Variation among United States hospitals in inpatient mortality for cirrhosis

Predictors of in-hospital mortality among cirrhotic patients in Ethiopia: A multicenter retrospective study

BACKGROUND

In Ethiopia, cirrhosis is the 6th leading cause of death and is responsible for high hospitalization and mortality rates. However, until now, factors affecting in-hospital mortality of patients with liver cirrhosis are poorly understood. This study assessed the predictors of in-hospital mortality among cirrhotic patients in Ethiopia.

METHODS

A retrospective cross-sectional study using data collected from the electronic medical records of patients who were admitted for complications of liver cirrhosis between January 1, 2023, and March 31, 2024, in the medical wards of Adera Medical Center, St. Paul's Hospital Millennium Medical College, and Tikur Anbessa Specialized Hospital. Frequency and cross-tabulation were used for descriptive statistics. Predictor variables with a p-value <0.25 in bivariate analyses were included in the logistic regression.

RESULTS

Of the 299 patients included in the final analysis, the majority (79.6%) were males, and the median age of the study participants was 45 (IQR, 36-56) years. Hepatitis B virus (32.1%) was the most common etiology, followed by alcohol (30.1%) and hepatitis C virus (13.4%). Ascites (69.2%), upper gastrointestinal bleeding (50.5%), and hepatic encephalopathy (44.8%) were the most common forms of presentation. The in-hospital mortality rate was 25.4%. West Haven grade III or IV hepatic encephalopathy (AOR: 12.0; 95% CI 2.33-61.63; P < 0.01), hepatocellular carcinoma (AOR: 9.05; 95% CI 2.18-37.14; P: 0.01), history of previous admission within one year period (AOR: 6.80; 95% CI 2.18-21.18; P < 0.01), acute kidney injury (AOR: 6.47; 95% CI 1.77-23.64; P < 0.01), and model for end-stage liver disease - sodium score (AOR: 1.17; 95% CI 1.05-1.30; P: 0.02), were found to be predictors of in-hospital mortality.

CONCLUSION

In-hospital mortality of cirrhotic patients is high in Ethiopia. West Haven grade III or IV hepatic encephalopathy is the leading cause of mortality. Hence, prompt identification and management of hepatic encephalopathy and its precipitant at an earlier stage is crucial for better treatment outcomes and survival.

Characterizing practice variations in the care of hospitalized patients with cirrhosis across the University of California Health

Despite publicly available practice guidelines, in-hospital cirrhosis care remains highly variable. Prior studies of cirrhosis guideline adherence have been limited by administrative claims data. We aimed to overcome these limitations by using a novel multicenter electronic health record (EHR) database, the University of California Health Data Warehouse (UCHDW), to compare guideline adherence in the 5 medical centers of the University of California Health (UCH). We identified adult patients with cirrhosis hospitalized from 2013 to 2022. We evaluated adherence to 5 care quality measures applicable to inpatients. We used t tests to compare pairwise differences between individual UCH sites. We assessed the impact of patient-level and center-level factors (transplant services) through multivariate logistic regressions. We identified 17,249 patients with cirrhosis with 31,512 admissions: 39% women, 43% White, 31% Hispanic/Latino, 11% Asian, 7% Black/African-American, and 8% Unknown/Other. In pairwise comparisons, we found differences in adherence rates across all measures except for antibiotics for gastrointestinal bleeding. In multivariate modeling, we found positive associations between care at transplant centers and receiving paracenteses for those admitted for ascites or HE, albumin/antibiotics for those admitted for spontaneous bacterial peritonitis, endoscopy for those admitted for gastrointestinal bleeding, and lactulose for those admitted for HE. In addition, we observed negative associations between Black/African-American race and guideline adherence for receiving paracenteses for ascites or HE. Through our analyses of high-dimensional EHR data, we found significant differences in care associated with admissions at the transplant center and race/ethnicity. Our use of high-dimensional EHR data indicates that there is still significant room for improvement in the provision of high-quality cirrhosis care.

Albumin for Spontaneous Bacterial Peritonitis: Care Variation, Disparities, and Outcomes

INTRODUCTION

Intravenous albumin reduces mortality in spontaneous bacterial peritonitis (SBP). We sought to characterize albumin use for SBP over time and investigate patient-level and hospital-level factors associated with use.

METHODS

A retrospective cohort study in the Veterans Health Administration between 2008 and 2021 evaluated trends and patient-level, practice-level, and facility-level factors associated with use among patients with cirrhosis hospitalized for SBP confirmed with ascitic fluid criteria.

RESULTS

Among 3,871 veterans with SBP, 803 (20.7%) did not receive albumin, 1,119 (28.9%) received albumin but not per guidelines, and 1,949 (50.3%) received albumin per guidelines; use increased from 66% in 2008 to 88% in 2022. Veterans who identified as Black compared with White were less likely to receive guideline-recommended albumin (Odds ratio [OR] 0.76, 95% confidence interval [CI] 0.59-0.98) in all analyses. Guideline-recommended albumin was more likely to be administered to veterans with Child-Turcotte-Pugh class B (OR 1.39, 95% CI 1.17-1.64) and C (OR 2.21, 95% CI 1.61-3.04) compared with Child-Turcotte-Pugh A; and acute kidney injury Stage 1 (OR 1.48, 95% CI 1.22-1.79), Stage 2 (OR 2.17, 95% CI 1.62-2.91), and Stage 3 (OR 1.68, 95% CI 1.18-2.40) compared with no acute kidney injury. gastroenterology/hepatology consultation (OR 1.60, 95% CI 1.29-1.99), nephrology consultation (OR 1.60, 95% CI 1.23-2.07), and having both gastroenterology/hepatology and nephrology consultations (OR 2.17, 95% CI 1.60-2.96) were associated with higher albumin administration. In exploratory analyses accounting for interactions between model for end-stage liver disease sodium and albumin, guideline-recommended albumin was associated with lower in-hospital mortality (HR 0.90, 95% CI 0.85-0.96).

DISCUSSION

Future studies should investigate optimizing albumin use for SBP to reduce the variability and mitigate healthcare disparities.

Presence of underlying cirrhosis is associated with increased in-hospital mortality and length of stay following pancreatoduodenectomy

BACKGROUND

Patient- and hospital-level factors associated with outcomes following pancreatoduodenectomy (PD) are well established. However, despite theoretical disruption in hepatopetal flow, the impact of cirrhosis on in-hospital mortality following PD is not well-studied. The objective of this study was to evaluate in-hospital mortality, length of stay (LOS), and post-discharge disposition in patients with cirrhosis undergoing PD.

METHODS

A retrospective analysis of the National Inpatient Sample (January 2002-August 2015) was conducted identifying patients undergoing PD. Using previously validated ICD-9-CM codes, patients were stratified into presence and absence of cirrhosis. Factors associated with in-hospital mortality following PD were analyzed adjusting for patient- and hospital-level factors. Following PD were analyzed after adjusting for patient- and hospital-level factors.

RESULTS

In 16,344 patients that underwent PD, 203 (1.2 %) patients had underlying cirrhosis prior to resection. Overall in-hospital mortality following PD was significantly worse in the cirrhosis cohort (11.3 % vs. 3.6 %, p < 0.001). Patients with underlying cirrhosis were less likely to be discharged home (73.9 % vs. 83.2 %, p < 0.001) and had a longer median LOS (12.0 vs. 10.0 days, p = 0.001).

CONCLUSION

The presence of underlying cirrhosis is associated with increased in-hospital mortality, longer LOS, and decreased likelihood of home discharge following PD. Given the prohibitive risks, PD should not be performed in patients with underlying cirrhosis.

Geographic disparities in access to liver transplantation

Since the Final Rule regarding transplantation was published in 1999, organ distribution policies have been implemented to reduce geographic disparity. While a recent change in liver allocation, termed acuity circles, eliminated the donor service area as a unit of distribution to decrease the geographic disparity of waitlisted patients to liver transplantation, recently published results highlight the complexity of addressing geographic disparity. From geographic variation in donor supply, as well as liver disease burden and differing model for end-stage liver disease (MELD) scores of candidates and MELD scores necessary to receive liver transplantation, to the urban-rural disparity in specialty care access, and to neighborhood deprivation (community measure of socioeconomic status) in liver transplant access, addressing disparities of access will require a multipronged approach at the patient, transplant center, and national level. Herein, we review the current knowledge of these disparities-from variation in larger (regional) to smaller (census tract or zip code) levels to the common etiologies of liver disease, which are particularly affected by these geographic boundaries. The geographic disparity in liver transplant access must balance the limited organ supply with the growing demand. We must identify patient-level factors that contribute to their geographic disparity and incorporate these findings at the transplant center level to develop targeted interventions. We must simultaneously work at the national level to standardize and share patient data (including socioeconomic status and geographic social deprivation indices) to better understand the factors that contribute to the geographic disparity. The complex interplay between organ distribution policy, referral patterns, and variable waitlisting practices with the proportion of high MELD patients and differences in potential donor supply must all be considered to create a national policy strategy to address the inequities in the system.

Rising incidence, progression and changing patterns of liver disease in Wales 1999-2019

BACKGROUND

Liver disease incidence and hence demand on hepatology services is increasing.

AIM

To describe trends in incidence and natural history of liver diseases in Wales to inform effective provision of hepatology services.

METHODS

The registry is populated by International Classification of Diseases-10 (ICD-10) code diagnoses for residents derived from mortality data and inpatient/day case activity between 1999-2019. Pseudo-anonymised linkage of: (1) Causative diagnoses; (2) Cirrhosis; (3) Portal hypertension; (4) Decompensation; and (5) Liver cancer diagnoses enabled tracking liver disease progression.

