Coordination of Care Is Associated With Survival and Health Care Utilization in a Population-Based Study of Patients With Cirrhosis

High Hospitalization Rates and Risk Factors Among Frail Patients With Cirrhosis: A 10-year Population-based Cohort Study

BACKGROUND & AIMS

Cirrhosis-related inpatient hospitalizations have increased dramatically over the past decade. We used a longitudinal dataset capturing a large metropolitan area in the United States from 2011 to 2021 to evaluate contemporary hospitalization rates and risk factors among frail patients with cirrhosis.

METHODS

We conducted a retrospective, longitudinal cohort study using the Chicago Area Patient-Centered Outcomes Research Network (CAPriCORN) database, an electronic health record repository that aggregates de-duplicated data across 7 health care systems in the Chicago metropolitan area, from 2011 to 2021. The primary outcome of our study was the rate of hospitalization encounters. Frailty was defined by the Hospital Frailty Risk Score. Hospitalization rates were reported per 100 patients per year, and a multivariable logistic regression analysis identified predictors of annual hospitalization probability.

RESULTS

During the study period, of 36,971 patients, 16,265 patients (44%) were hospitalized (compensated, 18.4%; decompensated, 81.6%). Hospitalization rates were highest in patients with decompensated cirrhosis, reaching nearly 77.3 hospitalizations/100 patients per year. Hospitalization rates among patients with compensated cirrhosis were also high (14.2 vs 77.3 hospitalization/100 patients per year), with odds of annual hospitalization 3 times (odds ratio, 3.1; 95% confidence interval, 2.9-3.4) as high among compensated patients with intermediate frailty and 5 times (odds ratio, 5.2; 95% confidence interval, 4.5-6.0) as high among those with severe frailty (compared with compensated patients with low frailty).

CONCLUSION

Compensated and decompensated cirrhosis patients with intermediate to severe frailty face a substantially increased odds of annual hospitalizations compared with those with low frailty. Future work should focus on targeted interventions to incorporate routine frailty screenings into cirrhosis care and to ultimately minimize high hospitalization rates.

Key Insights and Clinical Pearls in the Identification and Management of Cirrhosis and Its Complications

Cirrhosis is a prevalent, chronic condition with an asymptomatic compensated phase, in which patients may feel well, and a decompensated phase that begins with the onset of complications (eg hepatic encephalopathy, ascites, and/or variceal bleeding). Because patients with cirrhosis may appear healthy with normal liver enzymes, alkaline phosphatase, and serum bilirubin levels, awareness of clinical signals is important. For example, patients with thrombocytopenia should be evaluated for chronic liver disease and cirrhosis. Early recognition and management of cirrhosis-related complications (eg hepatic encephalopathy, ascites, and/or variceal bleeding) are important, given their association with hospitalization and poor prognosis (eg increased odds of short-term mortality). Hepatic encephalopathy can be the most subtle cirrhosis-related complication and associated cognitive impairment may be misdiagnosed. Because hepatic encephalopathy can be associated with hospital readmissions, reducing readmission rates after hepatic encephalopathy-related hospitalizations is critical. This includes incorporating ongoing therapy (eg rifaximin plus lactulose) in postdischarge management plans to reduce the risk of hepatic encephalopathy recurrence. Strategies that mitigate cirrhosis progression and prevent the development of cirrhosis-related complications are key to improving patient outcomes.

Inadequate Dietary Education and Poor Adherence to a High Protein, Low Sodium Diet in Cirrhosis: Mixed Methods Approach

BACKGROUND

Malnutrition in cirrhosis is associated with poor outcomes, leading to guidelines for a high protein, low sodium diet; however, there is no guidance regarding the implementation of diet education in clinical practice.

METHODS

A mixed methods study enrolled 21 patients with cirrhosis and their caregivers. Semi-structured interviews on barriers and facilitators of dietary education and adherence were conducted. Demographic and clinical data were obtained, along with quantitative measures of dietary adherence, including 24-h food recall and spot urine sodium. Combined deductive and inductive coding was used to identify qualitative themes, along with a quantitative assessment of interviews. Quantitative data was reported using descriptive statistics with frequencies, mean and confidence intervals.

RESULTS

Participants were mostly male (16/21) with a mean age 57.8 years (SE 2.8) and MELD-Na 9 (SE 1.2). 4 themes emerged: 1. More than 50% of participants and caregivers endorsed no or inadequate diet education 2. They reported mostly negative experiences with dietary adherence with largest impact on social life 3. Facilitators of adherence included the presence of household support and fear of complications of cirrhosis 4. Overwhelmingly desired non-generic handouts and information. Dietary adherence was poor with only one participant meeting protein and sodium requirements based on food recall. Four participants who adhered to < 2000 mg sodium had inadequate daily caloric intake.

