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Haque LY, Fiellin DA. Bridging the Gap: Dual Fellowship Training in Addiction Medicine and Digestive Diseases. Dig Dis Sci 2022; 67:2721-2726. [PMID: 35430700 PMCID: PMC9013212 DOI: 10.1007/s10620-022-07478-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Lamia Y Haque
- Program in Addiction Medicine, Yale School of Medicine, New Haven, US.
- Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, US.
| | - David A Fiellin
- Program in Addiction Medicine, Yale School of Medicine, New Haven, US
- Department of Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, US
- Department of Emergency Medicine, Yale School of Medicine, New Haven, US
- Department of Health Policy and Management, Yale School of Public Health, New Haven, US
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Characteristics and Outcomes of Black and White Patients Hospitalized With Nonalcoholic Steatohepatitis: A Nationwide Analysis. J Clin Gastroenterol 2022; 57:508-514. [PMID: 35357331 DOI: 10.1097/mcg.0000000000001698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/02/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND Nonalcoholic steatohepatitis (NASH) is an increasingly common etiology for liver-related hospitalizations in the United States. The aim of this study was to examine the differences of disease characteristics and outcomes between hospitalized Black and White patients with NASH. MATERIALS AND METHODS We used the National Inpatient Sample (NIS) to identify all adult hospitalizations with NASH (ICD-10 code: K75.81) from 2016 to 2018. We compared demographic and clinical characteristics between Black and White patients. Multivariable models were computed to compare all-cause mortality, length of stay (LOS), and total hospital costs between the groups. RESULTS There were 43,409 hospitalizations with NASH (41,143 White, 2266 Black). Black patients were less likely to have cirrhosis (33.6%) compared with Whites (56.4%), P<0.0001. Black patients were less likely to have esophageal variceal bleeding (1.2% vs. 3.5%), ascites (17.1% vs. 28.8%), and acute liver failure (16.2% vs. 28.9%) compared with Whites (all P<0.0001). These findings were consistent among patients with cirrhosis. Mortality was higher among Blacks compared with Whites (3.9% vs. 3.7%, adjusted odds ratio=1.34; 95% confidence interval: 1.05-1.71, P=0.018). Compared with Whites, Blacks had a longer LOS (6.3 vs. 5.6, P<0.001), and higher hospital costs ($18,602 vs. $17,467; P=0.03). CONCLUSION In this large population of inpatients with NASH, Black patients were less likely to have cirrhosis and liver disease-related complications, but had overall worse hospital mortality, longer LOS, and higher hospital costs. Further research is warranted to elaborate on factors that generate the health inequities in NASH outcomes between Black and White patients.
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Garg SK, Goyal H, Obaitan I, Shah PA, Sarvepalli S, Jophlin LL, Singh D, Asrani S, Kamath PS, Leise MD. Incidence and predictors of 30-day hospital readmissions for liver cirrhosis: insights from the United States National Readmissions Database. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1052. [PMID: 34422964 PMCID: PMC8339830 DOI: 10.21037/atm-20-1762] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/23/2021] [Indexed: 12/12/2022]
Abstract
Background Cirrhosis is associated with substantial inpatient morbidity and mortality. This study aimed to determine the trends in 30-day hospital readmission rates among patients with cirrhosis and identify factors associated with these readmissions. Methods We conducted a retrospective analysis of data retrieved from the Nationwide Readmissions Database to determine trends in 30-day readmission for patients discharged with a diagnosis of cirrhosis in 2010 through 2014. Multivariate logistic regression analysis was used to identify predictors of readmission. Results Among 303,346 patients identified from the database, the 30-day readmission rate for patients with a discharge diagnosis of cirrhosis was 31.4% (n=95,298). The trends in the readmission rates remained steady during the study period. On multivariate analysis, female sex, age 45 years or older, esophagogastroduodenoscopy (EGD) during admission, and disposition to a short-term care facility or skilled nursing facility protected against readmissions. In contrast, coverage by Medicaid insurance, admission during a weekend, nonalcoholic cause of cirrhosis, and history of hepatic encephalopathy and ascites were associated with readmission. Conclusions We found an exceptionally high 30-day readmission rate in patients with cirrhosis, although it remained stable during the study period. This study identified some modifiable factors such as disposition to a short-term care facility or skilled nursing facility and patients’ attendance of alcohol rehabilitation facilities that could decrease the likelihood of readmission and could inform local and national healthcare policymakers.
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Affiliation(s)
- Sushil Kumar Garg
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Hemant Goyal
- Mercer University School of Medicine, Macon, GA, USA
| | - Itegbemie Obaitan
- Department of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN, USA
| | | | | | - Loretta Lynn Jophlin
- Division of Gastroenterology-Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Dupinder Singh
- Department of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN, USA
| | - Sumeet Asrani
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Michael D Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Spiewak T, Taefi A, Patel S, Li CS, Chak E. Racial disparities of Black Americans hospitalized for decompensated liver cirrhosis. BMC Gastroenterol 2020; 20:245. [PMID: 32727386 PMCID: PMC7391571 DOI: 10.1186/s12876-020-01392-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 07/21/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Racial disparities have been reported in liver transplantation and chronic hepatitis C treatment outcomes. Determining causes of these disparities is important given the racially diverse American population and the economic burden associated with chronic liver disease. METHODS A retrospective study was performed among 463 patients diagnosed with cirrhosis admitted from (January 1, 2013 to January 1, 2018) to a tertiary care academic medical center. Patients were identified based on the International Classification of Diseases (ICD-10) for cirrhosis or its complications. Demographic information, laboratory data, medical comorbidities, insurance and adherence to cirrhosis quality care indicators were recorded to determine their relationship to readmission rates and other healthcare outcomes. RESULTS A total of 463 individual patients with cirrhosis were identified including Whites (n = 241), Hispanics (n = 106), Blacks (n = 50), Asian and Pacific Islander Americans (API, n = 27) and Other (n = 39). A significantly higher proportion of Blacks had Medicaid insurance compared to Whites (40% versus 20%, p = 0.0002) and Blacks had lower median income than Whites ($45,710 versus $54,844, p = 0.01). All groups received high quality cirrhosis care. Regarding healthcare outcomes, Black patients had the highest mean total hospital admissions (6.1 ± 6.3, p = 0.01) and the highest mean number of 30-day re-admissions (2.1 ± 3.7, p = 0.05) compared to all other racial groups. Multivariable proportional odds regression analysis showed that race was a statistically significant predictor of 90-day readmission (p = 0.03). CONCLUSIONS Black Americans hospitalized for complications of cirrhosis may experience significant disparities in healthcare outcomes compared to Whites despite high quality cirrhosis care. Socioeconomic factors may contribute to these disparities.
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Affiliation(s)
- Ted Spiewak
- Department of Internal Medicine, UC Davis Medical Center, Sacramento, California, USA
| | - Amir Taefi
- Department of Gastroenterology and Hepatology, UC Davis Medical Center, 4150 V Street, PSSB 3500, Sacramento, CA, 95817, USA
| | - Shruti Patel
- Department of Internal Medicine, UC Davis Medical Center, Sacramento, California, USA
| | - Chin-Shang Li
- School of Nursing, The State University of New York at Buffalo, Buffalo, New York, USA
| | - Eric Chak
- Department of Gastroenterology and Hepatology, UC Davis Medical Center, 4150 V Street, PSSB 3500, Sacramento, CA, 95817, USA.
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Abstract
OBJECTIVES Cirrhosis is often a consequence of substance use disorders (SUD) and can lead to significant morbidity, mortality, and hospitalizations. We aimed to determine presence and impact of SUD in recently hospitalized patients with cirrhosis, which has not been previously described. METHODS This is a retrospective study of consecutive patients with cirrhosis seen at a post-discharge hepatology clinic. The presence of clinically-recognized SUD and documented establishment of addiction treatment, as noted in routine clinical care, was determined through medical record review. Number of hospitalizations, 30-day readmissions, and all-cause mortality at 1 year were also examined. RESULTS Among 99 patients, 72% were male and the median age was 55 years. The most common etiologies of cirrhosis were alcohol-related liver disease and hepatitis C infection. Alcohol use disorder was documented in 71%. Nearly all patients with clinically-recognized SUD underwent social work evaluation during hospitalization and 65% were referred to addiction treatment. Establishment of addiction care at follow up was documented in 35%. Documented SUD was associated with greater odds of hospitalization over 1 year (adjusted odds ratio 5.77, 95% confidence interval [1.36, 24.49], P = 0.017), but not with 30-day readmissions or mortality. CONCLUSIONS Clinically-recognized SUD was common in recently hospitalized patients with cirrhosis and associated with at least 1 other hospitalization within a year. Establishment of addiction treatment was documented in only a minority of patients. Further research is needed to determine whether patients with cirrhosis and SUD experience unique barriers to addiction treatment and if integration of SUD care in hepatology settings may be beneficial.
