Healthcare utilisation and costing for decompensated chronic liver disease hospitalisations at a Victorian network

A Reassessment of Sodium Correction Rates and Hospital Length of Stay Accounting for Admission Diagnosis

Background Slow correction of severe hyponatremia has been historically recommended due to the risk of rare but catastrophic neurologic events with rapid correction. A recent study challenging this paradigm reported that rapid correction is associated with shorter hospital length of stay, but that study did not control for admission diagnosis. The objective of this study was to determine whether rapid correction is associated with shorter length of stay when controlling for admission diagnosis. Methods This retrospective cohort study is based on the fourth edition of the Medical Information Mart for Intensive Care, MIMIC-IV, a deidentified, publicly available clinical research database which includes admissions from 2008-2019. Patients were identified who presented to the hospital with initial sodium <120 mEq/L and were categorized according to total sodium correction achieved in the first day (<6 mEq/L; 6-10 mEq/L; >10 mEq/L). Linear regression was used to assess for an association between correction rate and hospital length of stay, and to determine if this association was significant when controlling for admission diagnosis classifications based on diagnosis related groups (DRGs). Results There were 419 patients with severe hyponatremia (<120 mEq/L) included in this study, of whom 374 survived to discharge. Median [IQR] hospital length of stay was 6 [4, 11] days. In a univariable linear regression, there was a trend towards a significant association between the highest rate of correction (>10 mEq/L) and shorter length of stay, as compared with a moderate rate of correction (coef. -2.764, 95% CI [-5.791, 0.263], p=0.073), but the association was not significant when controlling for admission diagnosis group (coef. -1.561, 95% CI [-4.398, 1.276], p=0.280). There was a significant association in the survivor subset (coef. -3.455, 95% CI [-6.668, -0.242], p=0.035), but it was also not significant when controlling for admission diagnosis group (coef. -2.200, 95% CI [-5.144, 0.743], p=0.142). Conclusions Rapid correction is not associated with shorter length of stay when controlling for admission diagnosis, suggesting that the disease state confounds this association. Findings from prior and future studies reporting this association should not drive clinical decision making if the confounding effect of hospital admission diagnosis and competing risk of death are not fully accounted for.

Rising hospital admissions for alcohol-related cirrhosis and the impact of sex and comorbidity - a data linkage study

OBJECTIVES

International studies have shown shifting demographic data and rising hospitalizations for alcohol-related cirrhosis (ARC), with a paucity of data from Australia. We examined hospitalizations, mortality and demographic data for people admitted with ARC over the last decade in Queensland, Australia.

STUDY DESIGN

Data linkage study.

METHODS

A retrospective analysis of adults hospitalized with ARC during 2008-2019 was performed using state-wide admissions data. International Classification of Diseases, 10th revision, codes identified admissions with the principal diagnosis of ARC based on validated algorithms. Comorbidity was assessed using the Charlson Comorbidity Index.

RESULTS

A total of 7152 individuals had 24,342 hospital admissions with ARC (16,388 were for ARC). There was a predominance of males (72.6%) and age ≥50 years (80.4%) at index admission. Females were admitted at a significantly younger age than men (59% of women and 43% of men were aged <60 years, P < 0.001). Comorbidities were common, with 45.1% of people having at least one comorbidity. More than half (54.6%) of the patients died over the study period (median follow-up time was 5.1 years; interquartile range 2.4-8.6). Women had significantly lower mortality, with 47.6% (95% confidence interval [CI] 45.0-50.2) probability of 5-year survival, compared with 40.1% (95% CI 38.5-41.6) in men. In multivariable analysis, this was attributable to significantly lower age and comorbidity burden in women. Significantly lower survival was seen in people with higher comorbidity burden. Overall, the number of admissions for ARC increased 2.2-fold from 869 admissions in 2008 to 1932 in 2019.