RESULTS

The population of Wales in 2019 was 3.1 million. Between 1999 and 2019 73054 individuals were diagnosed with a hepatic disorder, including 18633 diagnosed with cirrhosis, 10965 with liver decompensation and 2316 with hepatocellular carcinoma (HCC). Over 21 years the incidence of liver diseases increased 3.6 fold, predominantly driven by a 10 fold increase in non-alcoholic fatty liver disease (NAFLD); the leading cause of liver disease from 2014. The incidence of cirrhosis, decompensation, HCC, and all-cause mortality tripled. Liver-related mortality doubled. Alcohol-related liver disease (ArLD), autoimmune liver disease and congestive hepatopathy were associated with the highest rates of decompensation and all-cause mortality.

CONCLUSION

A 10 fold increase in NAFLD incidence is driving a 3.6 fold increase in liver disease in Wales over 21 years. Liver-related morbidity and mortality rose more slowly reflecting the lower progression rate in NAFLD. Incidence of ArLD remained stable but was associated with the highest rates of liver-related and all-cause mortality.

Impact of cardiac and noncardiac cirrhosis on coronary revascularization outcomes from the National Inpatient Sample, 2016 to 2018

Data on coronary revascularization in patients with cirrhosis are scarce because it is often deferred in the setting of significant comorbidities and coagulopathies. It is unknown whether patients with cardiac cirrhosis have a worse prognosis. The National Inpatient Sample was surveyed to identify patients who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS) from 2016 to 2018. Those with and without liver cirrhosis were propensity score-matched and compared within the PCI and CABG cohorts. Primary outcome was in-hospital mortality. Patients with cirrhosis were further classified into cardiac and noncardiac cirrhosis and their in-hospital mortalities were compared. A total of 1,069,730 PCIs and 273,715 CABGs were performed for ACS, of which 0.6% and 0.7%, respectively, were performed in patients with cirrhosis. In both the PCI cohort (odds ratio = 1.56; 95% confidence interval, 1.10-2.25; P = 0.01) and the CABG cohort (odds ratio = 2.34; 95% confidence interval, 1.19-4.62; P = 0.01), cirrhosis was associated with higher in-hospital mortality. In-hospital mortality was greatest in cardiac cirrhosis (8.4% and 7.1%), followed by noncardiac cirrhosis (5.5% and 5.0%) and no cirrhosis (2.6% and 2.3%) in PCI and CABG cohorts, respectively. Higher in-hospital mortality and periprocedural morbidities should be considered when performing coronary revascularization in patients with cirrhosis.

Association Between Kidney Dysfunction Types and Mortality Among Hospitalized Patients with Cirrhosis

BACKGROUND AND AIMS

Kidney dysfunction is associated with increased mortality among patients with cirrhosis. We investigated whether kidney dysfunction types [e.g., acute kidney injury (AKI), chronic kidney disease (CKD), and AKI on CKD] were differentially associated with inpatient mortality.

METHODS

We utilized the nationwide inpatient sample, a nationally representative database, from 2007 to 2014. We included all hospitalizations with previously validated codes for cirrhosis or associated decompensated cirrhosis diagnoses. We defined kidney dysfunction types also from previously validated codes, and we grouped hospitalizations into the following diagnoses: normal, AKI, CKD, and AKI on CKD. Our primary outcome was inpatient mortality.

RESULTS

There were 1,293,779 hospitalizations with cirrhosis sampled in this study. Of these hospitalizations, 849,193 (66%) had normal kidney function, 176,418 (14%) had AKI, 157,600 (12%) had CKD, and 110,568 (9%) had AKI on CKD. We found that the proportion of hospitalizations with AKI, CKD, and AKI on CKD increased significantly throughout the study period (p < 0.001, test for trend for all). Kidney dysfunction type was differentially associated with inpatient mortality, even after adjustment: as compared to those with CKD, normal kidney function: OR 0.75 [95 CI 0.73-0.78], AKI: OR 2.40 [95 CI 2.32-2.48], and AKI on CKD: OR 1.66 [95 CI 1.60-1.72].

DISCUSSION

Using a nationally representative cohort of all hospitalizations with cirrhosis, our study highlights that the burden of kidney dysfunction, especially AKI, among hospitalizations with cirrhosis is rising, and the inclusion of kidney dysfunction type may be an opportunity to improve prognostication.

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.

Practice patterns and outcomes associated with intravenous albumin in patients with cirrhosis and acute kidney injury

BACKGROUND & AIMS

Guidelines recommend albumin as the plasma-expander of choice for acute kidney injury (AKI) in cirrhosis. However, the impact of these recommendations on patient outcomes remains unclear. We aimed to determine the practice-patterns and outcomes associated with albumin use in a large, nationwide-US cohort of hospitalized cirrhotics with AKI.

METHODS

A retrospective cohort study was performed in hospitalized cirrhotics with AKI using Cerner-Health-Facts database from January 2009 to March 2018. 6786 were included for analysis on albumin-practice-patterns, and 4126 had available outcomes data. Propensity-score-adjusted model was used to determine the association between albumin use, AKI-recovery and in-hospital survival.

RESULTS

Median age was 61-years (60% male, 70% white), median serum-creatinine was 1.8 mg/dL and median Model for End-stage Liver Disease Sodium (MELD-Na) score was 24. Albumin was given to 35% of patients, of which 50% received albumin within 48-hours of AKI-onset, and 17% received appropriate weight-based dosing. Albumin was used more frequently in patients with advanced complications of cirrhosis, higher MELD-Na scores and patients admitted to urban-teaching hospitals. After propensity-matching and multivariable adjustment, albumin use was not associated with AKI-recovery (odds ratio [OR] 0.70, 95% confidence-interval [CI]: 0.59-1.07, P = .130) or in-hospital survival (OR 0.76 [95% CI: 0.46-1.25], P = .280), compared with crystalloids. Findings were unchanged in subgroup analyses of patients with varying cirrhosis complications and disease severity.

CONCLUSIONS

USA hospitalized patients with cirrhosis and AKI frequently do not receive intravenous albumin, and albumin use was not associated with improved clinical outcomes. Prospective randomised trials are direly needed to evaluate the impact of albumin in cirrhotics with AKI.

Association of treatments for acute appendicitis with pregnancy outcomes in the United States from 2000 to 2016: Results from a multi-level analysis

Background

Open appendectomy, laparoscopic appendectomy, and non-surgical treatment are three options to treat acute appendicitis during pregnancy. Previous studies on the association of different treatment methods for acute appendicitis with pregnancy outcomes have been limited by small sample sizes and residual confounding, especially with respect to hospital-level factors. This study aimed to investigate the association of treatment method for acute appendicitis with pregnancy outcomes using a multi-level analysis.

Methods

A retrospective cohort study was conducted based on a large electronic health records database in the United States during the period 2000 to 2016. All pregnancies diagnosed with acute appendicitis and treated in participating hospitals during the study period were included. We conducted multi-level hierarchical logistic regression to analyze both individual- and hospital-level factors for abortion, preterm labor, and cesarean section.

Results

A total of 10,271 acute appendicitis during pregnancy were identified during the study period. Of them, 5,872 (57.2%) were treated by laparoscopic appendectomy, 1,403 (13.7%) by open appendectomy, and 2,996 (29.2%) by non-surgical treatment. Compared with open appendectomy, both laparoscopic appendectomy (adjusted OR, 0.6, 95% CI, 0.4, 0.9) and non-surgical treatment (adjusted OR, 0.4; 95% CI, 0.3–0.7) showed a decreased risk of preterm labor. Other important individual-level determinants of adverse pregnancy outcomes included maternal age, gestational hypertension, and anemia during pregnancy, the hospital-level determinant included the number of beds.

Conclusions

Compared with open appendectomy, both laparoscopic appendectomy and non-surgical treatment may be associated with a lower risk of preterm labor, without increased risks of abortion and cesarean section.

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.

MELD is MELD is MELD? Transplant center-level variation in waitlist mortality for candidates with the same biological MELD

Recently, model for end-stage liver disease (MELD)-based liver allocation in the United States has been questioned based on concerns that waitlist mortality for a given biologic MELD (bMELD), calculated using laboratory values alone, might be higher at certain centers in certain locations across the country. Therefore, we aimed to quantify the center-level variation in bMELD-predicted mortality risk. Using Scientific Registry of Transplant Recipients (SRTR) data from January 2015 to December 2019, we modeled mortality risk in 33 260 adult, first-time waitlisted candidates from 120 centers using multilevel Poisson regression, adjusting for sex, and time-varying age and bMELD. We calculated a "MELD correction factor" using each center's random intercept and bMELD coefficient. A MELD correction factor of +1 means that center's candidates have a higher-than-average bMELD-predicted mortality risk equivalent to 1 bMELD point. We found that the "MELD correction factor" median (IQR) was 0.03 (-0.47, 0.52), indicating almost no center-level variation. The number of centers with "MELD correction factors" within ±0.5 points, and between ±0.5-± 1, ±1.0-±1.5, and ±1.5-±2.0 points was 62, 41, 13, and 4, respectively. No centers had waitlisted candidates with a higher-than-average bMELD-predicted mortality risk beyond ±2 bMELD points. Given that bMELD similarly predicts waitlist mortality at centers across the country, our results support continued MELD-based prioritization of waitlisted candidates irrespective of center.