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Skeletal muscle loss phenotype in cirrhosis: A nationwide analysis of hospitalized patients. Clin Nutr 2020; 39:3711-3720. [PMID: 32303380 DOI: 10.1016/j.clnu.2020.03.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/09/2020] [Accepted: 03/25/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS There are very limited data on the healthcare burden of muscle loss, the most frequent complication in hospitalized cirrhotics. We determined the healthcare impact of a muscle loss phenotype in hospitalized cirrhotics. METHODS The Nationwide Inpatient Sample (NIS) database (years 2010-2014) was analyzed. Search terms included cirrhosis and its complications, and an expanded definition of a muscle loss phenotype that included all conditions associated with muscle loss. In-hospital mortality, length of stay (LOS), post-discharge disposition, co-morbidities and cost during admission were analyzed. Univariate and multivariate analyses were performed to identify associations between a muscle loss phenotype and outcomes. Impact of muscle loss in cirrhotics was compared to that in a random sample (2%) of general medical inpatients. RESULTS A total of 162,694 hospitalizations for cirrhosis were reported, of which 18,261 (11.2%) included secondary diagnosis codes for a muscle loss phenotype. A diagnosis of muscle loss was associated with a significantly (p < 0.001 for all) higher mortality (19.3% vs 8.2%), LOS (14.2 ± 15.8 vs. 4.6 ± 6.9 days), and median hospital charge per admission ($21,400 vs. $8573) and a lower likelihood of discharge to home (30.1% vs. 60.2%). All evaluated outcomes were more severe in cirrhotics than general medical patients (n = 534,687). Multivariate regression analysis showed that a diagnosis of muscle loss independently increased mortality by 130%, LOS by 80% and direct cost of care by 119% (p < 0.001 for all). Alcohol use, female gender, malignancies and other organ dysfunction were independently associated with muscle loss. CONCLUSIONS Muscle loss contributed to higher mortality, LOS, and direct healthcare costs in hospitalized cirrhotics.
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Aseltine RH, Wang W, Benthien RA, Katz M, Wagner C, Yan J, Lewis CG. Reductions in Race and Ethnic Disparities in Hospital Readmissions Following Total Joint Arthroplasty from 2005 to 2015. J Bone Joint Surg Am 2019; 101:2044-2050. [PMID: 31764367 DOI: 10.2106/jbjs.18.01112] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Racial and ethnic disparities in hospital readmissions following total joint arthroplasty present opportunities for reducing cost and improving health equity. Despite efforts to reduce readmissions following total joint arthroplasty in the general population, no studies have documented the impact of these efforts on racial and ethnic disparities in total joint arthroplasty readmissions. The purpose of this study was to determine whether comprehensive efforts to reduce hospital readmissions following total joint arthroplasty have impacted racial and ethnic disparities in readmission rates during the period from 2005 to 2015. METHODS We conducted a retrospective analysis comparing patients readmitted and not readmitted to the hospital within 30 days of a total joint arthroplasty by estimating logistic regression models for clustered data using generalized estimating equations (GEEs) in R. Connecticut hospital discharge data for patients admitted for International Classification of Diseases, Ninth Revision (ICD-9) procedure codes 81.51 and 81.54 (Current Procedural Terminology [CPT] codes 27130 and 27447) during the 2005 to 2015 U.S. Centers for Medicare & Medicaid Services (CMS) fiscal years were analyzed. Models included quadratic terms to capture nonlinear time trends in readmissions, as well as terms for the statistical interaction between race or ethnicity and both the linear and quadratic time trends in predicting the odds of readmission. RESULTS There were 102,510 total admissions to Connecticut hospitals for total joint arthroplasty from 2005 to 2015. The 30-day (all-cause) readmission rate declined from 5.1% in 2005 to 3.6% in 2015, with a steeper downward trend observed from 2009 to 2015. The results from logistic models indicated that black patients (odds ratio [OR], 1.68; p < 0.0001) and Hispanic patients (OR, 1.48; p < 0.0001) were significantly more likely to be readmitted within 30 days of discharge following a total joint arthroplasty than white patients over the study period. The significant interaction of black race and the quadratic time trend in models capturing nonlinear trends in readmission over time indicated that the readmission rates for black patients increased compared with those for white patients from 2005 through 2008 and decreased relative to those for white patients from 2009 to 2015 (OR, 0.24; p = 0.030). CONCLUSIONS Data from Connecticut hospitals show that 30-day readmissions following a total joint arthroplasty declined by 1.5 percentage points from 2005 to 2015, and that this decline was much more pronounced among black patients, resulting in the narrowing of racial disparities in readmission following a surgical procedure. CLINICAL RELEVANCE Racial and ethnic minorities have historically been at increased risk for complications and readmission following hospital-based surgical care. This analysis of readmission following total joint arthroplasty reveals that such disparities are remediable and should foster further research on the primary drivers of and remedies for readmission disparities.
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Affiliation(s)
- Robert H Aseltine
- Division of Behavioral Science and Community Health, UConn Health, Farmington, Connecticut
- Center for Population Health, UConn Health, Farmington, Connecticut
- Department of Statistics, University of Connecticut, Storrs, Connecticut
| | - Wenjie Wang
- Center for Population Health, UConn Health, Farmington, Connecticut
- Department of Statistics, University of Connecticut, Storrs, Connecticut
| | - Ross A Benthien
- Hartford Healthcare Bone & Joint Institute, Hartford, Connecticut
| | - Matthew Katz
- Connecticut State Medical Society, New Haven, Connecticut
| | | | - Jun Yan
- Center for Population Health, UConn Health, Farmington, Connecticut
- Department of Statistics, University of Connecticut, Storrs, Connecticut
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Long-Term Mortality and Hospital Resource Use in ICU Patients With Alcohol-Related Liver Disease. Crit Care Med 2019; 47:23-32. [PMID: 30247272 DOI: 10.1097/ccm.0000000000003421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Data describing long-term outcomes following ICU for patients with alcohol-related liver disease are scarce. We aimed to report long-term mortality and emergency hospital resource use for patients with alcohol-related liver disease and compare this with two comparator cohorts. DESIGN Retrospective cohort study linking population registry data. SETTING All adult general Scottish ICUs (2005-2010) serving 5 million population. PATIENTS ICU patients with alcohol-related liver disease were compared with an unmatched cohort with Acute Physiology and Chronic Health Evaluation defined diagnoses of severe cardiovascular, respiratory, or renal comorbidity and a matched general ICU cohort. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Outcomes were 5-year mortality, emergency hospital resource use, and emergency hospital readmission. Multivariable regression was used to identify risk factors and adjust for confounders. Of 47,779 ICU admissions, 2,463 patients with alcohol-related liver disease and 3,590 patients with severe comorbidities were identified; 2,391(97.1%) were matched to a general ICU cohort. The alcohol-related liver disease cohort had greater 5-year mortality than comorbid (79.2% vs 75.3%; p < 0.001) and matched general (79.8% vs 63.3%; p < 0.001) cohorts. High liver Sequential Organ Failure Assessment score and three-organ support were associated with 90% 5-year mortality in alcohol-related liver disease patients. After confounder adjustment, alcohol-related liver disease patients had 31% higher hazard of death (adjusted hazard ratio, 1.31; 95% CI, 1.17-1.47; p < 0.001) and used greater resource than the severe comorbid comparator group. Findings were similar compared with the matched cohort. CONCLUSIONS ICU patients with alcohol-related liver disease have higher 5-year mortality and emergency readmission rates than ICU patients with other severe comorbidities and matched general ICU patients. These data can contribute to shared decision-making for alcohol-related liver disease patients.
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Pretransplant Sarcopenia in Patients With NASH Cirrhosis Does Not Impact Rehospitalization or Mortality. J Clin Gastroenterol 2019; 53:680-685. [PMID: 30180152 DOI: 10.1097/mcg.0000000000001109] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Malnutrition and muscle wasting are common in patients with end-stage liver disease (ESLD), yet go underdiagnosed. Frequently used indices of nutritional status, such as body mass index, are inflated in patients with ESLD due to a fluid overloaded state. Previous work has demonstrated a strong association between psoas muscle area, a surrogate for sarcopenia, and worse survival following liver transplantation; however, the impact of sarcopenia on post liver transplant outcomes in patients with nonalcoholic steatohepatitis (NASH) cirrhosis has not been evaluated. GOALS Describe the impact of sarcopenia in patients with NASH cirrhosis on post liver transplantation outcomes, including initial hospital length of stay, rehospitalization, and survival. MATERIALS AND METHODS A single-center, retrospective analysis was conducted of adult liver transplants performed for NASH cirrhosis between 2002 and 2015. Sarcopenia was defined by psoas area measured at the L3 vertebra from abdominal imaging within 6 months before orthotopic liver transplant (OLT). RESULTS A total of 146 patients were evaluated. The mean Model for End-Stage Liver Disease score at transplant was 34.9±7.4. Sarcopenia was present in 62% of patients and was more likely in female and Hispanic patients. There were no significant differences in length of initial hospitalization following OLT, days hospitalized within the first year post-OLT, survival at 1 year, or overall survival between sarcopenic and nonsarcopenic patients. CONCLUSIONS Sarcopenia in patients with NASH cirrhosis and high Model for End-Stage Liver Disease scores is not associated with an increase in mortality or rehospitalization following liver transplantation; however, the study findings were limited by a small sample size.
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Rao BB, Sobotka A, Lopez R, Romero-Marrero C, Carey W. Outpatient telephonic transitional care after hospital discharge improves survival in cirrhotic patients. World J Hepatol 2019; 11:646-655. [PMID: 31528247 PMCID: PMC6717714 DOI: 10.4254/wjh.v11.i8.646] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 06/12/2019] [Accepted: 07/05/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intervention to improve outcomes in cirrhotic patients (CP) after hospital discharge often focus on 30 d readmission rate (RR). However, recent studies suggest dissociation between RR and survival. At our center, CP are now offered outpatient telephonic transitional care (OTTC) by a care coordinator for 30 d after hospital discharge.