CONCLUSIONS

Dietary education is inadequate, and adherence to dietary recommendations is poor in patients with cirrhosis. Future studies should use these barriers and facilitators for intervention development.

Impact of continuity of care on older adults diagnosed with mental and behavioural disorders at risk of death due to intentional self-harm: a retrospective Korean cohort study

OBJECTIVES

The aim of this study was to evaluate the impact of continuity of care on older adults diagnosed with mental and behavioural disorders who are at risk of death due to intentional self-harm.

STUDY DESIGN

This was a retrospective cohort study.

METHODS

Data from the Korean National Health Insurance Service-Elderly Cohort Database (2002-2013) were used. A total of 53,980 patients who had visited the outpatient clinic three or more times within the year following the initial diagnosis of mental and behavioural disorders were included. A generalised estimating equation model was generated to examine the impact of continuity of care (CoC) on the risk of death due to intentional self-harm among older adults with mental illnesses.

RESULTS

The risk of death due to intentional self-harm was significantly higher in those with poor CoC for mental and behavioural disorders than in those with good CoC. The risk ratio, adjusting for all covariates, was larger for the Usual Provider of Care index (adjusted risk ratio [aRR]: 1.63, 95% confidence interval [CI]: 1.25-2.12) than for the CoC index (aRR: 1.50, 95% CI: 1.18-1.90), indicating a stronger association with the concentration of contact with the most frequently visited provider.

CONCLUSIONS

Poor CoC among Korean older adults diagnosed with mental and behavioural disorders was identified as a significant risk factor for death due to intentional self-harm. The results of this study highlight the need for interventions that can prevent suicidal behaviour in older adults, such as institutionalising the usual providers of mental health care for older adults.

The Association Between Homelessness and Key Liver-Related Outcomes in Veterans With Cirrhosis

INTRODUCTION

Homelessness adversely affects patient outcomes in broad cohort studies; however, its impact on key liver-related outcomes in patients with cirrhosis is understudied. We aimed to address this knowledge gap using data from the Veterans Health Administration, a cohort disproportionately affected by homelessness.

METHODS

This was a retrospective cohort study of the Veterans Health Administration patients with incident cirrhosis diagnosis between January 2008 and February 2022. Homeless status was classified at baseline and as time-updating variable during follow-up. Inverse probability treatment weighted Cox regression was performed to evaluate the association between homelessness and outcomes of all-cause mortality, cirrhosis decompensation, and hepatocellular carcinoma.

RESULTS

A total of 117,698 patients were included in the cohort, of whom 14,243 (12.1%) were homeless at baseline. In inverse probability treatment weighted Cox regression, homelessness was associated with a 24% higher hazard of all-cause mortality (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.22-1.26, P < 0.001). However, in competing risk regression models, homelessness was associated with a reduced subhazard of decompensation (subhazard ratio 0.86, 95% CI 0.84-0.88, P < 0.001) and hepatocellular carcinoma (subhazard ratio 0.86, 95% CI 0.83-0.89, P < 0.001). In cause-specific mortality analysis, homeless patients had significantly increased non-liver-related and liver-related mortality; however, the magnitude of effect size was greater for non-liver-related mortality (csHR 1.38, 95% CI 1.35-1.40, P < 0.001).

DISCUSSION

Homelessness in veterans with cirrhosis is associated with increased all-cause mortality; however, this is likely mediated primarily through non-liver-related factors. Future studies are needed to explore drivers of mortality and improve mitigation strategies in these patients.

Nursing care for patients with cirrhosis

Cirrhosis represents a major cause of morbidity and mortality, leading to a marked impairment in the quality of life of patients and their caregivers, and resulting in a major burden on healthcare systems. Currently, in most countries, nurses still play a limited role in the care of patients with cirrhosis, which is mainly restricted to the care of patients hospitalised for acute complications of the disease. The current manuscript reviews the established and potential new and innovative roles that nurses can play in the care of patients with cirrhosis. In the hospital setting, specialised nurses should become an integral part of interprofessional teams, helping to improve the quality of care and outcomes of patients with cirrhosis. In the primary care setting, nurses should play an important role in the care of patients with compensated cirrhosis and also facilitate early diagnosis of cirrhosis in those at risk of liver diseases. This review calls for an improved global liver disease education programme for nurses and increased awareness among all healthcare providers and policymakers of the positive impacts of advanced or specialist nursing practice in this domain.

