Validation of Risk Score in Predicting Early Readmissions in Decompensated Cirrhotic Patients: A Model Based on the Administrative Database

The burden and predictors of 30-day unplanned readmission in patients with acute liver failure: a national representative database study

BACKGROUND

Liver diseases were significant source of early readmission burden. This study aimed to evaluate the 30-day unplanned readmission rates, causes of readmissions, readmission costs, and predictors of readmission in patients with acute liver failure (ALF).

METHODS

Patients admitted for ALF from 2019 National Readmission Database were enrolled. Weighted multivariable logistic regression models were applied and based on Directed Acyclic Graphs. Incidence, causes, cost, and predictors of 30-day unplanned readmissions were identified.

RESULTS

A total of 3,281 patients with ALF were enrolled, of whom 600 (18.3%) were readmitted within 30 days. The mean time from discharge to early readmission was 12.6 days. The average hospital cost and charge of readmission were $19,629 and $86,228, respectively. The readmissions were mainly due to liver-related events (26.6%), followed by infection (20.9%). The predictive factors independently associated with readmissions were age, male sex (OR 1.227, 95% CI 1.023-1.472; P = 0.028), renal failure (OR 1.401, 95% CI 1.139-1.723; P = 0.001), diabetes with chronic complications (OR 1.327, 95% CI 1.053-1.672; P = 0.017), complicated hypertension (OR 1.436, 95% CI 1.111-1.857; P = 0.006), peritoneal drainage (OR 1.600, 95% CI 1.092-2.345; P = 0.016), etc. CONCLUSIONS: Patients with ALF are at relatively high risk of early readmission, which imposes a heavy medical and economic burden on society. We need to increase the emphasis placed on early readmission of patients with ALF and establish clinical strategies for their management.

Machine Learning-based Characterization of Longitudinal Health Care Utilization Among Patients With Inflammatory Bowel Diseases

BACKGROUND

Inflammatory bowel disease (IBD) is associated with increased health care utilization. Forecasting of high resource utilizers could improve resource allocation. In this study, we aimed to develop machine learning models (1) to cluster patients according to clinical utilization patterns and (2) to predict longitudinal utilization patterns based on readily available baseline clinical characteristics.

METHODS

We conducted a retrospective study of adults with IBD at 2 academic centers between 2015 and 2021. Outcomes included different clinical encounters, new prescriptions of corticosteroids, and initiation of biologic therapy. Machine learning models were developed to characterize health care utilization. Poisson regression compared frequencies of clinical encounters.

RESULTS

A total of 1174 IBD patients were followed for more than 5673 12-month observational windows. The clustering method separated patients according to low, medium, and high resource utilizers. In Poisson regression models, compared with low resource utilizers, moderate and high resource utilizers had significantly higher rates of each encounter type. Comparing moderate and high resource utilizers, the latter had greater utilization of each encounter type, except for telephone encounters and biologic therapy initiation. Machine learning models predicted longitudinal health care utilization with 81% to 85% accuracy (area under the receiver operating characteristic curve 0.84-0.90); these were superior to ordinal regression and random choice methods.

CONCLUSION

Machine learning models were able to cluster individuals according to relative health care resource utilization and to accurately predict longitudinal resource utilization using baseline clinical factors. Integration of such models into the electronic medical records could provide a powerful semiautomated tool to guide patient risk assessment, targeted care coordination, and more efficient resource allocation.

A randomized multicenter trial of a chronic disease management intervention for decompensated cirrhosis. The Australian Liver Failure (ALFIE) trial

BACKGROUND AND AIMS

Improving the care of decompensated cirrhosis is a significant clinical challenge. The primary aim of this trial was to assess the efficacy of a chronic disease management (CDM) model to reduce liver-related emergency admissions (LREA). The secondary aims were to assess model effects on quality-of-care and patient-reported outcomes.