CONCLUSIONS

Hospital admissions for ARC have risen substantially in the last decade. Females were admitted at a younger age, with fewer comorbidities and had lower mortality compared with males. The association between greater comorbidity burden and higher mortality has important clinical implications, as comorbidity-directed interventions may reduce mortality.

Diabetes mellitus and the progression of non-alcoholic fatty liver disease to decompensated cirrhosis: a retrospective cohort study

OBJECTIVE

To determine the incidence of decompensated cirrhosis and associated risk factors in people hospitalised with non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH) with or without cirrhosis.

DESIGN

Retrospective cohort study; analysis of linked Queensland Hospital Admitted Patient Data Collection, Queensland Registry of Births, Deaths and Marriages, and Queensland Cancer Register data.

SETTING, PARTICIPANTS

Queensland residents aged 20 years or older admitted to Queensland hospitals with NAFLD/NASH during 1 July 2009 - 31 December 2018.

MAIN OUTCOME MEASURES

Progression to decompensated cirrhosis (ascites, hepatic encephalopathy, or oesophageal variceal bleeding).

RESULTS

We included data for 8006 patients in our analysis (10 082 admissions), including 4632 women (58%) and 2514 people with diabetes mellitus (31%); median follow-up time was 4.6 years (interquartile range, 2.7-7.2 years). Three hundred and fifty-one people (4.4%) experienced decompensated cirrhosis during the follow-up period. Of the 6900 people without cirrhosis, 4.5% (95% confidence interval [CI], 3.6-5.7%) experienced decompensated cirrhosis within ten years (mean, 0.5% per year; 95% CI, 0.4-0.6% per year); risk of progression was greater for people aged 70 years or older (v 20-39 years: adjusted hazard ratio [aHR], 4.7; 95% CI, 2.0-11.0) and those who had extrahepatic cancers (aHR, 5.0; 95% CI, 3.0-8.2), history of major cardiovascular events (aHR, 1.9; 95% CI, 1.2-3.1), or diabetes mellitus (aHR, 2.8; 95% CI, 2.0-3.9). Of the 1106 people with cirrhosis, 32.4% (95% CI, 27.2-38.3%) experienced decompensated cirrhosis within ten years (mean, 5.5% per year; 95% CI, 4.8-6.3% per year); risk of progression was greater for those with portal hypertension (aHR, 1.8; 95% CI, 1.3-2.7), extrahepatic cancer (aHR, 1.8; 95% CI, 1.1-2.9), or diabetes mellitus (aHR, 1.5; 95% CI, 1.1-2.0). Compared with people who had neither cirrhosis nor diabetes mellitus, the risk of decompensation was greater for people with cirrhosis (aHR, 10.7; 95% CI, 7.6-15.0) or cirrhosis and diabetes mellitus (aHR, 14.4; 95% CI, 10.1-20.6).

CONCLUSIONS

Given the greater risk of progression to cirrhosis decompensation in people with diabetes mellitus, a disorder common in people with NAFLD/NASH, identifying advanced fibrosis and providing appropriate treatment for averting disease progression is vital.

Acute-on-chronic liver failure: Controversies and consensus

Acute-on-chronic liver failure (ACLF) is a poorly defined syndrome characterised by rapid clinical deterioration in patients with chronic liver disease. Consequences include high short-term morbidity, mortality, and healthcare resource utilisation. ACLF encompasses a dysregulated, systemic inflammatory response, which can precipitate extra hepatic organ failures. Common precipitants include infection, alcoholic hepatitis, and reactivation of viral hepatitis although frequently no cause is identified. Heterogenous definitions, diagnostic criteria, and treatment guidelines, have been proposed by international hepatology societies. This can result in delayed or missed diagnoses of ACLF, significant variability in clinical management, and under-estimation of disease burden. Liver transplantation may be considered but the mainstay of treatment is organ support, often in the intensive care unit. This review will provide clarity around where are the controversies and consensus in ACLF including: Epidemiology and resource utilisation, key clinical and diagnostic features, strategies for management, and research gaps.