AIM To determine the effect of OTTC on survival in CP.
METHODS In this cohort study from a tertiary center, CP who received OTTC formed the intervention group. They were compared with a control group discharged during the same period. Mortality and RR were compared between the groups.
RESULTS After OTTC introduction, 194 CP were discharged. After applying exclusion criteria, 169 CP (51% male, mean age 58 years ± 12 years) were included. OTTC group comprised 76 patients and was compared with 93 controls. Baseline disease and index admission related characteristics were not significantly different between the groups. The intervention group showed significantly higher 6 mo survival compared to controls (84.2% vs 68.8%; P = 0.03), while RR at 1, 3, and 6 mo were comparable. On multivariable analysis, the intervention group showed lower odds for mortality compared to the controls (hazard ratio: 0.4; 95% confidence interval: 0.2-0.82; P = 0.012), while higher model for end-stage liver disease scores were associated with higher mortality (hazard ratio: 1.05; 95% confidence interval: 1.01-1.1; P = 0.024).
CONCLUSION CP provided OTTC had higher 6 mo survival compared to controls without a difference in RR. Use of RR to gauge quality of care provided during hospitalization or subsequent transitional care programs should be revisited.
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Affiliation(s)
- Bhavana Bhagya Rao
- Department of Gastroenterology Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Anastasia Sobotka
- Department of Gastroenterology Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Rocio Lopez
- Department of Gastroenterology Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Carlos Romero-Marrero
- Department of Gastroenterology Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
| | - William Carey
- Department of Gastroenterology Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
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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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Patel R, Poddar P, Choksi D, Pandey V, Ingle M, Khairnar H, Sawant P. Predictors of 1-month and 3-months Hospital Readmissions in Decompensated Cirrhosis: A Prospective Study in a Large Asian Cohort. Ann Hepatol 2019; 18:30-39. [PMID: 31113606 DOI: 10.5604/01.3001.0012.7859] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 11/13/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM Considered as a healthcare quality indicator, hospital readmissions in decompensated cirrhosis predispose the patients and the society to physical, social and economic distresses. Few studies involving North American cohorts have identified different predictors. The aim of this study was to determine and validate the predictors of 1-month and 3-months readmission in an Asian cohort. MATERIAL AND METHODS We prospectively studied 281 hospitalised patients with decompensated cirrhosis at a large tertiary care public hospital in India between August 2014 and August 2016 and followed them for 3 months. Data regarding demographic, laboratory and disease related risk factors were compiled. We used multivariate logistic regression to determine predictors of readmission at 1-month and 3-months and receiver operating curves (ROC) for significant predictors to obtain the best cut-offs. RESULTS 1-month and 3-months readmission rates in our study were 27.8% and 42.3%, respectively. Model for End stage Liver Disease (MELD) score at discharge (OR:1.24, p < 0.001) and serum sodium (OR:0.94, p-0.039) independently predicted 1-month and MELD score (OR:1.11, p-0.003), serum sodium (OR:0.94, p-0.027) and male gender (OR:2.19, p-0.008) independently predicted 3-months readmissions. Neither aetiology nor complications of cirrhosis emerged as risk factors. MELD score >14 at discharge and serum sodium < 133 mEq/L best predicted readmissions; MELD score being a better predictor than serum sodium (p - 0.0001). CONCLUSIONS High rates of early and late readmissions were found in our study. Further, this study validated readmission predictors in Asian patients. Structured interventions targeting this risk factors may diminish readmissions in decompensated cirrhosis.
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Affiliation(s)
- Ruchir Patel
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra, India.
| | - Prateik Poddar
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra, India
| | - Dhaval Choksi
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra, India
| | - Vikas Pandey
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra, India
| | - Meghraj Ingle
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra, India
| | - Harshad Khairnar
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra, India
| | - Prabha Sawant
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra, India
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13
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Orman ES, Ghabril M, Emmett TW, Chalasani N. Hospital Readmissions in Patients with Cirrhosis: A Systematic Review. J Hosp Med 2018; 13:490-495. [PMID: 29694458 PMCID: PMC6202277 DOI: 10.12788/jhm.2967] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 01/29/2018] [Accepted: 02/09/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Hospital readmission is a significant problem for patients with complex chronic illnesses such as liver cirrhosis. PURPOSE We aimed to describe the range of readmission risk in patients with cirrhosis and the impact of the model for end-stage liver disease (MELD) score. DATA SOURCES We conducted a systematic review of studies identified in Ovid MEDLINE, PubMed, EMBASE, CINAHL, the Cochrane Library, Scopus, Google Scholar, and ClinicalTrials.gov from 2000 to May 2017. STUDY SELECTION We examined studies that reported early readmissions (up to 90 days) in patients with cirrhosis. Studies were excluded if they did not examine the association between readmission and at least 1 variable or intervention. DATA EXTRACTION Two reviewers independently extracted data on study design, setting, population, interventions, comparisons, and detailed information on readmissions. DATA SYNTHESIS Of the 1363 records reviewed, 26 studies met the inclusion and exclusion criteria. Of these studies, 21 were retrospective, and there was significant variation in the inclusion and exclusion criteria. The pooled estimate of 30-day readmissions was 26%(95% confidence interval [CI], 22%-30%). Few studies examined readmission preventability or the relationship between readmissions and social determinants of health. Reasons for readmission were highly variable. An increased MELD score was associated with readmissions in most studies. Readmission was associated with increased mortality. CONCLUSION Hospital readmissions frequently occur in patients with cirrhosis and are associated with liver disease severity. The impact of functional and social factors on readmissions is unclear.
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Affiliation(s)
- Eric S. Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
- Address for correspondence: Eric S. Orman, MD, MSCR, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN 46202; Telephone: (317) 278-1630; Fax: (317) 278-6870;
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Thomas W. Emmett
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, Indiana
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
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Sobotka LA, Modi RM, Vijayaraman A, Hanje AJ, Michaels AJ, Conteh LF, Hinton A, El-Hinnawi A, Mumtaz K. Paracentesis in cirrhotics is associated with increased risk of 30-day readmission. World J Hepatol 2018; 10:425-432. [PMID: 29988878 PMCID: PMC6033715 DOI: 10.4254/wjh.v10.i6.425] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/13/2018] [Accepted: 04/11/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the readmission rate, its reasons, predictors, and cost of 30-d readmission in patients with cirrhosis and ascites. METHODS A retrospective analysis of the nationwide readmission database (NRD) was performed during the calendar year 2013. All adults cirrhotics with a diagnosis of ascites, spontaneous bacterial peritonitis, or hepatic encephalopathy were identified by ICD-9 codes. Multivariate analysis was performed to assess predictors of 30-d readmission and cost of readmission. RESULTS Of the 59597 patients included in this study, 18319 (31%) were readmitted within 30 d. Majority (58%) of readmissions were for liver related reasons. Paracentesis was performed in 29832 (50%) patients on index admission. Independent predictors of 30-d readmission included age < 40 (OR: 1.39; CI: 1.19-1.64), age 40-64 (OR: 1.19; CI: 1.09-1.30), Medicaid (OR: 1.21; CI: 1.04-1.41) and Medicare coverage (OR: 1.13; CI: 1.02-1.26), > 3 Elixhauser comorbidity (OR: 1.13; CI: 1.05-1.22), nonalcoholic cirrhosis (OR: 1.16; CI: 1.10-1.23), paracentesis on index admission (OR: 1.28; CI: 1.21-1.36) and having hepatocellular carcinoma (OR: 1.21; CI: 1.05; 1.39). Cost of index admission was similar in patients readmitted and not readmitted (P-value: 0.34); however cost of care was significantly more on 30 d readmission ($30959 ± 762) as compared to index admission ($12403 ± 378), P-value: < 0.001. CONCLUSION Cirrhotic patients with ascites have a 33% chance of readmission within 30-d. Younger patients, with public insurance, nonalcoholic cirrhosis and increased comorbidity who underwent paracentesis are at increased risk of readmission. Risk factors for unplanned readmission should be targeted given these patients have higher healthcare utilization.
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Affiliation(s)
- Lindsay A Sobotka
- Department of Internal Medicine, the Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Rohan M Modi
- Department of Internal Medicine, the Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Akshay Vijayaraman
- Department of Internal Medicine, the Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - A James Hanje
- Division of Gastroenterology, Hepatology and Nutrition, the Ohio State Wexner Medical Center, Columbus, OH 43210, United States
| | - Anthony J Michaels
- Division of Gastroenterology, Hepatology and Nutrition, the Ohio State Wexner Medical Center, Columbus, OH 43210, United States
| | - Lanla F Conteh
- Division of Gastroenterology, Hepatology and Nutrition, the Ohio State Wexner Medical Center, Columbus, OH 43210, United States
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, the Ohio State University, Columbus, OH 43210, United States
| | - Ashraf El-Hinnawi
- Department of Surgery, the Ohio State Wexner Medical Center, Columbus, OH 43210, United States
| | - Khalid Mumtaz
- Division of Gastroenterology, Hepatology and Nutrition, the Ohio State Wexner Medical Center, Columbus, OH 43210, United States.