Disparities in Mortality and Health Care Utilization for 460,851 Hospitalized Patients with Cirrhosis and Hepatic Encephalopathy

BACKGROUND AND AIMS

Hepatic encephalopathy (HE) is a common cause of hospitalizations and readmissions for patients with decompensated cirrhosis. In this study, we proposed to investigate recent trends in in-hospital mortality and utilization for patients with cirrhosis and HE and to explore the effect of various sociodemographic, hospital, and clinical factors on mortality.

METHODS

We performed an observational study using serial cross-sectional data from the 2009-2013 National Inpatient Sample to examine hospitalizations of patients with cirrhosis and HE. We collected data on in-hospital mortality, length of stay, and total hospital costs. We used negative binomial regression and logistic regression to investigate trends in utilization and multilevel modeling to examine the association between sociodemographic, hospital, and clinical factors and in-hospital mortality.

RESULTS

The annual total number of hospitalizations from HE has steadily risen from 75,475 in 2009 to 106,915 in 2013 (P < 0.001). Annual in-hospital mortality (11.9-10.2%, P < 0.001) and length of stay (7.5-7.1 days, P = 0.015) have significantly decreased over this timeframe. The presence of septicemia, GI bleeding, and being uninsured were associated with 29.6%, 16.7%, and 15.7% of in-hospital death, respectively. Patients hospitalized in the South, Medicare beneficiaries, and patients hospitalized in the Midwest had a 9.8%, 9.2%, and 8.9% chance of dying in the hospital.

CONCLUSION

The number of hospitalizations from HE has increased while in-hospital mortality has concomitantly decreased from 2009 to 2013. Both traditional risk factors (sepsis and GI bleeding) strongly influence the probability of in-hospital death. However, disparities in mortality by sociodemographic factors (insurance status and geography) also exist.

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.

Contemporary Trends in Hospitalizations for Comorbid Chronic Liver Disease and Substance Use Disorders

INTRODUCTION

Chronic liver diseases (CLDs) and substance use disorders (SUDs) are increasingly prevalent and often coexist. Contemporary studies describing the characteristics and hospitalization trends of those with comorbid CLD-SUD are lacking. We aimed to characterize a population-based cohort with comorbid CLD-SUD and describe trends in these hospitalizations over time by individual-level characteristics.

METHODS

We performed a cross-sectional analysis of the National Inpatient Sample from 2005 through 2017. Diagnosis codes were used to identify adult hospitalizations with CLD, SUD, or both. Bivariate and multivariate analyses were used to make comparisons between diagnosis categories. Unadjusted and age-adjusted trends in these hospitalizations were described over time.

RESULTS

Of 401,867,749 adult hospital discharges, 3.2% had CLD-only and 1.7% had comorbid CLD-SUD. Compared with CLD-only, comorbid CLD-SUD hospitalizations resulted in higher inpatient mortality (3.1% vs 2.4%, P < 0.001) and were associated with younger age, male sex, Native American race, and urban and Western US location. Over time, comorbid hospitalizations grew 34%, and the demographics shifted with larger increases in hospitalization rates seen in younger individuals, women, Native Americans, and those publicly insured. In comorbid hospitalizations, alcoholic SUD and CLD decreased, but drug SUDs and nonalcoholic fatty liver diseases are fast-growing contributors.

DISCUSSION

In this comprehensive analysis of US hospitalizations, comorbid CLD-SUD hospitalizations are increasing over time and lead to higher inpatient mortality than CLD alone. We further characterize the changing demographics of these hospitalizations, providing a contemporary yet inclusive look at comorbid CLD-SUD hospitalizations. These data can guide interventions needed to improve the poor outcomes suffered by this growing population.

Statins for treatment of chronic liver disease

PURPOSE OF REVIEW

Statins are a class of lipid lower medications used primarily in patients with high-risk cardiovascular disease. Since their development, statins have been considered to be harmful in patients with liver disease, and many of the prescribing information labels consider them to be contraindicated in patients with active liver disease. However, recent studies have shown the contrary, warranting further investigation and discussion. This review aims to describe the latest literature on the mechanism, safety profile and potential benefits of statins use on the natural history of chronic liver disease (CLD) progression and its complications.

RECENT FINDINGS

A number of recently published studies have added to the existing body of literature supporting the concept that statins are safe and likely to be beneficial for treating patients with CLD. Patients with CLD including hepatitis B virus infection, hepatitis C virus infection, nonalcoholic fatty liver disease and alcohol on statins have been shown to have a lower rate of decompensating events, lower incidence of hepatocellular cancer, a lower rate of infections, and increased survival. However, the majority of the available literature supporting statin use in patients with liver disease comes from retrospective observational studies with high potential for bias.

SUMMARY

Statins appear to be safe in patients with compensated cirrhosis, and evidence suggests that they may reduce fibrosis, even in patients with advanced fibrosis and cirrhosis. Further high-quality research on this topic is needed to fully delineate the effect of statins in patients with liver disease.

Uncontrolled diabetes mellitus increases risk of infection in patients with advanced cirrhosis

BACKGROUND

Diabetes mellitus (DM) is common in patients with cirrhosis and is associated with increased risk of infection.

AIM

To analyze the impact of uncontrolled DM on infection and mortality among inpatients with advanced cirrhosis.

METHODS

This study utilized the Nationwide Inpatient Sample from 1998 to 2014. We defined advanced cirrhosis using a validated ICD-9-CM algorithm requiring a diagnosis of cirrhosis and clinically significant portal hypertension or decompensation. The primary outcome was bacterial infection. Secondary outcomes included inpatient mortality stratified by elderly age (age≥70). Multivariable logistic regression analyzed outcomes.

RESULTS

906,559 (29.2%) patients had DM and 109,694 (12.1%) were uncontrolled. Patients who had uncontrolled DM were younger, had less ascites, but more encephalopathy. Bacterial infection prevalence was more common in uncontrolled DM (34.2% vs. 28.4%, OR 1.33, 95% CI 1.29-1.37, p<0.001). Although uncontrolled DM was not associated with mortality, when stratified by age, elderly patients with uncontrolled DM had a significantly higher risk of inpatient mortality (OR 1.62, 95% CI 1.46-1.81).

CONCLUSIONS

Uncontrolled DM is associated with increased risk of infection, and when combined with elderly age is associated with increased risk of inpatient mortality. Glycemic control is a modifiable target to improve morbidity and mortality in patients with advanced cirrhosis.

Changing epidemiology and outcomes of acute kidney injury in hospitalized patients with cirrhosis - a US population-based study

BACKGROUND & AIMS

Acute kidney injury (AKI) is a significant clinical event in cirrhosis yet contemporary population-based studies on the impact of AKI on hospitalized cirrhotics are lacking. We aimed to characterize longitudinal trends in incidence, healthcare burden and outcomes of hospitalized cirrhotics with and without AKI using a nationally representative dataset.

METHODS

Using the 2004-2016 National Inpatient Sample (NIS), admissions for cirrhosis with and without AKI were identified using ICD-9 and ICD-10 codes. Regression analysis was used to analyze the trends in hospitalizations, costs, length of stay and inpatient mortality. Descriptive statistics, simple and multivariable logistic regression were used to assess associations between individual characteristics, comorbidities, and cirrhosis complications with AKI and death.

RESULTS

In over 3.6 million admissions for cirrhosis, 22% had AKI. AKI admissions were more costly (median $13,127 [IQR $7,367-$24,891] vs. $8,079 [IQR $4,956-$13,693]) and longer (median 6 [IQR 3-11] days vs. 4 [IQR 2-7] days). Over time, AKI prevalence doubled from 15% in 2004 to 30% in 2016. CKD was independently and strongly associated with AKI (adjusted odds ratio 3.75; 95% CI 3.72-3.77). Importantly, AKI admissions were 3.75 times more likely to result in death (adjusted odds ratio 3.75; 95% CI 3.71-3.79) and presence of AKI increased risk of mortality in key subgroups of cirrhosis, such as those with infections and portal hypertension-related complications.

CONCLUSIONS

The prevalence of AKI is significantly increased among hospitalized cirrhotics. AKI substantially increases the healthcare burden associated with cirrhosis. Despite advances in cirrhosis care, a significant gap remains in outcomes between cirrhotics with and without AKI, suggesting that AKI continues to represent a major clinical challenge.

LAY SUMMARY

Sudden damage to the kidneys is becoming more common in people who are hospitalized and have cirrhosis. Despite advances in cirrhosis care, those with damage to the kidneys remain at higher risk of dying.

Increasing Economic Burden in Hospitalized Patients With Cirrhosis: Analysis of a National Database

The prevalence of cirrhosis is increasing despite advances in therapeutics, and it remains an expensive medical condition. Studies examining the healthcare burden of inpatient cirrhosis-related care regardless of etiology, stage, or severity are lacking. This study aims to describe the current drivers of cost, length of stay (LOS), and mortality in hospitalized patients with cirrhosis.

Medicare Shared Savings Program and readmission rate among patients with ischemic stroke

OBJECTIVE

Hospitals participating in the Medicare Shared Savings Program (MSSP) share with the Centers for Medicare and Medicaid Services (CMS) the savings generated by reduced cost of care. Our aim was to determine whether MSSP is associated with changes in readmissions and mortality for Medicare patients hospitalized with ischemic stroke, and whether MSSP has a different impact on safety net hospitals (SNHs) compared to non-SNHs.

METHODS

This study was based on the CMS Hospital Compare data for risk-standardized 30-day readmission and mortality rates for Medicare patients hospitalized with ischemic strokes between 2010 and 2017. With a propensity score-matched sample, hospital-level difference-in-difference analysis was used to determine whether MSSP was associated with changes in hospital readmission and mortality as well as to examine the impact of MSSP on SNHs compared to non-SNHs.