Distinct health care use patterns of patients with chronic gastrointestinal diseases

OBJECTIVES

Patients with complex chronic conditions have varying multidisciplinary care needs and utilization patterns, which limit the effectiveness of initiatives designed to improve continuity of care (COC) and reduce utilization. Our objective was to categorize patients with complex chronic conditions into distinct groups by pattern of outpatient care use and COC to tailor interventions.

STUDY DESIGN

Observational cohort study from 2014 to 2015.

METHODS

We identified patients whose 1-year hospitalization risk was in at least the 90th percentile in 2014 who had a chronic gastrointestinal disease (cirrhosis, inflammatory bowel disease, chronic pancreatitis) as case examples of complex chronic disease. We described frequency of office visits, number of outpatient providers, and 2 COC measures (usual provider of care, Bice-Boxerman COC indices) over 12 months. We used latent profile analysis, a statistical method for identifying distinct subgroups, to categorize patients based on overall, primary care, gastroenterology, and mental health continuity patterns.

RESULTS

The 26,751 veterans in the cohort had a mean (SD) of 13.3 (8.6) office visits and 7.2 (3.8) providers in 2014. Patients were classified into 5 subgroups: (1) high gastroenterology-specific COC with mental health use; (2) high gastroenterology-specific COC without mental health use; (3) high overall utilization with mental health use; (4) low overall COC with mental health use; and (5) low overall COC without mental health use. These groups varied in their sociodemographic characteristics and risk for hospitalization, emergency department use, and mortality.

CONCLUSIONS

Patients at high risk for health care utilization with specialty care needs can be grouped by varying propensity for health care continuity patterns.

Exploring provider roles, continuity, and mental models in cirrhosis care: A qualitative study

BACKGROUND: Advanced cirrhosis results in frequent emergency department visits, hospital admissions and readmissions, and a high risk of premature death. We previously identified and compared differences in the mental models of cirrhosis care held by primary and specialty care physicians and nurse practitioners that may be addressed to improve coordination and transitions in care. The aim of this paper is to further explore how challenges to continuity and coordination of care influence how health care providers adapt in their approaches to and development of mental models of cirrhosis care. METHODS: Cross-sectional formal elicitation of mental models using Cognitive Task Analysis. Purposive and chain-referral sampling took place over 6 months across Alberta for a total of 19 participants, made up of family physicians (n = 8), specialists (n = 9), and cirrhosis nurse practitioners (n = 2). RESULTS: Lack of continuity in cirrhosis care, particularly informational and management continuity, not only hinders health care providers' ability to develop rich mental models of cirrhosis care but may also determine whether they form a patient-centred or task-based mental model, and whether they develop shared mental models with other providers. CONCLUSIONS: The system barriers and gaps that prevent the level of continuity needed to coordinate care for people with cirrhosis lead providers to create and work under mental models that perpetuate those barriers, in a vicious cycle. Understanding how providers approach cirrhosis care, adapt to the challenges facing them, and develop mental models offers insights into how to break that cycle and improve continuity and coordination.

The Impact of Social Workers in Cirrhosis Care: a Systematic Review

Purpose of review

To report social workers' involvement in supporting patients with cirrhosis.

Recent findings

Six intervention studies (three published in the past 3 years) highlighed the potential role of social worker-led interventions to improve the outcomes of patients with cirrhosis. In studies of patients with alcohol-related liver disease (n = 4), social workers conducted psychosocial assessments, screened for substance use disorder and psychological distress, coordinated referrals to addiction services, and provided relapse prevention therapy. In studies including transplant recipients or candidates (n = 2), social workers focused on psychosocial interventions. In two studies (n = 1 patient with alcohol-related liver disease; n = 1 transplant recipients), social workers provided practical support (e.g., housing, transportation). Most articles provided limited information about the intervention and the role of the social worker, making comparisons of the studies difficult.

Summary

More high-quality evidence is needed to formally assess the impact of social workers in improving the outcomes of patients with cirrhosis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11938-022-00381-2.

Inpatient Gastroenterology Consultation and Outcomes of Cirrhosis-Related Hospitalizations in Two Large National Cohorts

BACKGROUND

Little is known about use of specialty care among patients admitted with cirrhosis complications.