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15
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Wang J, Khan S, Wyer P, Vanderwilp J, Reynolds J, Bethancourt B, Ota KS. The Role of Ultrasound-Guided Therapeutic Paracentesis in an Outpatient Transitional Care Program: A Case Series. Am J Hosp Palliat Care 2018; 35:1256-1260. [DOI: 10.1177/1049909118755378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background: Patients with ascites suffer from distressing symptoms and are at high risk for readmission after hospitalization. Timely paracentesis is an important palliative tool in managing this vulnerable population. At our institution, we have developed a multidisciplinary transitional care program for patients discharged from the hospital with a wide range of complex conditions including refractory ascites. Methods: We present a case series of 10 patients with symptomatic ascites who were enrolled in our transitional care program and treated with ultrasound-guided therapeutic paracentesis in our clinic. Patient medical records were retrospectively reviewed to collect procedure details, outcomes, and follow-up data on emergency department (ED) visits and readmissions. Cost data were obtained from the hospital financial system. Results: Over the span of 9 months (September 2016 to July 2017), 22 total therapeutic paracenteses were performed on 10 unique patients in the transitional care clinic. Median age of the patient cohort was 52.5 years (range: 27-71 years). All patients reported immediate relief of ascites-related discomfort following the procedure. We did not observe any major adverse effects due to the in-clinic procedure. Nine of the 10 patients did not have any ED visits or readmissions within 30 days of discharge. The cost of performing ultrasound-guided paracentesis in the transitional care clinic was US$546.77 compared to US$978.32 when performed in the hospital. Conclusion: Our experience suggests that outpatient paracentesis may be a safe, feasible, and cost-effective means of providing symptom management for patients with ascites during their transition from hospital to home.
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Affiliation(s)
- Jeffrey Wang
- Center for Transitional Care, St Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- College of Arts and Sciences, Baylor University, Waco, TX, USA
| | - Shahida Khan
- Center for Transitional Care, St Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Paige Wyer
- Center for Transitional Care, St Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Jessica Vanderwilp
- Center for Transitional Care, St Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Justin Reynolds
- Center for Liver Disease and Transplantation, St Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Bruce Bethancourt
- Center for Transitional Care, St Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Ken S. Ota
- Center for Transitional Care, St Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
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16
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Siddique SM, Lane-Fall M, McConnell MJ, Jakhete N, Crismale J, Porges S, Khungar V, Mehta SJ, Goldberg D, Li Z, Schiano T, Regan L, Orloski C, Shea JA. Exploring opportunities to prevent cirrhosis admissions in the emergency department: A multicenter multidisciplinary survey. Hepatol Commun 2018; 2:237-244. [PMID: 29507899 PMCID: PMC5831018 DOI: 10.1002/hep4.1141] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/17/2017] [Accepted: 11/24/2017] [Indexed: 12/26/2022] Open
Abstract
Patients with cirrhosis have high admission and readmission rates, and it is estimated that a quarter are potentially preventable. Little data are available regarding nonmedical factors impacting triage decisions in this patient population. This study sought to explore such factors as well as to determine provider perspectives on low‐acuity clinical presentations to the emergency department, including ascites and hepatic encephalopathy. A survey was distributed in four liver transplant centers to both emergency medicine and hepatology providers, who included attending physicians, house staff, and advanced practitioners; 196 surveys were returned (estimated response rate 50.6%). Emergency medicine providers identified several influential nonmedical factors impacting inpatient triage decisions, including input from a hepatologist (77.7%), inadequate patient access to outpatient specialty care (68.6%), and patient need for diagnostic testing for a procedure (65.6%). When given patient‐based scenarios of low‐acuity cases, such as ascites requiring paracentesis, only 7.0% believed patients should be hospitalized while 48.9% said these patients would be hospitalized at their institution (P < 0.0001). For mild hepatic encephalopathy, the comparable numbers were 19.5% and 55.2%, respectively (P < 0.001). Several perceived barriers were cited for this discrepancy, including limited resources both in the outpatient setting and emergency department. Most providers believed that an emergency department observation unit protocol would influence triage toward an emergency department observation unit visit instead of inpatient admission for both ascites requiring large volume paracentesis (83.2%) and mild hepatic encephalopathy (79.4%). Conclusion: Many nonmedical factors that influence inpatient triage for patients with cirrhosis could be targeted for quality improvement initiatives. In some scenarios, providers are limited by resource availability, which results in triage to an inpatient admission even when they believe this is not the most appropriate disposition. (Hepatology Communications 2018;2:237‐244)
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Affiliation(s)
- Shazia Mehmood Siddique
- Division of Gastroenterology and Hepatology Perelman School of Medicine, University of Pennsylvania Philadelphia PA.,Center for Healthcare Improvement and Patient Safety, Penn Medicine, University of Pennsylvania Philadelphia PA
| | - Meghan Lane-Fall
- Center for Healthcare Improvement and Patient Safety, Penn Medicine, University of Pennsylvania Philadelphia PA.,Department of Anesthesiology and Critical CarePerelman School of Medicine, University of Pennsylvania Philadelphia PA
| | | | - Neha Jakhete
- Division of Gastroenterology Johns Hopkins Hospital Baltimore MD
| | - James Crismale
- Division of Gastroenterology Mount Sinai Hospital New York NY
| | - Stefanie Porges
- Department of Emergency Medicine Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Vandana Khungar
- Division of Gastroenterology and Hepatology Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Shivan J Mehta
- Division of Gastroenterology and Hepatology Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - David Goldberg
- Division of Gastroenterology and Hepatology Perelman School of Medicine, University of Pennsylvania Philadelphia PA
| | - Zhiping Li
- Center for Healthcare Improvement and Patient Safety, Penn Medicine, University of Pennsylvania Philadelphia PA
| | - Thomas Schiano
- Division of Gastroenterology Mount Sinai Hospital New York NY
| | - Linda Regan
- Department of Emergency Medicine Johns Hopkins Medicine Baltimore MD
| | - Clinton Orloski
- Division of Critical Care Medicine University of Washington Seattle WA
| | - Judy A Shea
- Division of General Internal Medicine Perelman School of Medicine, University of Pennsylvania Philadelphia PA
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17
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Rogal SS, Udawatta V, Akpan I, Moghe A, Chidi A, Shetty A, Szigethy E, Bielefeldt K, DiMartini A. Risk factors for hospitalizations among patients with cirrhosis: A prospective cohort study. PLoS One 2017; 12:e0187176. [PMID: 29149171 PMCID: PMC5693413 DOI: 10.1371/journal.pone.0187176] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 10/14/2017] [Indexed: 12/13/2022] Open
Abstract
This study was designed to assess unique baseline factors associated with subsequent hospitalizations in a cohort of outpatients with cirrhosis. A cohort of 193 patients with cirrhosis was recruited from an outpatient liver disease clinic at a single, tertiary medical center. Comorbidities, prescription medications, liver disease symptoms and severity, and psychiatric and pain symptoms were assessed at baseline using validated instruments. Inflammatory markers were measured using standardized Luminex assays. Subsequent hospitalizations and the primary admission diagnoses were collected via chart review. Multivariable models were used to evaluate which baseline factors were associated with time to hospitalization and number of hospitalizations. The cohort consisted of 193 outpatients, with an average age of 58±9 and model for end-stage liver disease (MELD) score of 12±5. Over follow-up, 57 (30%) were admitted to the hospital. The factors associated with time to hospitalization included the severity of liver disease (HR/MELD point:1.10, 95% CI:1.04,1.16), ascites (HR: 1.90, 95% CI: 1.01, 3.58), baseline symptoms of depression (HR:2.34, 95% CI:1.28,4.25), sleep medications (HR:1.81, 95% CI:1.01, 3.22) and IL-6 (HR:1.43, 95% CI: 1.10, 1.84). Similarly the number admissions was significantly associated with MELD (IIR: 1.08, CI: 1.07,1.09), ascites (IIR: 4.15, CI:3.89, 4.43), depressive symptoms (IIR:1.54, CI:1.44,1.64), IL-6 (IIR:1.26, CI:1.23,1.30), sleep medications (IIR:2.74, CI:2.57, 2.93), and widespread pain (IIR: 1.61, CI: 1.50, 1.73). In conclusion, consistent with prior studies, MELD and ascites were associated with subsequent hospitalization. However, this study also identified other factors associated with hospitalization including inflammation, depressive symptoms, sleep medication use, and pain.