RESULTS

MSSP-participating hospitals had slightly greater reductions in readmission rates compared to matched nonparticipating hospitals (difference, 0.25 percentage points; 95% confidence interval [CI], -0.42 to -0.08). Mortality rates decreased among all hospitals, but mortality reduction was not significantly different between MSSP-participating hospitals and matched hospitals (difference, 0.06 percentage points; 95% CI, -0.28 to 0.17). Prior to MSSP, readmission rates in SNHs were higher compared to non-SNHs, but MSSP did not have significantly different impact on hospital readmission and mortality rates for SNHs and non-SNHs.

CONCLUSION

MSSP led to slightly fewer readmissions without increases in mortality for Medicare patients hospitalized with ischemic stroke. Similar reductions in readmission rates were observed in SNHs and non-SNHs participating in MSSP, indicating persistent gaps between SNHs and non-SNHs.

Intestinal perforations after endoscopic retrograde cholangiopancreatography in the USA: a 16-year study using the National Inpatient Sample

BACKGROUND

Intestinal perforation is a rare but feared complication of ERCP. In this study, we identify patient and hospital factors for ERCP related intestinal perforation using a large national database. We also examine the effects of intestinal perforations on hospital outcomes.

METHODS

Data were obtained from the National Inpatient Sample, the largest publicly available inpatient care database in the United States. ICD-9-CM procedure codes for all ERCP procedures conducted between 1998 and 2013. Our primary outcome of interest was the incidence of intestinal perforations after ERCP. Secondary outcomes of interest included hospital length of stay and inpatient mortality.

RESULTS

A total of 392,336 ERCP procedures were performed over the study period, met our inclusion criteria, and were analyzed. Mean age of sample was 59 years and just over 60% were females. Low volume hospitals accounted for over 85% of ERCPs. Intestinal perforations occurred at a rate of 1.2 per 1000 ERCP procedures. Patient's age was the only patient-related factor significantly associated with perforation. (OR: 1.016; 95% CI 1.009-1.025). For hospitals, teaching status was the only hospital related factor associated with intestinal perforation after ERCP (OR: 1.56; 95% CI 1.28-1.91). Length of stay was much longer in patients with ERCP related perforations and mortality risk was ten times higher in the same cohort.

CONCLUSIONS

Patients who have ERCP related perforations have longer hospital stays and have a higher mortality risk. Older patients and those who had ERCP in teaching hospitals are at a higher risk of perforation.

Index admission cholecystectomy for acute biliary pancreatitis favorably impacts outcomes of hospitalization in cirrhosis

BACKGROUND AND AIM

Despite higher rates of gallstones in patients with cirrhosis, there are no population-based studies evaluating outcomes of acute biliary pancreatitis (ABP). Therefore, we sought to evaluate the predictors of early readmission and mortality in this high-risk population.

METHODS

We utilized the Nationwide Readmission Database (2011-2014) to evaluate all adults admitted with ABP. Multivariable logistic regression models were used to assess independent predictors for 30-day readmission, index admission mortality, and calendar year mortality.

RESULTS

Among 184 611 index admissions with ABP, 4344 (2.4%) subjects had cirrhosis (1649 with decompensation). Subjects with cirrhosis, when compared with those without, incurred higher rates of 30-day readmission (20.9% vs 11.2%; P < 0.001), index mortality (2.0% vs 1.0%; P < 0.001), and calendar year mortality (4.2% vs 0.9%; P < 0.001). Decompensation in cirrhosis was associated with significantly fewer cholecystectomies (26.7% vs 60.2%; P < 0.001) and endoscopic retrograde cholangiopancreatographies (23.3% vs 29.9%; P < 0.001). Multivariate analysis revealed that severe acute pancreatitis (odds ratio [OR]: 14.8; 95% confidence interval [CI]: 5.3, 41.2), sepsis (OR: 12.6; 95% CI: 5.8, 27.4), and decompensation (OR: 3.1; 96% CI: 1.4, 6.6) were associated with increased index admission mortality. Decompensated cirrhosis (OR: 1.8; 95% CI: 1.1, 3.0) and 30-day readmission (OR: 5.6; 95% CI: 3.3, 9.5) were predictors of calendar year mortality. However, index admission cholecystectomy was associated with decreased 30-day readmissions (OR: 0.6; 95% CI: 0.4, 0.7) and calendar year mortality (OR: 0.44; 95% CI: 0.25, 0.78).

CONCLUSIONS

The presence of cirrhosis adversely impacts hospital outcomes of patients with ABP. Among modifiable factors, index admission cholecystectomy portends favorable prognosis by reducing risk of early readmission and consequent calendar year mortality.

The North American Consortium for the Study of End-Stage Liver Disease-Acute-on-Chronic Liver Failure Score Accurately Predicts Survival: An External Validation Using a National Cohort

Acute-on-chronic liver failure (ACLF) carries high short-term mortality. The North American Consortium for the Study of End-Stage Liver Disease (NACSELD)-ACLF score, positive if ≥2 organ failures are present, is a bedside tool that predicts short-term mortality in patients with cirrhosis. However, it was created using major liver referral centers, where a minority of patients with cirrhosis are hospitalized. Therefore, this study used the Nationwide Inpatient Sample, a nationally representative database, from 2005 to 2014 to externally validate the NACSELD-ACLF score in a cohort of patients with decompensated cirrhosis who were identified by a validated algorithm. Organ failures were identified using diagnosis codes. The primary objective was to evaluate the association between the NACSELD-ACLF score and inpatient mortality, whereas secondary objectives compared outcomes depending on presence of infection or hospitalization at a transplant center. Multivariate logistic regression was used to compare outcomes, and area under the curve was calculated. There were 1,523,478 discharges that were included with 106,634 (7.0%) having a positive NACSELD-ACLF score. Patients were a mean 58 years old, and a majority were white men. Infection was present in 33.7% of the sample. Inpatient survival decreased with each organ failure and if infection was present. Patients with the NACSELD-ACLF score had significantly lower inpatient survival on crude (94% versus 48%; P < 0.001) and multivariate analysis (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.07-0.08) and area under the receiver operating characteristic curve 0.77 (95% CI, 0.77-0.78). Liver transplant centers had clinically similar but significantly better survival at each organ failure, in patients with the NACSELD-ACLF score, and on multivariate analysis (OR, 1.17; 95% CI, 1.13-1.22). Using a national cohort, our study validated the NACSELD-ACLF score as an excellent, simple bedside tool to predict short-term survival in patients with decompensated cirrhosis.

Quality Measures, All-Cause Mortality, and Health Care Use in a National Cohort of Veterans With Cirrhosis

Decompensated cirrhosis is associated with high morbidity and mortality. However, no standardized quality measures (QMs) have yet been adopted widely. The Veterans Affairs (VA) Advanced Liver Disease Technical Advisory Group recently developed a set of six internal QMs to guide quality improvement efforts in cirrhosis in the domains of access to care, hepatocellular carcinoma surveillance, variceal surveillance, quality of inpatient care for upper gastrointestinal bleeding, and cirrhosis-related rehospitalizations. We aimed to (1) quantify adherence to cirrhosis QMs and (2) determine whether adherence was associated with all-cause mortality and health care use within a large national cohort of veterans with cirrhosis. We performed a retrospective study using data from the Veterans Outcomes and Costs Asociated with Liver Disease cohort of 121,129 patients newly diagnosed with cirrhosis from January 1, 2008, to December 31, 2016, at 128 VA facilities. The mean follow-up time was 2.7 years (interquartile range, 1.1-5.1 years). Adherence to outpatient access to specialty care was 71%, variceal surveillance was 32%, and early postdischarge care was 54%. In adjusted analyses, outpatient access to specialty care (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.78-0.82), hepatocellular carcinoma surveillance (HR, 0.92; 95% CI, 0.90-0.95), variceal surveillance (HR, 0.93; 95% CI, 0.89-0.99), and early postdischarge care (HR, 0.57; 95% CI, 0.54-0.60) were associated with lower all-cause mortality. Readmissions after 30 days (HR, 1.53; 1.46-1.60) and 90 days (HR, 1.88; 95% CI, 1.54-1.70) were associated with higher all-cause mortality. Higher adherence to QMs was also associated with lower inpatient health care use. Conclusion: Five of the six proposed VA cirrhosis QMs were measurable using existing data sources, associated with mortality and health care use, and may be used to guide future quality improvement efforts in cirrhosis.

Early Paracentesis in High-Risk Hospitalized Patients: Time for a New Quality Indicator

INTRODUCTION

Symptomatic ascites is the most common indication for hospitalization in patients with cirrhosis. Although guidelines recommend paracentesis for all inpatients with ascites, the timing of paracentesis is likely to be crucial. Performance of an early paracentesis and its relationship to outcomes are unknown, particularly among patients at high risk of spontaneous bacterial peritonitis (SBP).

METHODS

We included 75,462 discharges of adult patients with cirrhosis presenting with ascites who underwent paracentesis from the State Inpatient Databases of New York, Florida, and Washington from 2009 to 2013. High-risk patients were identified as having concomitant hepatic encephalopathy or acute kidney injury present on admission. The primary outcome was performance of early paracentesis (within 1 hospital day) with secondary outcomes being inpatient mortality, SBP-related mortality, and 30-day readmission. Multivariable logistic regression models included a priori covariates known to impact outcomes.