APPROACH AND RESULTS

The study design was a 2-year, multicenter, randomized controlled study with 1:1 allocation of a CDM model versus usual care. The study setting involved both tertiary and community care. Participants were randomly allocated following a decompensated cirrhosis admission. The intervention was a multifaceted CDM model coordinated by a liver nurse. A total of 147 participants (intervention=75, control=71) were recruited with a median Model for End-Stage Liver Disease score of 19. For the primary outcome, there was no difference in the overall LREA rate for the intervention group versus the control group (incident rate ratio 0.89; 95% CI: 0.53-1.50, p=0.666) or in actuarial survival (HR=1.14; 95% CI: 0.66-1.96, p=0.646). However, there was a reduced risk of LREA due to encephalopathy in the intervention versus control group (HR=1.87; 95% CI: 1.18-2.96, p=0.007). Significant improvement in quality-of-care measures was seen for the performance of bone density (p<0.001), vitamin D testing (p<0.001), and HCC surveillance adherence (p=0.050). For assessable participants (44/74 intervention, 32/71 controls) significant improvements in patient-reported outcomes at 3 months were seen in self-management ability and quality of life as assessed by visual analog scale (p=0.044).

CONCLUSIONS

This CDM intervention did not reduce overall LREA events and may not be effective in decompensated cirrhosis for this end point.

Thirty-Day Readmissions Are Largely Not Preventable in Patients With Cirrhosis

INTRODUCTION

Hospital readmissions are common in patients with cirrhosis, but there are few studies describing readmission preventability. We aimed to describe the incidence, causes, and risk factors for preventable readmission in this population.

METHODS

We performed a prospective cohort study of patients with cirrhosis hospitalized at a single center between June 2014 and March 2020 and followed up for 30 days postdischarge. Demographic, clinical, and socioeconomic data, functional status, and quality of life were collected. Readmission preventability was independently and systematically adjudicated by 3 reviewers. Multinomial logistic regression was used to compare those with (i) preventable readmission, (ii) nonpreventable readmission/death, and (iii) no readmission.

RESULTS

Of 654 patients, 246 (38%) were readmitted, and 29 (12%) were preventable readmissions. Reviewers agreed on preventability for 70% of readmissions. Twenty-two (including 2 with preventable readmission) died. The most common reasons for readmission were hepatic encephalopathy (22%), gastrointestinal bleeding (13%), acute kidney injury (13%), and ascites (6%), and these reasons were similar between preventable and nonpreventable readmissions. Preventable readmission was often related to paracentesis timeliness, diuretic adjustment monitoring, and hepatic encephalopathy treatment. Compared with nonreadmitted patients, preventable readmission was independently associated with racial and ethnic minoritized individuals (odds ratio [OR] 5.80; 95% CI, 1.96-17.13), nonmarried marital status (OR 2.88; 95% CI, 1.18-7.05), and admission in the prior 30 days (OR 3.45; 95% CI, 1.48-8.04).

DISCUSSION

For patients with cirrhosis, readmission is common, but most are not preventable. Preventable readmissions are often related to ascites and hepatic encephalopathy and are associated with racial and ethnic minorities, nonmarried status, and prior admissions.

Randomized intervention and outpatient follow-up lowers 30-d readmissions for patients with hepatic encephalopathy, decompensated cirrhosis

BACKGROUND

We previously reported national 30-d readmission rates of 27% in patients with decompensated cirrhosis (DC).

AIM

To study prospective interventions to reduce early readmissions in DC at our tertiary center.

METHODS

Adults with DC admitted July 2019 to December 2020 were enrolled and randomized into the intervention (INT) or standard of care (SOC) arms. Weekly phone calls for a month were completed. In the INT arm, case managers ensured outpatient follow-up, paracentesis, and medication compliance. Thirty-day readmission rates and reasons were compared.

RESULTS

Calculated sample size was not achieved due to coronavirus disease 2019; 240 patients were randomized into INT and SOC arms. 30-d readmission rate was 33.75%, 35.83% in the INT vs 31.67% in the SOC arm (P = 0.59). The top reason for 30-d readmission was hepatic encephalopathy (HE, 32.10%). There was a lower rate of 30-d readmissions for HE in the INT (21%) vs SOC arm (45%, P = 0.03). There were fewer 30-d readmissions in patients who attended early outpatient follow-up (n = 17, 23.61% vs n = 55, 76.39%, P = 0.04).