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Affiliation(s)
- Shari S. Rogal
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, United States of America
- * E-mail:
| | - Viyan Udawatta
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Imo Akpan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Akshata Moghe
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Alexis Chidi
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Amit Shetty
- University of Pittsburgh, School of Medicine, Pittsburgh, PA, United States of America
| | - Eva Szigethy
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Klaus Bielefeldt
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Andrea DiMartini
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States of America
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18
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Morales BP, Planas R, Bartoli R, Morillas RM, Sala M, Cabré E, Casas I, Masnou H. Early hospital readmission in decompensated cirrhosis: Incidence, impact on mortality, and predictive factors. Dig Liver Dis 2017; 49:903-909. [PMID: 28410915 DOI: 10.1016/j.dld.2017.03.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 02/05/2017] [Accepted: 03/09/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS The early hospital readmission of patients with decompensated cirrhosis is a current problem. A study is presented on the incidence, the impact on mortality, and the predictive factors of early hospital readmission. PATIENTS AND METHODS On the study included 112 cirrhotic patients, discharged after some decompensation between January 2013 and May 2014. Multivariate analyses were performed to identify predictors of early readmission and mortality. RESULTS The early readmission rate was 29.5%. The predictive factors were male gender (OR: 2.81; 95% CI: 1.07-7.35), Model for End-Stage Liver Disease-sodium score ≥15 (OR: 3.79; 95% CI 1.48-9.64), and Charlson index ≥7 (OR: 4.34, 95% CI 1.65-11.4). This model enabled patients to be classified into low or high risk of early readmissions (13.6% vs. 52.2%). The mortality rate was significantly higher among patients with early readmission (73% vs. 35%) (p<.0001). After adjusting for the Model for End-Stage Liver Disease-sodium score, Charlson index, dependence in activities of daily living, educational status, and number of medications on discharge, the early readmission was independently associated with mortality. CONCLUSIONS Early hospital readmission is common, and is independently associated with mortality. Male gender, MELD-Na ≥15, and Charlson index ≥7 are predictors of early readmission. These results could be used to develop future strategies to reduce early readmission.
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Affiliation(s)
- Betty P Morales
- Hospital Universitari Germans Trias i Pujol, Liver Unit, Gastroenterology, Departament of Medicine, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain.
| | - Ramon Planas
- Hospital Universitari Germans Trias i Pujol, Liver Unit, Gastroenterology, Departament of Medicine, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERHED, Barcelona, Spain
| | - Ramon Bartoli
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERHED, Barcelona, Spain; Fundació Germans Trias i Pujol, Gastroenterology, Badalona, Spain
| | - Rosa M Morillas
- Hospital Universitari Germans Trias i Pujol, Liver Unit, Gastroenterology, Departament of Medicine, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERHED, Barcelona, Spain
| | - Margarita Sala
- Hospital Universitari Germans Trias i Pujol, Liver Unit, Gastroenterology, Departament of Medicine, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERHED, Barcelona, Spain
| | - Eduard Cabré
- Hospital Universitari Germans Trias i Pujol, Liver Unit, Gastroenterology, Departament of Medicine, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERHED, Barcelona, Spain
| | - Irma Casas
- Hospital Universitari Germans Trias i Pujol, Preventive Medicine and Epidemiology Department, Autonomous University of Barcelona, Badalona, Barcelona, Spain
| | - Helena Masnou
- Hospital Universitari Germans Trias i Pujol, Liver Unit, Gastroenterology, Departament of Medicine, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
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Hayward KL, Martin JH, Cottrell WN, Karmakar A, Horsfall LU, Patel PJ, Smith DD, Irvine KM, Powell EE, Valery PC. Patient-oriented education and medication management intervention for people with decompensated cirrhosis: study protocol for a randomized controlled trial. Trials 2017; 18:339. [PMID: 28728560 PMCID: PMC5520368 DOI: 10.1186/s13063-017-2075-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 07/01/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND People with decompensated cirrhosis require complex medical care and are often prescribed an intricate and frequently changing medication and lifestyle regimen. However, many patients mismanage their medications or have poor comprehension of their disease and self-management tasks. This can lead to harm, hospitalization, and death. METHODS/DESIGN A patient-oriented education and medication management intervention has been developed for implementation at a tertiary hospital hepatology outpatient center in Queensland, Australia. Consenting patients with decompensated cirrhosis will be randomly allocated to education intervention or usual care treatment arms when they attend routine follow-up appointments. In the usual care arm, participants will be reviewed by their hepatologist according to the current model of care in the hepatology clinic. In the intervention arm, participants will be reviewed by a clinical pharmacist to receive the education and medication management intervention at baseline in addition to review by their hepatologist. Intervention participants will also receive three further educational contacts from the clinical pharmacist within the following 6-month period, in addition to routine hepatologist review that is scheduled within this time frame. All participants will be surveyed at baseline and follow-up (approximately 6 months post-enrollment). Validated questionnaire tools will be used to determine participant adherence, medication beliefs, illness perceptions, and quality of life. Patients' knowledge of dietary and lifestyle modifications, their current medications, and other clinical data will be obtained from the survey, patient interview, and medical records. Patient outcome data will be collected at 52 weeks. DISCUSSION The intervention described within this protocol is ready to adapt and implement in hepatology ambulatory care centers globally. Investigation of potentially modifiable variables that may impact medication management, in addition to the effect of a clinical pharmacist-driven education and medication management intervention on modifying these variables, will provide valuable information for future management of these patients. TRIAL REGISTRATION Australian and New Zealand Clinical Trial Registry identifier: ACTRN12616000780459 . Registered on 15 June 2016.
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Affiliation(s)
- Kelly L. Hayward
- School of Medicine, The University of Queensland, Brisbane, QLD Australia
- Pharmacy Department, Princess Alexandra Hospital, Brisbane, QLD Australia
| | - Jennifer H. Martin
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW Australia
| | - W. Neil Cottrell
- School of Pharmacy, The University of Queensland, Brisbane, QLD Australia
| | - Antara Karmakar
- School of Medicine, The University of Queensland, Brisbane, QLD Australia
| | - Leigh U. Horsfall
- The Centre for Liver Disease Research, Translational Research Institute, The University of Queensland, Brisbane, QLD Australia
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD Australia
| | - Preya J. Patel
- The Centre for Liver Disease Research, Translational Research Institute, The University of Queensland, Brisbane, QLD Australia
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD Australia
| | - David D. Smith
- Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, QLD Australia
| | - Katharine M. Irvine
- The Centre for Liver Disease Research, Translational Research Institute, The University of Queensland, Brisbane, QLD Australia
| | - Elizabeth E. Powell
- The Centre for Liver Disease Research, Translational Research Institute, The University of Queensland, Brisbane, QLD Australia
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD Australia
| | - Patricia C. Valery
- Cancer and Chronic Disease Research Group, Level 4, Central, QIMR Berghofer Medical Research Institute, 300 Herston Rd, Brisbane, QLD 4006 Australia
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20
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Symptom Domain Groups of the Patient-Reported Outcomes Measurement Information System Tools Independently Predict Hospitalizations and Re-hospitalizations in Cirrhosis. Dig Dis Sci 2017; 62:1173-1179. [PMID: 28258378 DOI: 10.1007/s10620-017-4509-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 02/21/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patient-Reported Outcomes Measurement Information System (PROMIS) tools can identify health-related quality of life (HRQOL) domains that could differentially affect disease progression. Cirrhotics are highly prone to hospitalizations and re-hospitalizations, but the current clinical prognostic models may be insufficient, and thus studying the contribution of individual HRQOL domains could improve prognostication. AIM Analyze the impact of individual HRQOL PROMIS domains in predicting time to all non-elective hospitalizations and re-hospitalizations in cirrhosis. METHODS Outpatient cirrhotics were administered PROMIS computerized tools. The first non-elective hospitalization and subsequent re-hospitalizations after enrollment were recorded. Individual PROMIS domains significantly contributing toward these outcomes were generated using principal component analysis. Factor analysis revealed three major PROMIS domain groups: daily function (fatigue, physical function, social roles/activities and sleep issues), mood (anxiety, anger, and depression), and pain (pain behavior/impact) accounted for 77% of the variability. Cox proportional hazards regression modeling was used for these groups to evaluate time to first hospitalization and re-hospitalization. RESULTS A total of 286 patients [57 years, MELD 13, 67% men, 40% hepatic encephalopathy (HE)] were enrolled. Patients were followed at 6-month (mth) intervals for a median of 38 mths (IQR 22-47), during which 31% were hospitalized [median IQR mths 12.5 (3-27)] and 12% were re-hospitalized [10.5 mths (3-28)]. Time to first hospitalization was predicted by HE, HR 1.5 (CI 1.01-2.5, p = 0.04) and daily function PROMIS group HR 1.4 (CI 1.1-1.8, p = 0.01), independently. In contrast, the pain PROMIS group were predictive of the time to re-hospitalization HR 1.6 (CI 1.1-2.3, p = 0.03) as was HE, HR 2.1 (CI 1.1-4.3, p = 0.03). CONCLUSIONS Daily function and pain HRQOL domain groups using PROMIS tools independently predict hospitalizations and re-hospitalizations in cirrhotic patients.
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Yataco M, Cowell A, David W, Keaveny AP, Taner CB, Patel T. Predictors and impacts of hospital readmissions following liver transplantation. Ann Hepatol 2017; 15:356-62. [PMID: 27049489 DOI: 10.5604/16652681.1198805] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
While liver transplantation is the definitive therapy for end stage liver disease, it remains a major procedure, with many potential complications. Hospital readmissions after the initial hospitalization for liver transplantation can be associated with adverse outcomes, increased cost, and resource utilization. Our aim was to define the incidence and reasons for hospital readmission after liver transplant and the impact of readmissions on patient outcomes. We retrospectively analyzed 30- and 90-day readmission rates and indications in patients who underwent liver transplant at a large-volume transplant center over a 3-year period. Four hundred seventy-nine adult patients underwent their first liver transplant during the study period. The 30-day readmission rate was 29.6%. Recipient and donor age, etiology of liver disease, biological Model for End-Stage Liver Disease score, and cold ischemia time were similar between patients who were readmitted within 30 days and those who were not readmitted. Readmissions occurred in 25% of patients who were hospitalized prior to liver transplant compared to 30% who were admitted for liver transplant. The most common indications for readmission were infection, severe abdominal pain, and biliary complications. Early discharge from hospital (fewer than 7 days after liver transplant), was not associated with readmission; however, a prolonged hospital stay after liver transplant was associated with an increased risk of readmission (p = 0.04). In conclusion, patients who undergo liver transplant have a high rate of readmission. In our cohort, readmissions were unrelated to pre-existing recipient or donor factors, but were associated with a longer hospital stay after liver transplant.