RESULTS

There were 43,492 (57.6%) patients who underwent early paracentesis. High-risk patients (27,496) had lower rates of early paracentesis (52.8% vs 60.5%, P < 0.001). On multivariable analysis, high-risk patients had significantly decreased odds of undergoing early paracentesis (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.71-0.78, P < 0.001). Early paracentesis was associated with a reduced inpatient all-cause mortality (OR 0.68, 95% CI 0.63-0.73, P < 0.001), SBP-related mortality (OR 0.84, 95% CI 0.73-0.94, P = 0.01), and 30-day readmission (OR 0.87, 95% CI 0.82-0.92, P < 0.001).

DISCUSSION

Early paracentesis is associated with reduced inpatient mortality, SBP-related mortality, and 30-day readmission. Given its impact on outcomes, early paracentesis should be a new quality metric. Further education and interventions are needed to improve both adherence and outcomes.

Increasing Clinical and Economic Burden of Nonalcoholic Fatty Liver Disease Among Hospitalized Adults in the United States

GOALS

The aim of this study was to understand the burden of nonalcoholic fatty liver disease (NAFLD) among hospitalized patients in the United States.

BACKGROUND

A major driver of the rapidly increasing US clinical and economic burden of NAFLD is attributed to inpatient health care resource utilization.

METHODS

We performed a cross-sectional study of the 2007 to 2014 Nationwide Inpatient Sample. A total of 481,122 hospitalizations in patients with NAFLD were identified using ICD-9 codes after excluding other etiologies of chronic liver disease. We analyzed survey-weighted annual trends in national estimates of hospitalizations in patients with NAFLD, stratified by metabolic comorbidities, cirrhosis, and other liver-related complications. Annual trends in total hospitalization charges were inflation adjusted to 2014 USD.

RESULTS

From 2007 to 2014, hospitalizations in patients with NAFLD increased by 83.4% (42,060 to 77,143, P<0.0001), and the proportion of total hospitalizations represented by patients with NAFLD increased by 104.4% (6.34 to 13.0 per 1000 hospitalizations). During this time, there was a 159% increase in total inpatient hospitalization charges in patients with NAFLD ($7.7 billion in 2007 to $19.9 billion in 2014, P<0.001). This increasing clinical and economic burden was observed across all metabolic comorbidities and liver complications evaluated among hospitalizations in patients with NAFLD.

CONCLUSIONS

With the rising prevalence of NAFLD in the United States, the inpatient clinical and economic burden of NAFLD is also rapidly rising. In 2014, total estimated national hospitalization charges in patients with NAFLD reached nearly $20 billion, with metabolic comorbidities and liver-related complications being major contributors to this rising burden.

Cirrhosis as a Comorbidity in Conditions Subject to the Hospital Readmissions Reduction Program

INTRODUCTION

Although the Hospital Readmissions Reduction Program (HRRP) has decreased readmissions in targeted conditions, outcomes in high-risk subgroups are unknown. This study analyzed the impact of cirrhosis as a comorbidity on readmissions in conditions subjected to the HRRP.

METHODS

Using a longitudinal analysis of the New York, Florida, and Washington State inpatient databases from 2009 to 2013, adult Medicare beneficiaries with a diagnosis-related group of targeted conditions by the HRRP-pneumonia, congestive heart failure (CHF), and myocardial infarction (MI)-were included. Exclusion criteria included inability to assess for readmission, previous liver transplant, or having a readmission not subject to penalty under the HRRP. A sensitivity analysis used the International Classification of Diseases, 9th Revision, Clinical Modification codes to identify pneumonia, CHF, and MI hospitalizations. The primary outcome was 30-day readmission, with secondary outcomes including 90-day readmission, trends, and cirrhosis-specific risk factors for readmission.

RESULTS

Of the 797,432 patients included, 8,964 (1.1%) had cirrhosis. Patients with cirrhosis had significantly higher 30-day readmissions overall (29.3% vs 23.8%, P < 0.001) and specifically for pneumonia and CHF, but not for MI. Thirty-day readmission rates significantly decreased in patients without cirrhosis (annual percent change -1.8%, P < 0.001), but not in patients with cirrhosis (P = 0.39). Similar findings were present for 90-day readmissions. A sensitivity analysis confirmed these findings. On multivariable analysis, cirrhosis was associated with significantly higher 30-day readmissions (odds ratio 1.13, P < 0.001).

DISCUSSION

When cirrhosis is comorbid in patients with conditions subjected to the HRRP, readmissions are higher and have not improved. Focused efforts are needed to improve outcomes in cirrhosis and other high-risk comorbidities within the HRRP cohort.

Rural-Urban Differences in In-Hospital Mortality Among Admissions for End-Stage Liver Disease in the United States

Access to quality hospital care is a persistent problem for rural patients. Little is known about disparities between rural and urban populations regarding in-hospital outcomes for end-stage liver disease (ESLD) patients. We aimed to determine whether rural ESLD patients experienced higher in-hospital mortality than urban patients and whether disparities were attributable to the rurality of the patient or the center. This was a retrospective study of patient admissions in the National Inpatient Sample, a population-based sample of hospitals in the United States. Admissions were included if they were from adult patients who had an ESLD-related admission defined by codes from the International Classification of Diseases, Ninth Revision, between January 2012 and December 2014. The primary exposures of interest were patient-level rurality and hospital-level rurality. The main outcome was in-hospital mortality. We stratified our analysis by disease severity score. After accounting for patient- and hospital-level covariates, ESLD admissions to rural hospitals in every category of disease severity had significantly higher odds of in-hospital mortality than patient admissions to urban hospitals. Those with moderate or major risk of dying had more than twice the odds of in-hospital mortality (odds ratio [OR] for moderate risk, 2.41; 95% confidence interval [CI], 1.62-3.59; OR for major risk, 2.49; 95% CI, 1.97-3.14). There was no association between patient-level rurality and mortality in the adjusted models. In conclusion, ESLD patients admitted to rural hospitals had increased odds of in-hospital mortality compared with those admitted to urban hospitals, and the differences were not attributable to patient-level rurality. Our results suggest that interventions to improve outcomes in this population should focus on the level of the health system.

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

Early readmission in patients with decompensated liver cirrhosis leads to an enormous burden on health care use. A retrospective cohort study using the 2013 and 2014 Nationwide Readmission Database (NRD) was conducted. Patients with a diagnoses of cirrhosis and at least one feature of decompensation were included. The primary outcome was to develop a validated risk model for early readmission. Secondary outcomes were to study the 30-day all-cause readmission rate and the most common reasons for readmission. A multivariable logistic regression model was fit to identify predictors of readmissions. Finally, a risk model, the Mumtaz readmission risk score, was developed for prediction of 30-day readmission based on the 2013 NRD and validated on the 2014 NRD. A total of 123,011 patients were included. The 30-day readmission rate was 27%, with 79.6% of patients readmitted with liver-related diagnoses. Age <65 years; Medicare or Medicaid insurance; nonalcoholic etiology of cirrhosis; ≥3 Elixhauser score; presence of hepatic encephalopathy, ascites, variceal bleeding, hepatocellular carcinoma, paracentesis, or hemodialysis; and discharge against medical advice were independent predictors of 30-day readmission. This validated model enabled patients with decompensated cirrhosis to be stratified into groups with low (<20%), medium, (20%-30%), and high (>30%) risk of 30-day readmissions. Conclusion: One third of patients with decompensated cirrhosis are readmitted within 30 days of discharge. The use of a simple risk scoring model with high generalizability, based on demographics, clinical features, and interventions, can bring refinement to the prediction of 30-day readmission in high-risk patients; the Mumtaz readmission risk score highlights the need for targeted interventions in order to decrease rates of readmission within this population.

Increasing Burden of Hepatic Encephalopathy Among Hospitalized Adults: An Analysis of the 2010-2014 National Inpatient Sample

BACKGROUND

Hepatic encephalopathy (HE) is associated with substantial morbidity and mortality, contributing significant burden on healthcare systems.

AIM

We aim to evaluate trends in clinical and economic burden of HE among hospitalized adults in the USA.

METHODS

Using the 2010-2014 National Inpatient Sample, we identified adults hospitalized with HE using ICD-9-CM codes. Annual trends in hospitalizations with HE, in-hospital mortality, and hospital charges were stratified by the presence of acute liver failure (ALF) or cirrhosis. Adjusted multivariable regression models were evaluated for predictors of in-hospital mortality and hospitalization charges.

RESULTS

Among 142,860 hospitalizations with HE (mean age 59.3 years, 57.8% male), 67.7% had cirrhosis and 3.9% ALF. From 2010 to 2014, total number of hospitalizations with HE increased by 24.4% (25,059 in 2010 to 31,182 in 2014, p < 0.001). Similar increases were seen when stratified by ALF (29.7% increase) and cirrhosis (29.7% increase). Overall in-hospital mortality decreased from 13.4% (2010) to 12.3% (2014) (p = 0.001), with similar decreases observed in ALF and cirrhosis. Total inpatient charges increased by 46.0% ($8.15 billion, 2010 to $11.9 billion, 2014). On multivariable analyses, ALF was associated with significantly higher odds of in-hospital mortality (OR 5.37; 95% CI 4.97-5.80; p < 0.001) as well as higher mean inpatient charges (122.6% higher; 95% CI + 115.0-130.3%; p < 0.001) compared to cirrhosis. The presence of ascites, hepatocellular carcinoma, and hepatorenal syndrome was associated with increased mortality.

CONCLUSIONS

The clinical and economic burden of hospitalizations with HE in the USA continues to rise. In 2014, estimated national economic burden of hospitalizations with HE reached $11.9 billion.