CONCLUSION

Our 30-d readmission rate was higher than the national rate but reduced by interventions in patients with DC with HE and early outpatient follow-up. Development of interventions to reduce early readmission in patients with DC is needed.

Low haemoglobin level predicts early hospital readmission in patients with cirrhosis and acute decompensation

Background & Aims

Patients with decompensated cirrhosis present frequent hospitalisations with a relevant clinical and socio-economic impact. This study aims to characterise unscheduled readmissions up to 1-year follow-up and identify predictors of 30-day readmission after an index hospitalisation for acute decompensation (AD).

Methods

We performed a secondary analysis of a prospectively collected cohort of patients admitted for AD. Laboratory and clinical data at admission and at discharge were collected. Timing and causes of unscheduled readmissions and mortality were recorded up to 1 year.

Results

A total of 329 patients with AD were included in the analysis. Acute-on-chronic liver failure was diagnosed in 19% of patients at admission or developed in an additional 9% of patients during the index hospitalisation. During the 1-year follow-up, 182 patients (55%) were rehospitalised and 98 (30%) more than once. The most frequent causes of readmission were hepatic encephalopathy (36%), ascites (22%), and infection (21%). Cumulative incidence of readmission was 20% at 30 days, 39% at 90 days, and 63% at 1 year. Fifty-four patients were readmitted for emergent liver-related causes within 30 days. Early readmission was associated with a higher 1-year mortality (47 vs. 32%, p = 0.037). Multivariable Cox regression analysis showed that haemoglobin (Hb) ≤8.7 g/dl (hazard ratio 2.63 [95% CI 1.38-5.02], p = 0.003) and model for end-stage liver disease-sodium score (MELD-Na) >16 at discharge (hazard ratio 2.23 [95% CI 1.27-3.93], p = 0.005), were independent predictors of early readmission. In patients with MELD-Na >16 at discharge, the presence of Hb ≤8.7 g/dl doubles the risk of early rehospitalisation (44% vs. 22%, p = 0.02).

Conclusion

Besides MELD-Na, a low Hb level (Hb ≤8.7 g/dl) at discharge emerged as a new risk factor for early readmission, contributing to identification of patients who require closer surveillance after discharge.

Impact and Implications

Patients with decompensated cirrhosis face frequent hospitalisations. In the present study, type and causes of readmissions were analysed during 1-year follow-up in patients discharged after the index hospitalisation for an acute decompensation of the disease. Early (30-day) liver-related readmission was associated with higher 1-year mortality. The model for end-stage liver disease-sodium score and low haemoglobin at discharge were identified as independent risk factors for early readmissions. Haemoglobin emerged as a new easy-to-use parameter associated with early readmission warranting further investigation.

Patient-Reported Outcome Measures Modestly Enhance Prediction of Readmission in Patients with Cirrhosis

BACKGROUND & AIMS

Patients with cirrhosis have high rates of hospital readmission, but prediction models are suboptimal and have not included important patient-reported outcome measures (PROMs). In a large prospective cohort, we examined the impact of PROMs on prediction of 30-day readmissions.

METHODS

We performed a prospective cohort study of adults with cirrhosis admitted to a tertiary center between June 2014 and March 2020. We collected clinical information, socioeconomic status, and PROMs addressing functional status and quality of life. We used hierarchical competing risk time-to-event analysis to examine the impact of PROMs on readmission prediction.

RESULTS

A total of 654 patients were discharged alive, and 247 (38%) were readmitted within 30 days. Readmission was independently associated with cerebrovascular disease, ascites, prior hospital admission, admission via the emergency department, lower albumin, higher Model for End-Stage Liver Disease, discharge with public transportation, and impaired basic activities of daily living and quality-of-life activity domain. Reduced readmission was associated with cancer, admission for infection, children at home, and impaired emotional function. Compared with a model including only clinical variables, addition of functional status and quality-of-life variables improved the area under the receiver-operating characteristic curve from 0.72 to 0.73 and 0.75, with net reclassification indices of 0.22 and 0.18, respectively. Socioeconomic variables did not significantly improve prediction compared with clinical variables alone. Compared with a model using electronically available variables only, no models improved prediction when examined with integrated discrimination improvement.