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Affiliation(s)
- Maria Yataco
- Department of Transplant, Mayo Clinic, Jacksonville, FL, USA
| | - Alissa Cowell
- Department of Transplant, Mayo Clinic, Jacksonville, FL, USA
| | - Waseem David
- Department of Transplant, Mayo Clinic, Jacksonville, FL, USA
| | | | - C Burcin Taner
- Department of Transplant, Mayo Clinic, Jacksonville, FL, USA
| | - Tushar Patel
- Department of Transplant, Mayo Clinic, Jacksonville, FL, USA
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Frailty as Tested by Gait Speed is an Independent Risk Factor for Cirrhosis Complications that Require Hospitalization. Am J Gastroenterol 2016; 111:1768-1775. [PMID: 27575708 DOI: 10.1038/ajg.2016.336] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 07/01/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Frailty is a known risk factor for major life-threatening liver transplant complications, deaths, and waitlist attrition. Whether frailty indicates risk for adverse outcomes in cirrhosis short of lethality is not well defined. We hypothesized that clinical measurements of frailty using gait speed and grip strength would indicate the risk of subsequent hospitalization for the complications of cirrhosis. METHODS We assessed frailty as gait speed and grip strength in a 1-year prospective study of 373 cirrhotic patients evaluated for or awaiting liver transplantation. We determined its association with the outcome of subsequent hospital days/100 days at risk for 7 major complications of cirrhosis. We tested potential covariate influences of Model for Endstage Liver Disease (MELD) and Child-Turcotte-Pugh (CTP) scores, age, sex, height, depression, narcotic use, vitamin D deficiency, and hepatocellular carcinoma using multivariable modeling. RESULTS Patients experienced 2.14 hospital days/100 days at risk, or 7.81 days/year. Frailty measured by gait speed was a strong risk factor for hospitalization for all cirrhosis complications. Each 0.1 m/s gait speed decrease was associated with 22% greater hospital days (P<0.001). Grip strength showed a similar but nonsignificant association. Gait speed remained independently significant when adjusted for MELD, CTP, and other covariates. At hospital costs of $4,000/day, patients with normal 1 m/s gait speed spent 6.2 days and $24,800/year; patients with 0.5 m/s speed spent 21.2 days and $84,800/year; and patients with 0.25 m/s speed spent 40.2 days and $160,800/year. CONCLUSIONS Frailty as measured by gait speed is an independent and potentially modifiable risk factor for cirrhosis complications requiring hospitalization. The potential clinical value of frailty measurements to help define such risk merits broader evaluation.
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Hayward KL, Valery PC, Cottrell WN, Irvine KM, Horsfall LU, Tallis CJ, Chachay VS, Ruffin BJ, Martin JH, Powell EE. Prevalence of medication discrepancies in patients with cirrhosis: a pilot study. BMC Gastroenterol 2016; 16:114. [PMID: 27618841 PMCID: PMC5020443 DOI: 10.1186/s12876-016-0530-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 09/01/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cirrhosis patients are prescribed multiple medications for their liver disease and comorbidities. Discrepancies between medicines consumed by patients and those documented in the medical record may contribute to patient harm and impair disease management. The aim of the present study was to assess the magnitude and types of discrepancies among patient-reported and medical record-documented medications in patients with cirrhosis, and examine factors associated with such discrepancies. METHODS Fifty patients who attended a hospital hepatology outpatient clinic were interviewed using a questionnaire composed of mixed short-response and multiple-choice questions. Patients' reported medication use was compared with documentation in the hospital medical records and pharmacy database. Medication adherence was assessed using the 8-question ©Morisky Medication Adherence Scale (MMAS-8). The multivariate logistic regression model was constructed using clinically relevant and/or statistically significant variables as determined by univariate analysis. All p-values were 2-sided (α = 0.05). RESULTS Twenty-seven patients (54.0 %) had ≥1 discrepancy between reported and documented medicines. Patients with ≥1 discrepancy were older (p = 0.04) and multivariate analysis identified taking ≥5 conventional medicines or having a 'low' or 'medium' adherence ranking as independent predictors of discrepancy (adjusted OR 11.0 (95 % CI 1.8-67.4), 20.7 (95 % CI 1.3-337.7) and 49.0 (95 % CI 3.3-718.5) respectively). Concordance was highest for liver disease medicines (71.9 %) and lowest for complementary and alternative medicines (14.5 %) and respiratory medicines (0 %). CONCLUSION There is significant discrepancy between sources of patient medication information within the hepatology clinic. Medication reconciliation and medicines-management intervention may address the complex relationship between medication discrepancies, number of medications and patient adherence identified in this study.
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Affiliation(s)
- Kelly L Hayward
- School of Medicine, The University of Queensland, Translational Research Institute, Brisbane, Australia.,Pharmacy Department, Princess Alexandra Hospital, Brisbane, Australia
| | | | - W Neil Cottrell
- School of Pharmacy, The University of Queensland, Brisbane, Australia
| | - Katharine M Irvine
- Centre for Liver Disease Research, The University of Queensland, Brisbane, Australia
| | - Leigh U Horsfall
- Centre for Liver Disease Research, The University of Queensland, Brisbane, Australia
| | - Caroline J Tallis
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba 4102, Brisbane, Queensland, Australia
| | - Veronique S Chachay
- School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Australia
| | - Brittany J Ruffin
- Centre for Liver Disease Research, The University of Queensland, Brisbane, Australia
| | - Jennifer H Martin
- School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia
| | - Elizabeth E Powell
- Centre for Liver Disease Research, The University of Queensland, Brisbane, Australia. .,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba 4102, Brisbane, Queensland, Australia.
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Atla PR, Sheikh MY, Gill F, Kundu R, Choudhury J. Predictors of hospital re-admissions among Hispanics with hepatitis C-related cirrhosis. Ann Gastroenterol 2016; 29:515-520. [PMID: 27708520 PMCID: PMC5049561 DOI: 10.20524/aog.2016.0072] [Citation(s) in RCA: 3] [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] [Received: 05/17/2016] [Accepted: 06/23/2016] [Indexed: 12/23/2022] Open
Abstract
Background Hospital re-admissions in decompensated cirrhosis are associated with worse patient outcomes. Hispanics have a disproportionately high prevalence of hepatitis C virus (HCV)-related morbidity and mortality. The goal of this study was to evaluate the factors affecting re-admission rates among Hispanics with HCV-related cirrhosis. Methods A total of 292 consecutive HCV-related cirrhosis admissions (Hispanics 189, non-Hispanics 103) from January 2009 to December 2012 were retrospectively reviewed; 132 were cirrhosis-related re-admissions. The statistical analysis was performed using STATA version 11.1. Chi-square/Fisher’s exact and Student’s t-tests were used to compare categorical and continuous variables, respectively. Multivariate logistic regression analysis was performed to identify predictors for hospital readmissions. Results Among the 132 cirrhosis-related readmissions, 71% were Hispanics while 29% were non-Hispanics (P=0.035). Hepatic encephalopathy (HE) and esophageal variceal hemorrhage were the most frequent causes of the first and subsequent readmissions. Hispanics with readmissions had a higher Child-Turcotte-Pugh (CTP) class (B and C) and higher model for end-stage liver disease (MELD) scores (≥15), as well as a higher incidence of alcohol use, HE, spontaneous bacterial peritonitis, hepatocellular carcinoma, and varices (P<0.05). The majority of the study patients (81%) had MELD scores <15. Multivariate regression analysis identified alcohol use (OR 2.63; 95%CI 1.1-6.4), HE (OR 5.5; 95%CI 2-15.3), varices (OR 3.2; 95%CI 1.3-8.2), and CTP class (OR 3.3; 95%CI 1.4–8.1) as predictors for readmissions among Hispanics. Conclusion CTP classes B and C, among other factors, were the major predictors for hospital readmissions in Hispanics with HCV-related cirrhosis. The majority of these readmissions were due to HE and variceal hemorrhage.