AIMS

We sought to characterize the use and impact of gastroenterology/hepatology (GI/HEP) consultations in hospitalized patients with cirrhosis. We studied two national cohorts-the Veterans Affairs Costs and Outcomes in Liver Disease (VOCAL) and a nationally representative database of commercially insured patients (Optum Clinformatics™ DataMart).

METHODS

Cirrhosis-related admissions were classified by ICD9/10 codes for ascites, hepatic encephalopathy, alcohol-associated hepatitis, spontaneous bacterial peritonitis, or infection related. We included 20,287/222,166 index admissions from VOCAL/Optum from 2010 to 2016. Propensity-matched analyses were conducted to balance clinical characteristics. Mortality and readmission were evaluated using competing risk regression (subhazard ratios, sHR), and length of stay (LOS) was assessed using negative binomial regression.

RESULTS

GI/HEP consultations were completed among 37% and 42% patients in VOCAL and Optum, respectively. In propensity-matched analyses for VOCAL, GI/HEP consultation was associated with adjusted estimates of increased LOS (1.55 + 1.03 additional days), 90-day mortality (sHR 1.23, 95% CI 1.14-1.36), and lower 30-day readmissions (sHR 0.82, 95% CI 0.75-0.89). In Optum, inpatient consultation was associated with higher LOS (1.13 + 1.01 additional days), higher 90-day mortality (sHR 1.57, 95% CI 1.43-1.72), and higher 30-day readmission risk (sHR 1.04, 95% CI 1.02-1.05). Post-discharge primary and specialty care was higher among admissions receiving GI/HEP consultation in both cohorts.

CONCLUSIONS

Use of GI/HEP consultation for cirrhosis-related admissions was low. Patients who received consultation had higher disease severity, and consultation was not associated with lower mortality but was associated with lower 30-day readmissions in the VA cohort only.

Identifying Alcohol Use Disorder in Patients With Cirrhosis Reduces 30-Days Readmission Rate

AIMS

Readmission is frequent among patients with cirrhosis and is a complex multifactorial process. To examine the association of alcohol use disorder (AUD) and risk of readmission in patients with alcohol-associated cirrhosis.

METHODS AND RESULTS

National Readmission Dataset (2016-2017) was used to extract a retrospective cohort of 53,348 patients with primary or secondary discharge diagnosis code of alcohol-associated cirrhosis with their first admission (26,674 patients with vs. propensity matched 26,674 without a primary or secondary discharge diagnosis code of AUD). Readmission within 30-day was lower (43.9 vs. 48%, P < 0.001) among patients identified to have AUD at the time of discharge. In a conditional logistic regression model, a diagnosis of AUD was associated with 15% reduced odds of 30-day readmission, 0.85 (0.83-0.88). Furthermore, the reason for readmission among patients identified vs. not identified to have AUD was less likely to be liver disease complication. The findings remained similar in a matched cohort of patients where the AUD diagnosis at discharge was listed as one of the secondary diagnoses only.

CONCLUSION

Although, our study findings suggest that identification of AUD at the time of discharge among patients hospitalized for alcohol-associated cirrhosis reduces the risk of 30-day readmission, unavailable information on patient counseling, referral for mental health specialist and treatment received for AUD limit the causality assessment. Future studies are needed overcoming the inherent limitations of the database to establish the role of identification and treatment of AUD in reducing readmission and liver decompensation in patients with alcohol-associated cirrhosis.

Burdensome Transitions of Care for Patients with End-Stage Liver Disease and Their Caregivers

BACKGROUND

Patients with end-stage liver disease (ESLD) experience frequent readmissions; however, studies focused on patients' and caregivers' perceptions of their transitional care experiences to identify root causes of burdensome transitions of care are lacking.

AIM

To explore the transitional care experiences of patients with ESLD and their caregivers in order to identify their supportive care needs.

METHODS

We conducted interviews with 15 patients with ESLD and 14 informal caregivers. We used semi-structured interview guides to explore their experiences since the diagnosis of ESLD including their care transitions. Two raters coded interviews independently (κ = 0.95) using template analysis.

RESULTS

Participants reported feeling unprepared to manage their informational, psychosocial, and practical care needs as they transitioned from hospital to home after the diagnosis of ESLD. Delay in the timely receipt of supportive care services addressing these care needs resulted in hospital readmissions, emotional distress, caregiver burnout, reduced work capacity, and financial hardship. Participants shared the following resources that they perceived would improve their quality of care: (1) discharge checklist, (2) online resources, (3) mental health support, (4) caregiver support and training, and (5) financial navigation.