CONCLUSIONS

PROMs may marginally add to the prediction of 30-day readmissions for patients with cirrhosis. Poor social support and disability are associated with readmissions and may be high-yield targets for future interventions.

The time to advocate for influenza vaccines in patients with cirrhosis is now

BACKGROUND AND AIM

The effect of an influenza infection on patients with cirrhosis remains unclear. This study aimed to compare the rate of influenza hospitalizations, influenza associated complications, and healthcare outcomes in patients with and without cirrhosis.

METHODS

Utilizing the Nationwide Inpatient Sample between 2005 and 2013, hospitalized patients with a diagnosis of influenza were identified. Patients with cirrhosis were classified as compensated or decompensated based on the Baveno criteria. Multivariable analyses were performed to evaluate complications of influenza, inpatient mortality and healthcare utilization including length of stay and cost of admission.

RESULTS

In total, 236,513 patients with a diagnosis of influenza were admitted during the study period, including 1,553 (0.66%) with cirrhosis. Of those with cirrhosis, 1,176 (75.7%) were compensated and 377 (24.3%) were decompensated. On multivariable analysis, influenza patients with cirrhosis had a higher total cost of admission [$1,030; CI: $710-$1,351] compared to the general population. Influenza patients with decompensated cirrhosis had a longer length of stay [1.92 days; CI:1.63-2.21], higher total cost of admission [$5,005; CI: $4,459-$5,551] and increased rates of influenza complications [OR: 2.56; CI:1.32-4.93] compared to patients with compensated cirrhosis.

CONCLUSIONS

Patients with cirrhosis have increased healthcare utilization when admitted with influenza compared to the general population. Providers must advocate for patients with cirrhosis to obtain the influenza vaccine.

Burden and Cost of Gastrointestinal, Liver, and Pancreatic Diseases in the United States: Update 2021

BACKGROUND & AIMS

Gastrointestinal diseases account for considerable health care use and expenditures. We estimated the annual burden, costs, and research funding associated with gastrointestinal, liver, and pancreatic diseases in the United States.

METHODS

We generated estimates using data from the National Ambulatory Medical Care Survey; National Hospital Ambulatory Medical Care Survey; Nationwide Emergency Department Sample; National Inpatient Sample; Kids' Inpatient Database; Nationwide Readmissions Database; Surveillance, Epidemiology, and End Results program; National Vital Statistics System; Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research; MarketScan Commercial Claims and Encounters data; MarketScan Medicare Supplemental data; United Network for Organ Sharing registry; Medical Expenditure Panel Survey; and National Institutes of Health (NIH).

RESULTS

Gastrointestinal health care expenditures totaled $119.6 billion in 2018. Annually, there were more than 36.8 million ambulatory visits for gastrointestinal symptoms and 43.4 million ambulatory visits with a primary gastrointestinal diagnosis. Hospitalizations for a principal gastrointestinal diagnosis accounted for more than 3.8 million admissions, with 403,699 readmissions. A total of 22.2 million gastrointestinal endoscopies were performed, and 284,844 new gastrointestinal cancers were diagnosed. Gastrointestinal diseases and cancers caused 255,407 deaths. The NIH supported $3.1 billion (7.5% of the NIH budget) for gastrointestinal research in 2020.

CONCLUSIONS

Gastrointestinal diseases are responsible for millions of health care encounters and hundreds of thousands of deaths that annually costs billions of dollars in the United States. To reduce the high burden of gastrointestinal diseases, focused clinical and public health efforts, supported by additional research funding, are warranted.

Mortality, sepsis, and organ failure in hospitalized patients with cirrhosis vary by type of infection

BACKGROUND AND AIM

Infection is associated with substantial morbidity and mortality in cirrhosis, but presumably, not all infections carry the same risk of mortality. We compared outcomes of different sites of infection in a nationally representative sample of inpatients with cirrhosis.

METHODS

We queried the Nationwide Readmissions Database for patients with cirrhosis from 2011 to 2014. Cirrhosis and infection diagnoses were identified by previously used algorithms of ICD-9 codes. The following infections were compared: urinary tract infection (UTI), pneumonia, cellulitis, spontaneous bacterial peritonitis (SBP), and Clostridium difficile infection (CDI). The primary outcome was inpatient mortality. Secondary outcomes included sepsis, any organ failure, multiple organ failures, and 30-day readmission. Outcomes were analyzed using logistic regression and included a priori covariates.