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Affiliation(s)
- Pradeep R Atla
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Francisco, Fresno MEP (Pradeep R. Atla, Muhammad Y. Sheikh, Rabindra Kundu, Jayanta Choudhury), Fresno, California, USA
| | - Muhammad Y Sheikh
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Francisco, Fresno MEP (Pradeep R. Atla, Muhammad Y. Sheikh, Rabindra Kundu, Jayanta Choudhury), Fresno, California, USA
| | - Firdose Gill
- Department of Medicine, Kaiser Permanente Fresno Medical Center (Firdose Gill), Fresno, California, USA
| | - Rabindra Kundu
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Francisco, Fresno MEP (Pradeep R. Atla, Muhammad Y. Sheikh, Rabindra Kundu, Jayanta Choudhury), Fresno, California, USA
| | - Jayanta Choudhury
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Francisco, Fresno MEP (Pradeep R. Atla, Muhammad Y. Sheikh, Rabindra Kundu, Jayanta Choudhury), Fresno, California, USA
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Bajaj JS, Reddy KR, Tandon P, Wong F, Kamath PS, Garcia-Tsao G, Maliakkal B, Biggins SW, Thuluvath PJ, Fallon MB, Subramanian RM, Vargas H, Thacker LR, O’Leary JG. The 3-month readmission rate remains unacceptably high in a large North American cohort of patients with cirrhosis. Hepatology 2016; 64:200-8. [PMID: 26690389 PMCID: PMC4700508 DOI: 10.1002/hep.28414] [Citation(s) in RCA: 177] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 12/17/2015] [Indexed: 12/12/2022]
Abstract
UNLABELLED In smaller single-center studies, patients with cirrhosis are at a high readmission risk, but a multicenter perspective study is lacking. We evaluated the determinants of 3-month readmissions among inpatients with cirrhosis using the prospective 14-center North American Consortium for the Study of End-Stage Liver Disease cohort. Patients with cirrhosis hospitalized for nonelective indications provided consent and were followed for 3 months postdischarge. The number of 3-month readmissions and their determinants on index admission and discharge were calculated. We used multivariable logistic regression for all readmissions and for hepatic encephalopathy (HE), renal/metabolic, and infection-related readmissions. A score was developed using admission/discharge variables for the total sample, which was validated on a random half of the total population. Of the 1353 patients enrolled, 1177 were eligible on discharge and 1013 had 3-month outcomes. Readmissions occurred in 53% (n = 535; 316 with one, 219 with two or more), with consistent rates across sites. The leading causes were liver-related (n = 333; HE, renal/metabolic, and infections). Patients with cirrhosis and with worse Model for End-Stage Liver Disease score or diabetes, those taking prophylactic antibiotics, and those with prior HE were more likely to be readmitted. The admission model included Model for End-Stage Liver Disease and diabetes (c-statistic = 0.64, after split-validation 0.65). The discharge model included Model for End-Stage Liver Disease, proton pump inhibitor use, and lower length of stay (c-statistic = 0.65, after split-validation 0.70). Thirty percent of readmissions could not be predicted. Patients with liver-related readmissions consistently had index-stay nosocomial infections as a predictor for HE, renal/metabolic, and infection-associated readmissions (odds ratio = 1.9-3.0). CONCLUSIONS Three-month readmissions occurred in about half of discharged patients with cirrhosis, which were associated with cirrhosis severity, diabetes, and nosocomial infections; close monitoring of patients with advanced cirrhosis and prevention of nosocomial infections could reduce this burden. (Hepatology 2016;64:200-208).
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Affiliation(s)
- Jasmohan S. Bajaj
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | | | | | | | | | | | | | | | | | | | | | | | - Leroy R. Thacker
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
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Tapper EB, Finkelstein D, Mittleman MA, Piatkowski G, Chang M, Lai M. A Quality Improvement Initiative Reduces 30-Day Rate of Readmission for Patients With Cirrhosis. Clin Gastroenterol Hepatol 2016; 14:753-9. [PMID: 26407750 PMCID: PMC5394424 DOI: 10.1016/j.cgh.2015.08.041] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 08/18/2015] [Accepted: 08/31/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Many hospitalized patients with cirrhosis are readmitted to the hospital within 30 days, particularly those with hepatic encephalopathy (HE). We performed a prospective study to assess the effects of a quality improvement protocol on readmission to a transplant center's liver unit within 30 days. METHODS We studied the effects of a quality improvement program in 824 unique patients with decompensated cirrhosis or receiving liver transplants (mean Model for End-Stage Liver Disease score, 17.7 ± 7.4) admitted to an inpatient hepatology unit from 2010 through 2013. The study had a year-long control period (626 admissions receiving usual care) and 2 intervention phases: a hand-held checklist phase (470 admissions) and an electronic phase that incorporated the checklist items into the electronic provider order entry system (624 admissions). The intervention phases included goal-directed lactulose therapy and rifaximin for overt HE, and prompts for antibiotic prophylaxis of spontaneous bacterial peritonitis. The primary endpoint was the difference in 30-day readmissions between the control and intervention phases. Trends in 30-day readmissions were compared with those of patients with decompensated cirrhosis admitted at another center. RESULTS During the electronic phase, study subjects had 40% lower adjusted odds of 30-day readmission than during the control period. The slope of the decline in readmissions over time was significantly greater than for patients at the other center (P < .0001). The proportion of patients with greater than grade 2 HE and 30-day readmission was 48.9% (66 of 135) in the control period versus 26.0% (27 of 104) in the electronic phase (P = .0003). Treatment of HE with rifaximin and secondary prophylaxis of spontaneous bacterial peritonitis with antibiotics (on discharge) were associated with lower adjusted odds of readmission (odds ratios, 0.39 and 0.40, respectively). The electronic phase was associated with 1.34 fewer hospital days for HE compared with the control period (P = .01). CONCLUSIONS In a prospective study, a quality improvement initiative that included electronic decision support reduced readmissions of patients with cirrhosis to the hospital within 30 days.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School
| | | | - Murray A. Mittleman
- Cardiovascular Epidemiology Research Unit, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Gail Piatkowski
- Decision Support, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Matthew Chang
- Division of Gastroenterology, Brigham and Women’s Hospital, Harvard Medical School
| | - Michelle Lai
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School
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Okafor PN, Chiejina M, de Pretis N, Talwalkar JA. Secondary analysis of large databases for hepatology research. J Hepatol 2016; 64:946-56. [PMID: 26739689 DOI: 10.1016/j.jhep.2015.12.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 12/15/2015] [Accepted: 12/21/2015] [Indexed: 12/15/2022]
Abstract
Secondary analysis of large datasets involves the utilization of existing data that has typically been collected for other purposes to advance scientific knowledge. This is an established methodology applied in health services research with the unique advantage of efficiently identifying relationships between predictor and outcome variables but which has been underutilized for hepatology research. Our review of 1431 abstracts published in the 2013 European Association for the Study of Liver (EASL) abstract book showed that less than 0.5% of published abstracts utilized secondary analysis of large database methodologies. This review paper describes existing large datasets that can be exploited for secondary analyses in liver disease research. It also suggests potential questions that could be addressed using these data warehouses and highlights the strengths and limitations of each dataset as described by authors that have previously used them. The overall goal is to bring these datasets to the attention of readers and ultimately encourage the consideration of secondary analysis of large database methodologies for the advancement of hepatology.
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Affiliation(s)
- Philip N Okafor
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States.
| | - Maria Chiejina
- Department of Internal Medicine, Good Shepard Medical Center, Longview, TX 75601, United States
| | - Nicolo de Pretis
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Medicine, University of Verona, Piazzale L.A. Scuro, 10, 37134 Verona, Italy
| | - Jayant A Talwalkar
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States
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Abstract
Advanced liver disease is becoming more prevalent in the United States. This increase has been attributed largely to the growing epidemic of nonalcoholic fatty liver disease and an aging population infected with hepatitis C. Complications of cirrhosis are a major cause of hospital admissions and readmissions. It is important to target efforts for preventing rehospitalization toward patients with cirrhosis who are at the highest risk for readmission, such as those who have high Model for End-Stage Liver Disease scores, are at risk for fluid/electrolyte abnormalities or overt hepatic encephalopathy recurrence, and those who have comorbid conditions (e.g. diabetes). The heart failure management paradigm may provide valuable insights for managing patients with cirrhosis, given the extensive research on preventing hospital readmission and improving health care utilization in this subpopulation. As quality measures related to hospital readmissions for cirrhosis and its complications are adopted by the Centers for Medicare & Medicaid Services and private payers in the future, understanding drivers of hospital readmissions and health care utilization in this vulnerable population are key to improving quality measure performance.
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Affiliation(s)
- Archita P Desai
- a Liver Research Institute, Department of Medicine , University of Arizona , Tucson , AZ , USA
| | - Nancy Reau
- b Section of Hepatology , Rush University , Chicago , IL , USA
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29
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Guirguis J, Chhatwal J, Dasarathy J, Rivas J, McMichael D, Nagy LE, McCullough AJ, Dasarathy S. Clinical impact of alcohol-related cirrhosis in the next decade: estimates based on current epidemiological trends in the United States. Alcohol Clin Exp Res 2015; 39:2085-94. [PMID: 26500036 PMCID: PMC4624492 DOI: 10.1111/acer.12887] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 08/24/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND Identifying changes in the epidemiology of liver disease is critical for establishing healthcare priorities and allocating resources to develop therapies. The projected contribution of different etiologies toward development of cirrhosis in the United States was estimated based on current publications on epidemiological data and advances in therapy. Given the heterogeneity of published reports and the different perceptions that are not always reconcilable, a critical overview rather than a formal meta-analysis of the existing data and projections for the next decade was performed. METHODS Data from the World Health Organization Global Status Report on Alcohol and Health of 2014, Scientific Registry of Transplant Recipients from 1999 to 2012, National Institute on Alcohol Abuse and Alcoholism, and the Centers for Disease Control and Prevention were inquired to determine future changes in the epidemiology of liver disease. RESULTS Alcohol consumption has increased over the past 60 years. In 2010, transplant-related costs for liver recipients were the highest for hepatitis C (~$124 million) followed by alcohol-related cirrhosis (~$86 million). We anticipate a significant reduction in incidence cirrhosis due to causes other than alcohol because of the availability of high efficiency antiviral agents for hepatitis C, universal and effective vaccination for hepatitis B, relative stabilization of the obesity trends in the United States, and novel, potentially effective therapies for nonalcoholic steatohepatitis. The proportion of alcohol-related liver disease is therefore likely to increase in both the population as a whole and the liver transplant wait list. CONCLUSIONS Alcohol-related cirrhosis and alcohol-related liver disorders will be the major cause of liver disease in the coming decades. There is an urgent need to allocate resources aimed toward understanding the pathogenesis of the disease and its complications so that effective therapies can be developed.
