

Improving Quality of Care in Patients with Liver Cirrhosis

Liver cirrhosis is a major chronic disease in the field of digestive diseases. It causes more than one million deaths per year. Despite established evidence based guidelines, the adherence to standard of care or quality indicators are variable. Complete adherence to the recommendations of guidelines is less than 50%. To improve the quality of care in patients with cirrhosis, we need a more holistic view. Because of high rate of death due to cardiovascular disease and neoplasms, the care of comorbid conditions and risk factors such as smoking, hypertension, high blood sugar or cholesterol, would be important in addition to the management of primary liver disease. Despite a holistic multidisciplinary approach for this goal, the management of such patients should be patient centered and individualized. The diagnosis of underlying etiology and its appropriate treatment is the most important step. Definition and customizing the quality indicators for quality measure in patients are needed. Because most suggested quality indicators are designed for measuring the quality of care in decompensated liver cirrhosis, we need special quality indicators for compensated and milder forms of chronic liver disease as well. Training the patients for participation in their own management, design of special clinics with dedicated health professionals in a form of chronic disease model, is suggested for improvement of quality of care in this group of patients. Special day care centers by a dedicated gastroenterologist and a trained nurse may be a practical model for better management of such patients.