RESULTS

A total of 1 798 830 weighted index admissions were identified. Infection was present in 29.2% overall-including UTI (13.7%), pneumonia (8.9%), cellulitis (5.2%), CDI (2.8%), and SBP (2.0%). Mortality was significantly higher in pneumonia (19.6%), SBP (18.6%), and CDI (17.4%) compared with cellulitis (7.6%) and UTI (11.8%). Sepsis, any, and multiple organ failures were most commonly seen in pneumonia, SBP, and CDI. Multivariable analysis demonstrated that pneumonia had the highest associated mortality (odds ratio [OR] 2.73, confidence interval [CI] 2.68-2.80) and multiple organ failures (OR 3.59, CI 3.50-3.68). Significantly increased 30-day readmission was seen only with SBP (24.9%).

CONCLUSIONS

Outcomes of inpatients with cirrhosis vary significantly depending on the type of infection. The severity and epidemiology of infection in cirrhosis appears to be shifting with pneumonia, not SBP, having the highest prevalence of multiple organ failures and inpatient mortality.

Nationwide analysis of incidence and predictors of 30-day readmissions in patients with decompensated cirrhosis

BACKGROUND AND OBJECTIVE

Cirrhosis is the number one cause of non-cancer deaths among gastrointestinal diseases and is responsible for significant morbidity and healthcare utilisation. The objectives were to measure the 30-day readmissions rate following index hospitalisation, to determine the predictors of readmission, and to estimate the cost of 30-day readmission in patients with decompensated cirrhosis.

METHODS

We performed a retrospective cohort study of patients with decompensated cirrhosis using 2014 Nationwide Readmission Database from January to November. Decompensated cirrhosis was identified based on the presence of at least one of the following: ascites, hepatic encephalopathy, variceal bleeding, spontaneous bacterial peritonitis and hepatorenal syndrome. We excluded patients less than 18 years of age, pregnant patients, patients with missing length of stay data, and those who died during the index admission.

RESULTS

Among 57 305 unique patients with decompensated cirrhosis, the 30-day readmission rate was 23.2%. The top three predictors of 30-day readmission were leaving against medical advice (AMA), ascites and acute kidney injury, which increased the risk of readmission by 47%, 22% and 20%, respectively. Index admission for variceal bleeding was associated with a lower 30-day readmission rate by 18%. The estimated total cost associated with 30-day readmission in our study population was US$234.4 million.

CONCLUSION

In a nationwide population study, decompensated cirrhosis is associated with a 30-day readmission rate of 23%. Leaving AMA, ascites and acute kidney injury are positively associated with readmission. Targeted interventions and quality improvement efforts should be directed toward these potential risk factors to reduce readmissions.

Strategies to Improve Delivery of Cirrhosis Care

Purpose of review

This review provides an overview of the current state of research around improving healthcare delivery for patients with cirrhosis in the outpatient, inpatient, and transitional care settings.

Recent findings

Recent studies have broadly employed changes to the model of care delivery, team composition, and technology to improve cirrhosis care. In the outpatient setting, approaches have included engaging caregivers, patient navigators, and non-physicians and using virtual care, smartphone applications, and wearables. Inpatient care approaches have focused on the role of interdisciplinary teams, education interventions, and changes to the medical record system, while post-discharge interventions have included day hospitals and care coordinator interventions. This review also describes the Veterans Health Administration’s novel, population-level approach to delivery of cirrhosis care, and addressed how the pandemic has impacted the delivery of cirrhosis care.

Summary

Comprehensive, evidence-based approaches to delivering high-quality cirrhosis care continue to evolve to meet the needs of a growing population in an ever-changing healthcare environment.

Bariatric Surgery in Patients with Cirrhosis: Careful Patient and Surgery-Type Selection Is Key to Improving Outcomes

PURPOSE

Previous reports suggest an increased mortality in cirrhotic patients undergoing bariatric surgery (BS). With advancements in management of BS, we aim to study the trends, outcomes, and their predictors in patients with cirrhosis undergoing BS.