Role of ascitic prostaglandin E2 in diagnosis of spontaneous bacterial peritonitis and prediction of in-hospital mortality in patients with decompensated cirrhosis

Spontaneous bacterial peritonitis (SBP) is one of the most frequent and severe complications in patients with decompensated cirrhosis. Early antibiotic therapy is extremely important for successful treatment and reducing mortality. Prostaglandin E2 (PGE2) is a regulator of the immune response and infection. This study aimed to explore whether ascitic PGE2 could be used as a marker for diagnosing SBP and predicting in-hospital mortality.Patients with cirrhosis and ascites undergoing abdominal paracentesis were enrolled in our study. Demographic, clinical, and laboratory parameters were recorded at the time of paracentesis and ascitic PGE2 levels were determined by ELISA. The correlation between ascitic PGE2 level and SBP as well as in-hospital mortality were analyzed.There were 224 patients enrolled, 29 (13%) patients diagnosed as SBP based on the current guideline criteria. The ascitic PGE2 level of patients with SBP [32.77 (26.5-39.68) pg/mL] was significantly lower than that of patients without SBP [49.72 (37.35-54.72) pg/mL]. In ROC analysis, the AUC of ascitic PGE2 for the diagnosis of SBP was 0.75, and the AUC of ascitic PGE2 combined with WBC and ascitic PGE2 combined with neutrophils were 0.90 and 0.90, respectively, which were significantly higher than that of ascitic PGE2. In multivariate analysis, ascites PGE2≤32.88 pg/mL (OR: 9.39; 95% CI: 1.41-67.44, P = .026), hepatic encephalopathy (OR: 18.39; 95% CI: 3.00-113.13, P = .002) and a higher MELD score (OR: 1.25; 95% CI: 1.05-1.40, P = .009) remained independent predictors of in-hospital mortality.Ascitic PGE2 level is likely to be a valuable marker in prediction of in-hospital mortality in patients with decompensated cirrhosis, and its value in diagnosis of SBP was not superior to other inflammatory indicators.

A Roadmap for Value-Based Payment Models Among Patients With Cirrhosis

Healthcare reimbursement is shifting from fee-for-service to fee-for-value. Cirrhosis, which costs the U.S. healthcare system as much as heart failure, is a prime target for value-based care. This article describes models in which physician groups or health systems are paid for improving quality and lowering costs for a given population of patients with cirrhosis. If done correctly, we believe that such frameworks, once adopted, could help reduce burnout by freeing physicians of the burden of checking boxes in the electronic medical record so that they can devote their energies to managing populations. Conclusion: Value-based payment models for cirrhosis have the potential to benefit patients, physicians, and healthcare insurers.

A validated risk model for prediction of early readmission in patients with hepatic encephalopathy

INTRODUCTION AND AIM

Hepatic encephalopathy (HE) is a common complication in cirrhotics and is associated with an increased healthcare burden. Our aim was to study independent predictors of 30-day readmission and develop a readmission risk model in patients with HE. Secondary aims included studying readmission rates, cost, and the impact of readmission on mortality.

MATERIALS AND METHODS

We utilized the 2013 Nationwide Readmission Database (NRD) for hospitalized patients with HE. A risk assessment model based on index hospitalization variables for predicting 30-day readmission was developed using multivariate logistic regression and validated with the 2014 NRD. Patients were stratified into Low Risk and High Risk groups. Cox regression models were fit to identify predictors of calendar-year mortality.

RESULTS

Of 24,473 cirrhosis patients hospitalized with HE, 32.4% were readmitted within 30 days. Predictors of readmission included presence of ascites (OR: 1.19; 95% CI: 1.06-1.33), receiving paracentesis (OR: 1.43; 95% CI: 1.26-1.62) and acute kidney injury (OR: 1.11; 95% CI: 1.00-1.22). Our validated model stratified patients into Low Risk and High Risk of 30-day readmissions (29% and 40%, respectively). The cost of the first readmission was higher than index admission in the 30-day readmission cohort ($14,198 vs. $10,386; p-value <0.001). Thirty-day readmission was the strongest predictor of calendar-year mortality (HR: 4.03; 95% CI: 3.49-4.65).

CONCLUSIONS

Nearly one-third of patients with HE were readmitted within 30 days, and early readmission adversely impacted healthcare utilization and calendar-year mortality. With our proposed simple risk assessment model, patients at high risk for early readmissions can be identified to potentially avert poor outcomes.

Superior Performance of Teaching and Transplant Hospitals in the Management of Hepatic Encephalopathy from 2007 to 2014

Background and Aims: Hepatic encephalopathy is a liver disease complication with significant mortality and costs. The aim of this study was to evaluate the relative performance of facilities based on their teaching status and transplant capability by correlating their connections to mortality, cost, and length of stay from 2007 to 2014. Methods: The Nationwide Inpatient Sample database was utilized to collect information on (USA) American patients admitted with a primary diagnosis of hepatic encephalopathy from 2007-2014. Hospitals were placed into one of four categories using their teaching and transplant status. Using regression analysis, mortality, length of stay and cost adjusted rate ratios were calculated. Results: The study revealed that teaching transplant centers had a mortality risk ratio of 0.783 (95% confidence interval (CI): 0.750-0.819, p < 0.001). Blacks had the highest mortality risk ratio, of 1.273 (95%CI: 1.217-1.331, p < 0.001). Furthermore, teaching transplant hospitals had a cost rate ratio of 1.226 (95%CI: 1.214-1.238, p < 0.001) and a length of stay rate ratio of 1.104 (95%CI: 1.093-1.115, p < 0.001). Conclusions: It appears that admission to transplant facilities for hepatic encephalopathy is associated with reduced mortality but increased costs and longer stay independent of transplantation. Moreover, factors impacting black mortality should also be examined more closely.

Geographical differences exist in high-value care delivery for inpatient management of cirrhosis: Cost conscious care in cirrhosis

BACKGROUND AND AIMS

The United States spends more money per person on health care than any other country in the world. Patients with cirrhosis are at an increased risk of health-care utilization. The aim of this study is to evaluate differences in health-care utilization based on the region of treatment during the inpatient management of patients with cirrhosis.

METHOD

A retrospective database analysis using the Nationwide Inpatient Sample was performed, including adult patients with a primary diagnosis of cirrhosis determined by ICD-9 codes. Univariate and multivariate analyses were performed to analyze liver decompensation, mortality, length of stay, and total charges in different regions across the United States.

RESULTS

A total of 75 280 patients with cirrhosis who received treatment in nine different regions across the United States were included. Rates of liver decompensation were significantly decreased in the Pacific region compared to the New England region (OR: 0.69, 95% CI: 0.51-0.94). Length of stay was significantly different between regions; however, the means only varied by half a day and were of minimal clinical significance. Inpatient mortality rates were not significantly different between regions. Total charges for inpatient management between regions were significantly different, with the Pacific region having the highest total hospital charges with a mean of $82 731.

CONCLUSIONS

Health-care utilization during the inpatient management of cirrhosis varies based on the region. The charges for treatment were the highest in the West despite no impact on mortality, minimal improvement in length of stay, and fewer features of decompensation on admission.

Assessing the Quality of Microvascular Breast Reconstruction Performed in the Urban Safety-Net Setting: A Doubly Robust Regression Analysis

BACKGROUND

Safety-net hospitals serve vulnerable populations; however, care delivery may be of lower quality. Microvascular immediate breast reconstruction, relative to other breast reconstruction subtypes, is sensitive to the performance of safety-net hospitals and an important quality marker. The authors' aim was to assess the quality of care associated with safety-net hospital setting.

METHODS

The 2012 to 2014 National Inpatient Sample was used to identify patients who underwent microvascular immediate breast reconstruction after mastectomy. Primary outcomes of interest were rates of medical complications, surgical inpatient complications, and prolonged length of stay. A doubly-robust approach (i.e., propensity score and multivariate regression) was used to analyze the impact of patient and hospital-level characteristics on outcomes.

RESULTS

A total of 858 patients constituted our analytic cohort following propensity matching. There were no significant differences in the odds of surgical and medical inpatient complications among safety-net hospital patients relative to their matched counterparts. Black (OR, 2.95; p < 0.001) and uninsured patients (OR, 2.623; p = 0.032) had higher odds of surgical inpatient complications. Safety-net hospitals (OR, 1.745; p = 0.005), large bedsize hospitals (OR, 2.170; p = 0.023), and Medicaid patients (OR, 1.973; p = 0.008) had higher odds of prolonged length of stay.

CONCLUSIONS

Safety-net hospitals had comparable odds of adverse clinical outcomes but higher odds of prolonged length of stay, relative to non-safety-net hospitals. Institution-level deficiencies in staffing and clinical processes of care might underpin the latter. Ongoing financial support of these institutions will ensure delivery of needed breast cancer care to economically disadvantaged patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Hospital Cirrhosis Volume and Readmission in Patients with Cirrhosis in California

BACKGROUND

Patients with cirrhosis are at high readmission risk. Using a large statewide database, we evaluated the effect of hospital cirrhosis-related patient volume on 30-day readmissions in patients with cirrhosis.

METHODS

We conducted a retrospective study of the Healthcare Cost and Utilization Project State Inpatient Database for adult patients with cirrhosis, as defined by International Classification of Diseases, Ninth Revision (ICD-9) codes, hospitalized in California between 2009 and 2011. Multivariable logistic regression analysis was performed to evaluate the effect of hospital volume on 30-day readmissions.