CONCLUSION

Transitional care models that attend to the informational, psychosocial, and practical domains of care are needed to better support patients with ESLD and their caregivers at the time of diagnosis and beyond. Without attending to the multidimensional care needs of newly diagnosed patients with ESLD and their caregivers, they are at risk of burdensome transitions of care, high healthcare utilization, and poor health-related quality of life.

Hepatocellular Carcinoma Screening Process Failures in Patients with Cirrhosis

Professional society guidelines recommend semiannual screening for hepatocellular carcinoma (HCC) in patients with cirrhosis; however, studies suggest underuse of screening in clinical practice. Our study's aim was to characterize reasons for HCC screening underuse among patients with cirrhosis. We conducted a retrospective cohort study of patients with cirrhosis diagnosed with HCC in two large health systems from 2011 to 2019. We classified screening receipt as consistent, inconsistent, or no screening in the year before HCC diagnosis. We categorized reasons for screening underuse as a potential failure at each of the following steps required for HCC screening: receipt of regular outpatient care, recognition of liver disease, recognition of cirrhosis, screening orders in patients with cirrhosis, and adherence to screening ultrasound appointments. Among 1,014 patients with cirrhosis with HCC, only 377 (37.2%) had regular outpatient care in the year before HCC presentation. Consistent screening was observed in 93 (24.7%) patients under regular outpatient care, whereas 161 (42.7%) had inconsistent screening and 123 (32.6%) no screening. We found screening underuse related to failures at each step in the screening process, although nearly half (49.6%) were due to lack of screening orders in patients with known cirrhosis. Conclusion: The most common reasons for HCC screening underuse in patients with cirrhosis are lack of regular outpatient care and lack of screening orders in those with known cirrhosis, highlighting the need for interventions targeted at these steps to increase HCC screening use.

Eliciting and Understanding Primary Care and Specialist Mental Models of Cirrhosis Care: A Cognitive Task Analysis Study

BACKGROUND

Gaps in coordination and transitions of care for liver cirrhosis contribute to high rates of hospital readmissions and inadequate quality of care. Understanding the differences in the mental models held by specialty and primary care physicians may help to identify the root causes of problems in the coordination of cirrhosis care.

AIM

To compare and identify differences in the mental models of cirrhosis care held by primary and specialty care physicians and nurse practitioners that may be addressed to improve coordination and transitions.

METHODS

Cross-sectional formal elicitation of mental models using Cognitive Task Analysis. Purposive and chain-referral sampling to select family physicians (n = 8), specialists (n = 9), and cirrhosis-dedicated nurse practitioners (n = 2) across Alberta.

RESULTS

Family physicians do not maintain rich mental models of cirrhosis care. They see cirrhosis patients relatively infrequently, rebuilding their mental models when required (knowledge on demand). They have reactive and patient-need-focused, rather than proactive and system-of-care, mental models. Specialists' mental models are rich but vary widely between patient-centered and task-centered and in the degree to which they incorporate responsibility for addressing system gaps. Nurse practitioners hold patient-centered mental models like specialists but take responsibility for addressing gaps in the system.

CONCLUSIONS

Improving the coordination of cirrhosis care will require infrastructure to design care pathways and work processes that will support family physicians' knowledge-on-demand needs, facilitate primary care-specialist relationships, and deliberately work toward building a shared mental model of responsibilities for addressing medical care and social determinants of health.

The COVID-19 pandemic will have a long-lasting impact on the quality of cirrhosis care

The coronavirus disease 2019 (COVID-19) pandemic has shattered the meticulously developed processes by which we delivered quality care for patients with cirrhosis. Care has been transformed by the crisis, but enduring lessons have been learned. In this article, we review how COVID-19 will impact cirrhosis care. We describe how this impact unfolds over 3 waves; i) an intense period with prioritized high-acuity care with delayed elective procedures and routine care during physical distancing, ii) a challenging 'return to normal' following the end of physical distancing, with increased emergent decompensations, morbidity, and systems of care overwhelmed by the backlog of deferred care, and iii) a protracted period of suboptimal outcomes characterized by missed diagnoses, progressive disease and loss to follow-up. We outline the concrete steps required to preserve the quality of care provided to patients with cirrhosis. This includes an intensification of the preventative care provided to patients with compensated cirrhosis, proactive chronic disease management, robust telehealth programs, and a reorganization of care delivery to provide a full service of care with flexible clinical staffing. Managing the pandemic of a serious chronic disease in the midst of a global infectious pandemic is challenging. It is incumbent upon the entire healthcare establishment to be strong enough to weather the storm. Change is needed.