MATERIALS AND METHODS

A retrospective study was performed using the National Database from 2008 to 2013. Outcomes of BS in patients with cirrhosis were studied. In-hospital mortality, length of stay, and cost of care were compared between patients with no cirrhosis (NC), compensated cirrhosis (CC), and decompensated cirrhosis (DC). Multivariable logistic regression analysis was performed to study the predictors of mortality.

RESULTS

Of the 558,017 admissions of patients who underwent BS during the study period, 3086 (0.55%) had CC and 103 (0.02%) had DC. An upward trend of vertical sleeve gastrectomy (VSG) utilization was seen during the study period. On multivariate analysis, mortality in CC was comparable with those in NC (aOR 1.88; CI 0.65-5.46); however, it was higher in DC (aOR 83.8; CI 19.3-363.8). Other predictors of mortality were older age (aOR 1.06; CI 1.04-1.08), male (aOR 2.59; CI 1.76-3.81), Medicare insurance (aOR 1.93; CI 1.24-3.01), lower income (aORs 0.44 to 0.55 for 2nd to 4th income quartile vs. 1st quartile), > 3 Elixhauser Comorbidity Index (aOR 5.30; CI 3.45-8.15), undergoing Roux-en-Y gastric bypass as opposed to VSG (aOR 3.90; CI 1.79-8.48), and centers performing < 50 BS per year (aOR 5.25; CI 3.38-8.15). Length of stay and hospital cost were also significantly higher in patients with cirrhosis as compared with those with NC.

CONCLUSION

Patients with compensated cirrhosis can be considered for bariatric surgery. However, careful selection of patients, procedure type, and volume of surgical center is integral in improving outcomes and healthcare utilization in patients with cirrhosis undergoing BS.

Lower household income is associated with an increased risk of hospital readmission in patients with decompensated cirrhosis

BACKGROUND AND AIM

The impact of household income, a surrogate of socioeconomic status, on hospital readmission rates for patients with decompensated cirrhosis has not been well characterized.

METHODS

The Nationwide Readmission Database from 2012 to 2014 was used to study the association of lower median household income on 30-, 90-, and 180-day hospital readmission rates for patients with decompensated cirrhosis.

RESULTS

From the 42 679 001 hospital admissions contained in the sample, there were 82 598 patients with decompensated cirrhosis who survived a hospital admission in the first 6 months of the year. During a uniform 6-month follow-up period, 25 914 (31.4%), 39 928 (48.3%), and 47 496 (57.5%) patients were readmitted at 30, 90, and 180 days, respectively. After controlling for demographic and clinical confounders, patients residing in the three lowest income quartiles were significantly more likely to be readmitted at 30 days than those in the fourth quartile (first quartile, odds ratio [OR] 1.32 [95% confidence interval, CI, 1.17-1.47, P < 0.01]; second quartile, OR 1.25 [95% CI 1.13-1.38, P < 0.01]; and third quartile, OR 1.08 [95% CI 0.97-1.20, P = 0.07]). The association between lower socioeconomic status and the higher risk of readmissions persisted at 90 days (first quartile, OR 1.21 [95% CI 1.14-1.30, P < 0.01]) and 180 days (first quartile, OR 1.32 [95% CI 1.20-1.44, P < 0.01]).

CONCLUSION

Patients with decompensated cirrhosis residing in the lowest income quartile had a 32% higher odds of hospital readmissions at 30, 90, and 180 days compared with those in the highest income quartile.

Rate, reasons, predictors, and burden of readmissions after transjugular intrahepatic portosystemic shunt placement

BACKGROUND AND AIM

Nationwide data on readmissions after the transjugular intrahepatic portosystemic shunt (TIPS) procedure are lacking. We aimed to investigate the 30-day readmission rate after TIPS procedure, reasons, and predictors for readmissions and its impact on resource utilization and mortality in the USA.

METHODS

We identified all adults who underwent an inpatient TIPS procedure between 2010 and 2014 using the National Readmission Database. Outcomes included all-cause 30-day readmission rate, reasons and predictors of readmissions, mortality rate, and mean hospitalization charges.