RESULTS

A total of 69,612 patients with cirrhosis were identified in 405 hospitals; 24,062 patients were discharged from the top 10% of hospitals (N = 41) by cirrhosis volume, and 45,550 patients in the bottom 90% (N = 364). Compared with higher-volume centers, lower-volume hospitals cared for patients with similar average Quan-Charlson-Deyo (QCD) comorbidity scores (6.54 vs. 6.68), similar proportion of hepatitis B and fatty liver disease, lower proportion of hepatitis C (34.8 vs. 41.5%) but greater proportion of alcoholic liver disease (53.1 vs. 47.4%). Multivariable logistic regression analysis demonstrated admission to a lower-volume hospital did not predict 30-day readmission (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.92-1.01) after adjusting for sociodemographics, QCD score, cirrhosis severity, and hospital characteristics. Instead, liver transplant center status significantly decreased the risk of readmission (OR 0.87, 95% CI 0.80-0.94). Ascites, hepatic encephalopathy, hepatocellular carcinoma, higher QCD, and presence of alcoholic liver disease and hepatitis C were also independent predictors.

CONCLUSIONS

Readmissions within 30 days were common among patients with cirrhosis hospitalized in California. While hospital cirrhosis volume did not predict 30-day readmissions, liver transplant center status was protective of readmissions. Medically complicated patients with cirrhosis at hospitals without liver transplant centers may benefit from additional support to prevent readmission.

The high burden of alcoholic cirrhosis in privately insured persons in the United States

Alcoholic cirrhosis (AC) is a major cause of liver-related morbidity and mortality in the United States. Rising rates of alcohol use disorders in the United States will likely result in more alcoholic liver disease. Our aim was to determine the prevalence, health care use, and costs of AC among privately insured persons in the United States. We collected data from persons aged 18-64 with AC (identified by codes from the International Classification of Diseases, Ninth and Tenth Revisions) enrolled in the Truven MarketScan Commercial Claims and Encounters database (2009-2015). We determined yearly prevalence, weighted to the national employer-sponsored, privately insured population. Using competing risk analysis, we estimated event rates for portal hypertensive complications and estimated the association between AC and costs as well as admissions and readmissions. In 2015, 294,215 people had cirrhosis and 105,871 (36%) had AC. Mean age at AC diagnosis was 53.5 years, and 32% were women. Over the 7 years queried, estimated national cirrhosis prevalence rose from 0.19% to 0.27% (P < 0.001) and for AC from 0.07% to 0.10% (P < 0.001). Compared to non-AC, AC enrollees were significantly more likely to have portal hypertensive complications at diagnosis and higher yearly cirrhosis and alcohol-related admissions (25 excess cirrhosis admissions and 6.3 excess alcohol-related admissions per 100 enrollees) as well as all-cause readmissions. Per-person costs in the first year after diagnosis nearly doubled for AC versus non-AC persons (US$ 44,835 versus 23,319).

CONCLUSION

In a nationally representative cohort of privately insured persons, AC enrollees were disproportionately sicker at presentation, were admitted and readmitted more often, and incurred nearly double the per-person health care costs compared to those with non-AC. (Hepatology 2018).

Predictors of clinical outcomes in cirrhosis patients

PURPOSE OF REVIEW

The current review aims to explain the different systems available to clinicians for predicting clinical outcomes in patients with cirrhosis.

RECENT FINDINGS

Cirrhosis is the final stage of chronic liver disease and is associated with high morbidity and mortality. The most commonly utilized tools to predict outcomes in patients with cirrhosis include the following: assessing severity of portal hypertension using hepatic venous pressure gradient (HVPG) measurements, using scoring systems such as the Model for End-stage Liver Disease (MELD) and Child-Pugh-Turcotte (CPT) scores, and recently, clinical staging systems based on cirrhosis-related clinical complications. Assessing portal pressure with HVPG measurements provides valuable prognostic information, yet is costly, time-consuming, and invasive. MELD and CPT scores can be calculated quickly and not only assess liver function, but also yield predictive information. However, they represent only one point in time, and do not take into account the full clinical picture. Clinical staging systems have traditionally been focused on compensated and decompensated stages, with newer models assessing the influence of cirrhosis-related complications. However, these are not commonly utilized.

SUMMARY

Predicting clinical outcomes in patients with cirrhosis is challenging, and is likely best accomplished with a combination of objective data (such as MELD and HVPG provide) in addition to the clinical course of cirrhosis.

Hospital volume and mortality after transjugular intrahepatic portosystemic shunt creation in the United States

The link between higher procedure volume and better outcomes for surgical procedures is well established. We aimed to determine whether procedure volume affected inpatient mortality in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). An epidemiological analysis of an all-payer database recording hospitalizations during 2013 in the United States (Nationwide Readmissions Database) was performed. All patients ≥ 18 years old undergoing TIPS during a hospital admission (n = 5529) without concurrent or prior liver transplantation were selected. All-cause inpatient mortality was assessed. Risk-adjusted mortality was assessed for hospitals categorized into quintiles based on annual TIPS volume (very low, 1-4/year; low, 5-9/year; medium, 10-19/year; high, 20-29/year; and very high, ≥ 30/year). TIPS were placed in all 5529 patients (mean age, 57 years [standard deviation, ± 10.9 years]; women, n = 2071; men, n = 3458). Mortality decreased with rising annual TIPS volume (13% for very low to 6% for very high volume hospitals; P < 0.01). Elective admissions were more common in hospitals with higher annual TIPS volume (20.3% for very low to 30.8% for very high; P < 0.01). On multivariate analysis, compared with hospitals performing ≥30 TIPS per year, only hospitals performing 1-4/year (adjusted odds ratio [aOR], 1.9; 95% confidence interval [CI], 1.21-3.01; P = 0.01), 5-9/year (aOR, 2.0; 95% CI, 1.25-3.17; P < 0.01), and 10-19/year (aOR, 1.9; 95% CI, 1.17-3.00; P = 0.01) had higher inpatient mortality (20-29/year: aOR, 1.4; 95% CI, 0.84-2.84; P = 0.19). The absolute difference between risk-adjusted mortality rate for very low volume and very high volume hospitals was 6.1% (13.9% versus 7.8%). TIPS volume of ≤ 20 TIPS/year, variceal bleeding, and nosocomial infections were independent risk factors for inpatient mortality in patients with both elective and emergent admissions. Conclusion: The risk of inpatient mortality is lower in hospitals performing ≥20 TIPS per year. Future research exploring preventable factors for higher mortality and benefits of patient transfer to higher volume centers is warranted. (Hepatology 2018;67:690-699).

Hospitalization Rates, Prevalence of Cardiovascular Manifestations, and Outcomes Associated With Sarcoidosis in the United States

BACKGROUND

Recent trends of hospitalizations and in-hospital mortality are not well defined in sarcoidosis. We examined aforementioned trends and prevalence of cardiovascular manifestations and explored rates of implantable cardioverter-defibrillator implantation in hospitalizations with sarcoidosis.

METHODS AND RESULTS

Using data from the National Inpatient Sample, a retrospective population cohort from 2005 to 2014 was studied. To identify sarcoidosis, an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code was used. We excluded hospitalizations with myocardial infarction, coronary artery disease, and ischemic cardiomyopathy. Cardiovascular manifestations were defined by the presence of diagnosis codes for conduction disorders, arrhythmias, heart failure, nonischemic cardiomyopathy, and pulmonary hypertension. A total of 609 051 sarcoidosis hospitalizations were identified, with an age of 55±14 years, 67% women, and 50% black. The number of sarcoidosis hospitalizations increased from 2005 through 2014 (138 versus 175 per 100 000, Ptrend<0.001). We observed declining trends of unadjusted in-hospital mortality (6.5 to 4.9 per 100 sarcoidosis hospitalizations, Ptrend<0.001). Overall ≈31% (n=188 438) of sarcoidosis hospitalizations had coexistent cardiovascular manifestations of one or more type. Heart failure (≈16%) and arrhythmias (≈15%) were the most prevalent cardiovascular manifestations. Rates of implantable cardioverter-defibrillator placement were ≈7.5 per 1000 sarcoidosis hospitalizations (Ptrend=0.95) during the study period. Black race was associated with 21% increased risk of in-hospital mortality (odds ratio, 1.21; 95% confidence interval, 1.16-1.27 [P<0.001]).

CONCLUSIONS

Sarcoidosis hospitalizations have increased over the past decade with a myriad of coexistent cardiovascular manifestations. Black race is a significant predictor of in-hospital mortality, which is declining. Further efforts are needed to improve care in view of low implantable cardioverter-defibrillator rates in sarcoidosis.

Cirrhosis Is Associated with Increased Mortality in Patients with Diverticulitis: A Nationwide Cross-Sectional Study

BACKGROUND

Diverticulitis in patients with cirrhosis has been associated with higher surgical mortality, but no prior studies evaluate non-surgical treatment results.

AIMS

Our aim was to compare the outcomes of hospitalization for diverticulitis in patients with and without cirrhosis.

METHODS

We utilized the Nationwide Inpatient Sample (2007-2013) for patients with and without cirrhosis hospitalized for diverticulitis. Patients were further stratified by the presence of compensated versus decompensated cirrhosis. Validated ICD-9 codes captured patients and surgical procedures. Multivariate logistic regression models were fit. The primary outcomes of interest were mortality and surgical intervention rates.

RESULTS

There were 1,555,469 patients hospitalized for diverticulitis without cirrhosis, and 7523 patients hospitalized for diverticulitis with cirrhosis. On multivariate analysis, patients with cirrhosis had an increased mortality rate (OR 2.28; 95% CI 1.48-3.5). There were no significant differences in surgical interventions. Subgroup multivariate analyses of compensated cirrhosis (n = 6170) and decompensated cirrhosis (n = 1353) revealed that decompensated cirrhosis had an increased mortality rate (OR 4.99; 95% CI 2.48-10.03) when compared to patients without cirrhosis, whereas those with compensated cirrhosis did not (OR 1.67; 95% CI 0.96-2.91). Those with compensated cirrhosis underwent less surgical interventions (OR 0.82; 95% CI 0.67-0.99) compared to those without cirrhosis. Patients with diverticulitis and cirrhosis had increased costs and lengths of hospitalization.