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Affiliation(s)
- John Guirguis
- Departments of Gastroenterology, Hepatology and Transplant Surgery, Cleveland Clinic, Cleveland OHIO
| | - Jagpreet Chhatwal
- Department of Health Services Research, Massachusetts General Hospital, Harvard Medical School, Boston
| | | | - John Rivas
- Departments of Gastroenterology, Hepatology and Transplant Surgery, Cleveland Clinic, Cleveland OHIO
| | | | - Laura E. Nagy
- Department of Pathobiology Lerner Research Institute The Cleveland Clinic Foundation
| | - Arthur J McCullough
- Departments of Gastroenterology, Hepatology and Transplant Surgery, Cleveland Clinic, Cleveland OHIO
| | - Srinivasan Dasarathy
- Departments of Gastroenterology, Hepatology and Transplant Surgery, Cleveland Clinic, Cleveland OHIO
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Tapper EB, Finkelstein D, Mittleman MA, Piatkowski G, Lai M. Standard assessments of frailty are validated predictors of mortality in hospitalized patients with cirrhosis. Hepatology 2015; 62:584-90. [PMID: 25846824 PMCID: PMC4768731 DOI: 10.1002/hep.27830] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 04/01/2015] [Indexed: 12/13/2022]
Abstract
UNLABELLED The risk of morbidity and mortality for hospitalized patients with cirrhosis is high and incompletely captured by conventional indices. We sought to evaluate the predictive role of frailty in an observational cohort study of inpatients with decompensated cirrhosis between 2010 and 2013. The primary outcome was 90-day mortality. Secondary outcomes included discharge to a rehabilitation hospital, 30-day readmission, and length of stay. Frailty was assessed with three metrics: activities of daily living (ADL), the Braden Scale, and the Morse fall risk score. A predictive model was validated by randomly dividing the population into training and validation cohorts: 734 patients were admitted 1358 times in the study period. The overall 90-day mortality was 18.3%. The 30-day readmission rate was 26.6%, and the rate of discharge to a rehabilitation facility was 14.3%. Adjusting for sex, age, Model for End-Stage Liver Disease, sodium, and Charlson index, the odds ratio for the effect of an ADL score of less than 12 of 15 on mortality is 1.83 (95% confidence interval [CI] 1.05-3.20). A predictive model for 90-day mortality including ADL and Braden Scale yielded C statistics of 0.83 (95% CI 0.80-0.86) and 0.77 (95% CI 0.71-0.83) in the derivation and validation cohorts, respectively. Discharge to a rehabilitation hospital is predicted by both the ADL (<12) and Braden Scale (<16), with respective adjusted odds ratios of 3.78 (95% CI 1.97-7.29) and 6.23 (95% CI 2.53-15.4). Length of stay was associated with the Braden Scale (<16) (hazard ratio = 0.63, 95% CI 0.44-0.91). No frailty measure was associated with 30-day readmission. CONCLUSIONS Readily available, standardized measures of frailty predict 90-day mortality, length of stay, and rehabilitation needs for hospitalized patients with cirrhosis.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School
| | | | - Murray A. Mittleman
- Cardiovascular Epidemiology Research Unit,,, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Gail Piatkowski
- Decision Support, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Michelle Lai
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School
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Fagan KJ, Zhao EY, Horsfall LU, Ruffin BJ, Kruger MS, McPhail SM, O'Rourke P, Ballard E, Irvine KM, Powell EE. Burden of decompensated cirrhosis and ascites on hospital services in a tertiary care facility: time for change? Intern Med J 2015; 44:865-72. [PMID: 24893971 DOI: 10.1111/imj.12491] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 05/25/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ascites, the most frequent complication of cirrhosis, is associated with poor prognosis and reduced quality of life. Recurrent hospital admissions are common and often unplanned, resulting in increased use of hospital services. AIMS To examine use of hospital services by patients with cirrhosis and ascites requiring paracentesis, and to investigate factors associated with early unplanned readmission. METHODS A retrospective review of the medical chart and clinical databases was performed for patients who underwent paracentesis between October 2011 and October 2012. Clinical parameters at index admission were compared between patients with and without early unplanned hospital readmissions. RESULTS The 41 patients requiring paracentesis had 127 hospital admissions, 1164 occupied bed days and 733 medical imaging services. Most admissions (80.3%) were for management of ascites, of which 41.2% were unplanned. Of those eligible, 69.7% were readmitted and 42.4% had an early unplanned readmission. Twelve patients died and nine developed spontaneous bacterial peritonitis. Of those eligible for readmission, more patients died (P = 0.008) and/or developed spontaneous bacterial peritonitis (P = 0.027) if they had an early unplanned readmission during the study period. Markers of liver disease, as well as haemoglobin (P = 0.029), haematocrit (P = 0.024) and previous heavy alcohol use (P = 0.021) at index admission, were associated with early unplanned readmission. CONCLUSION Patients with cirrhosis and ascites comprise a small population who account for substantial use of hospital services. Markers of disease severity may identify patients at increased risk of early readmission. Alternative models of care should be considered to reduce unplanned hospital admissions, healthcare costs and pressure on emergency services.
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Affiliation(s)
- K J Fagan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; Centre for Liver Disease Research, School of Medicine, The University of Queensland, Translational Research Institute, Brisbane, Queensland, Australia
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Kimbrough CW, Agle SC, Scoggins CR, Martin RC, Marvin MR, Davis EG, McMasters KM, Jones CM. Factors predictive of readmission after hepatic resection for hepatocellular carcinoma. Surgery 2014; 156:1039-46. [DOI: 10.1016/j.surg.2014.06.057] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 06/24/2014] [Indexed: 12/12/2022]
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Paterno F, Wilson GC, Wima K, Quillin RC, Abbott DE, Cuffy MC, Diwan TS, Kaiser T, Woodle ES, Shah SA. Hospital utilization and consequences of readmissions after liver transplantation. Surgery 2014; 156:871-8. [DOI: 10.1016/j.surg.2014.06.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 06/20/2014] [Indexed: 02/09/2023]
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Rogal SS, Winger D, Bielefeldt K, Rollman BL, Szigethy E. Healthcare utilization in chronic liver disease: the importance of pain and prescription opioid use. Liver Int 2013; 33:1497-503. [PMID: 23758842 PMCID: PMC3795935 DOI: 10.1111/liv.12215] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 05/11/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND & AIMS The aim of this study was to assess factors associated with healthcare utilization in patients with chronic liver disease with a focus on pain, opioid use and psychiatric symptoms. METHODS We retrospectively assessed a consecutive sample of 1286 visitors to a hepatology clinic with chronic liver disease. Baseline psychiatric symptoms, pain and opioid prescriptions were collected. Liver-related clinic visits, total clinic visits, phone calls and hospitalizations were assessed over a subsequent 6-month period. Multivariable logistic and negative binomial regression models were used to determine the medical and psychosocial factors associated with increased healthcare utilization. RESULTS Over a 6-month period, hospitalization was more common among patients with pain (13% vs. 7%, P < 0.0001) and opioid usage (18% vs. 6% P < 0.0001). Pain and opioid usage were independently and significantly associated with an increased hospitalizations and median number of clinic visits and phone calls (P < 0.0001). In multivariable modelling, hospitalization was significantly associated with opioid use (OR = 2.72, CI = 1.72, 4.29), Child's Class B (OR = 2.24, CI = 1.19, 4.14) and C (OR = 8.51, CI = 4.18, 17.27) cirrhosis, and cardiopulmonary disease (OR = 2.11, CI = 1.28, 3.41). Pain and opioid usage were independently and significantly associated with the numbers of phone calls and total outpatient visits, as were medical comorbidities and Child's Class. The significant predictors of increased outpatient liver-related visits were pain (IRR = 1.13, CI = 1.02, 1.26), interferon usage (IRR = 1.75, CI = 1.54, 1.98) and more advanced liver disease (IRR = 1.58, CI = 1.32, 1.88). CONCLUSIONS Pain and prescription opioid usage were significantly linked to increased healthcare utilization, suggesting the need to evaluate and incorporate evidence-based pain management strategies into routine care of patients with chronic liver disease.
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Affiliation(s)
- Shari S. Rogal
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh
| | - Daniel Winger
- Clinical and Translational Science Institute, University of Pittsburgh
| | - Klaus Bielefeldt
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh
| | | | - Eva Szigethy
- Department of Psychiatry, University of Pittsburgh
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