RESULTS

Out of a total of 31 230 hospitalizations with TIPS procedure, 28 021 patients met the study criteria and were finally included. The mean age of patients was 56.90 years, and 63.84% were men. All-cause 30-day readmission rate was 27.81%. Hepatic encephalopathy with or without coma was the most common reason for readmissions in at least 36.43% patients. The in-hospital mortality for index hospitalization and 30-day readmission was 10.69% and 5.85%, respectively. The mean hospitalization charges for index hospitalization and readmissions were $153 357 and $45 751, respectively. Advanced age, Medicaid insurance, higher Charlson comorbidy index, ascites as indication of TIPS, and nonspecific or hepatitis C cirrhosis etiologies for cirrhosis were found to be independent predictors of 30-day readmissions after a TIPS procedure.

CONCLUSIONS

Our study found a high rate of readmission for patients undergoing TIPS procedure, and the majority of these readmissions were related to hepatic encephalopathy. Further studies highlighting areas for improvement, particularly for patient selection and post-discharge care, are needed to reduce readmissions.

Thirty-day readmission rates, trends and its impact on liver transplantation recipients: a national analysis

Reduction of early hospital readmissions is a declared goal in the United States economic and quality improvement agenda. A retrospective study was performed using the Nationwide Readmissions Database from 2010 to 2014. Our primary aim was to study the rate of early readmissions and its predictors in liver transplant recipients (LTRs). Our secondary aims were to determine the trends of LT, reasons for readmission, costs and predictors of calendar year mortality. Multivariable logistic regression and Cox proportional hazards models were utilized. The 30-day readmission rate was 30.6% among a total of 25,054 LTRs. Trends of LT were observed to be increased in patients > 65 years (11.7-17.8%, p < 0.001) and decreased in 40-64 years (78.0-73.5%, p = 0.001) during study period. The majority of 30-day readmissions were due to post transplant complications, with packed red blood cell transfusions being the most common intervention during readmission. Medicaid or Medicare insurance, surgery at low and medium volume centers, infections, hemodialysis, liver biopsy, and length of stay > 10 days were the predictors of 30-day readmission. Moreover, number of early readmission, age > 64 years, non-alcoholic cirrhosis, and length of stay > 10 days were significant predictor of calendar year mortality in LTRs. Approximately one third of patients require early admission after LT. Early readmission not only increases burden on healthcare, but is also associated with calendar year mortality. Strategies should be implemented to reduce readmission in patients with high risk of readmission identified in our study.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Thirty-Day Readmission and Cost Analysis in Patients With Cirrhosis: A Nationwide Population-Based Data

Accurate population‐based data are needed on the rate, economic impact, and the long‐term outcomes of readmission among patients with cirrhosis. To examine the rates, costs, and 1‐year outcomes of patients readmitted within 30 days following their index hospitalization for complications of cirrhosis, we conducted a nationwide, population‐based cohort study involving all patients with cirrhosis in Thailand from 2009 through 2013, using data from the National Health Security Office databases, which included those from nationwide hospitalizations. Readmission was captured from hospitals at all health care levels across the country within the Universal Coverage Scheme. For the 134,038 patients hospitalized with cirrhosis, the overall 30‐day readmission rate was 17%. Common causes of readmission consisted of complications of portal hypertension (47%) and infections (17%). After adjusting for multiple covariates, predictors of 30‐day readmission included hepatocellular carcinoma (odds ratio [OR] 1.95, 95% confidence interval [CI] 1.84‐2.06), human immunodeficiency virus–related admission (OR 1.81, 95% CI 1.51‐2.17) and cholangiocarcinoma (OR 1.64, 95% CI 1.3‐2.05). In all, 2,936 deaths (13%) occurred during readmission, and an additional 14,425 deaths up to 1 year (63.5% total mortality among readmitted patients). Causes of death were mostly from liver‐related mortality. Average cost at index admission for those with a 30‐day readmission were significantly higher than those readmitted beyond 30 days or not readmitted. Conclusions: Patients hospitalized with cirrhosis complications had high rates of unscheduled 30‐day readmission. Average hospitalization costs were high, and only 36.5% of patients readmitted within 30 days survived at 1 year.