CONCLUSION

Presence of cirrhosis in patients hospitalized for diverticulitis is associated with an increased mortality rate. These are novel findings, and future clinical studies should focus on improving diverticulitis outcomes in this group.

Development of a prognostic nomogram for cirrhotic patients with upper gastrointestinal bleeding

BACKGROUND AND AIM

Upper gastrointestinal bleeding (UGIB) is a complication with a high mortality rate in critically ill patients presenting with cirrhosis. Today, there exist few accurate scoring models specifically designed for mortality risk assessment in critically ill cirrhotic patients with upper gastrointestinal bleeding (CICGIB). Our aim was to develop and evaluate a novel nomogram-based model specific for CICGIB.

PATIENTS AND METHODS

Overall, 540 consecutive CICGIB patients were enrolled. On the basis of Cox regression analyses, the nomogram was constructed to estimate the probability of 30-day, 90-day, 270-day, and 1-year survival. An upper gastrointestinal bleeding-chronic liver failure-sequential organ failure assessment (UGIB-CLIF-SOFA) score was derived from the nomogram. Performance assessment and internal validation of the model were performed using Harrell's concordance index (C-index), calibration plot, and bootstrap sample procedures. UGIB-CLIF-SOFA was also compared with other prognostic models, such as CLIF-SOFA and model for end-stage liver disease, using C-indices.

RESULTS

Eight independent factors derived from Cox analysis (including bilirubin, creatinine, international normalized ratio, sodium, albumin, mean artery pressure, vasopressin used, and hematocrit decrease>10%) were assembled into the nomogram and the UGIB-CLIF-SOFA score. The calibration plots showed optimal agreement between nomogram prediction and actual observation. The C-index of the nomogram using bootstrap (0.729; 95% confidence interval: 0.689-0.766) was higher than that of the other models for predicting survival of CICGIB.

CONCLUSION

We have developed and internally validated a novel nomogram and an easy-to-use scoring system that accurately predicts the mortality probability of CICGIB on the basis of eight easy-to-obtain parameters. External validation is now warranted in future clinical studies.

Outcomes of Transcatheter Versus Surgical Aortic Valve Implantation for Aortic Stenosis in Patients With Hepatic Cirrhosis

Current risk prediction tools for transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) do not include variables associated with clinically significant hepatic disease. Accordingly, outcome data of TAVI or SAVR in patients with liver cirrhosis are limited. We sought to assess contemporary trends and outcomes of TAVI and SAVR in patients with liver cirrhosis using a national database. The Nationwide Inpatient Sample was used to identify patients with liver cirrhosis who underwent TAVI or SAVR between 2003 and 2014. Outcomes of propensity-matched groups of patients undergoing TAVI or SAVR were assessed. The reported number of TAVI and SAVR procedures in patients with liver cirrhosis increased from 376 cases in 2003 to 1,095 cases in 2014. A total of 1,766 patients with liver cirrhosis who underwent TAVI (n = 174) or SAVR (n = 1,592) were included in the analysis. In-hospital mortality was higher in patients who underwent SAVR versus TAVI (20.2% vs 8%, p <0.001). Major adverse events were also more frequent after SAVR. Propensity matching attained 2 groups of 268 patients who underwent TAVI (n = 134) or SAVR (n = 134). Following propensity matching, in-hospital mortality remained higher in the SAVR group (18.7% vs 8.2%, p = 0.018), but major adverse events were not different between the 2 groups. Hospital length of stay was longer, and nonhome disposition rates were higher in the SAVR group. In conclusion, the number of reported TAVI and SAVR in patients with liver cirrhosis and aortic stenosis increased 3-folds between 2003 and 2014. In these patients, TAVI was associated with lower in-hospital mortality when compared with SAVR.

Hospital resource intensity and cirrhosis mortality in United States

AIM

To determine whether hospital characteristics predict cirrhosis mortality and how much variation in mortality is attributable to hospital differences.

METHODS

We used data from the 2005-2011 Nationwide Inpatient Sample and the American Hospital Association Annual survey to identify hospitalizations for decompensated cirrhosis and corresponding facility characteristics. We created hospital-specific risk and reliability-adjusted odds ratios for cirrhosis mortality, and evaluated patient and facility differences based on hospital performance quintiles. We used hierarchical regression models to determine the effect of these factors on mortality.

RESULTS

Seventy-two thousand seven hundred and thirty-three cirrhosis admissions were evaluated in 805 hospitals. Hospital mean cirrhosis annual case volume was 90.4 (range 25-828). Overall hospital cirrhosis mortality rate was 8.00%. Hospital-adjusted odds ratios (aOR) for mortality ranged from 0.48 to 1.89. Patient characteristics varied significantly by hospital aOR for mortality. Length of stay averaged 6.0 ± 1.6 days, and varied significantly by hospital performance (P < 0.001). Facility level predictors of risk-adjusted mortality were higher Medicaid case-mix (OR = 1.00, P = 0.029) and LPN staffing (OR = 1.02, P = 0.015). Higher cirrhosis volume (OR = 0.99, P = 0.025) and liver transplant program status (OR = 0.83, P = 0.026) were significantly associated with survival. After adjusting for patient differences, era, and clustering effects, 15.3% of variation between hospitals was attributable to differences in facility characteristics.

CONCLUSION

Hospital characteristics account for a significant proportion of variation in cirrhosis mortality. These findings have several implications for patients, providers, and health care delivery in liver disease care and inpatient health care design.

Time trends in the health care burden and mortality of acute on chronic liver failure in the United States

Acute on chronic liver failure (ACLF) is associated with multisystem organ failure and poor prognosis in hospitalized patients with cirrhosis. We aimed to determine time trends in the epidemiology, economic burden, and mortality of ACLF in the United States. The National Inpatient Sample database was queried between 2001 and 2011. ACLF was defined as two or more extrahepatic organ failures in patients with cirrhosis. The primary outcomes were trends in hospitalizations, hospital costs, and inpatient mortality. The number of hospitalizations for cirrhosis in the United States nearly doubled from 371,000 in 2001 to 659,000 in 2011. The prevalence of ACLF among those hospitalizations increased from 1.5% (n = 5,400) to 5% (n = 32,300). The inpatient costs increased 2-fold for cirrhosis ($4.8 billion to $9.8 billion) and 5-fold ($320 million to $1.7 billion) for ACLF. In 2011, the cost per hospitalization for ACLF was 3.5-fold higher than that for cirrhosis ($53,570 versus $15,193). The in-hospital fatality rates decreased from 65% to 50% for ACLF and from 10% to 7% for cirrhosis. The organ failure trends in ACLF showed an increasing proportion of cardiovascular and cerebral and decreasing proportion of respiratory and renal failure. Age, male sex, and the number and types of organ failure were predictors of death in ACLF.

CONCLUSION

Cirrhosis and ACLF represent a substantial and increasing health and economic burden in the United States; these data highlight an urgent need for research on pathophysiological mechanisms and effective therapy as well as for education of health care providers of its importance in the care of patients with cirrhosis. (Hepatology 2016;64:2165-2172).

Rates of and Reasons for Hospital Readmissions in Patients With Cirrhosis: A Multistate Population-based Cohort Study

BACKGROUND & AIMS

There have been few population-based studies of the rates of and reasons for readmission to the hospital within 30 days among patients with cirrhosis.

METHODS

We identified all adult patients with cirrhosis who were admitted in 2011 to hospitals in California, Florida Massachusetts, Mississippi, New York, and Washington (119,722 unique index admissions with cirrhosis). We analyzed data from the State Inpatient Databases, which are longitudinal all-payer databases. Data were linked to the American Hospital Association's national survey for hospital characteristics. Outcomes included readmission to any hospital within 30 and 90 days, and the reasons for readmission.

RESULTS

The 30- and 90-day rates of readmission were 12.9% and 21.2% overall, with limited variation among states. Among patients with more than 3 complications of cirrhosis, 24.2% were readmitted within 30 days and 35.9% were readmitted within 90 days. The presence of hepatic encephalopathy was most strongly associated with readmission within 30 and 90 days (odds ratio, 1.77 for each). Almost 1 in every 4 readmissions was to a different hospital than the one from which the patient was discharged. Among patients with alcoholic liver disease and a history of a complications of cirrhosis, the 2 most common reasons for readmission were acute complications of cirrhosis (in 41.7%) and substance abuse (in 25.0%). Conversely, the most common reasons for readmission of patients with a history of complications of cirrhosis without alcoholic liver disease were acute complications (in 41.0%) and cancer complications (in 16.2%).

CONCLUSIONS

A high proportion of patients with cirrhosis are readmitted to the hospital (often to a different hospital) within 30 or 90 days; encephalopathy is most strongly associated with readmission. Reasons for readmission differ based on the cause of liver disease, and there are opportunities for quality improvement.

Quality of Care in the Cirrhotic Patient

Cirrhosis is a common, complex, chronic condition requiring care by multiple specialists in different locations. Emerging data demonstrates limitations in the quality of care these patients receive—in large part due to the problems with care coordination rather than failures of individual providers. This article will discuss approaches for measuring quality, and provide a step-by-step guide for developing quality improvement programs for this patient population.