Identifying cirrhosis, decompensated cirrhosis and hepatocellular carcinoma in health administrative data: A validation study

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.

Systemic Therapies for Psoriatic Disease and Serious Infections in Older Adults

Importance

Systemic treatments for psoriatic disease affect the immune system and may increase infection risk. Older adults are at high risk for infection, and the relative safety of systemic treatments for them is unknown.

Objective

To evaluate the association of systemic treatments for psoriatic disease with rates of serious infection among older adults.

Design, Setting, and Participants

This cohort study used linked population-based health administrative data from 2002 to 2021 in Ontario, Canada. Participants included Ontario residents 66 years and older with psoriatic disease who were dispensed their first systemic medication between April 1, 2002, and December 31, 2020. Data were analyzed between November 2021 and August 2024.

Exposure

Time-varying use of systemic medications categorized as (1) methotrexate; (2) other older systemic medications; (3) anti-tumor necrosis factor (anti-TNF) biologics; (4) other biologics (targeting interleukin [IL]-12, IL-23, and IL-17); and (5) tofacitinib.

Main Outcomes and Measures

The main outcome was time to serious infection, defined as hospitalization for any infectious cause occurring up to March 2021. Multivariable Andersen-Gill recurrent event regression was used to estimate the association between each medication category and serious infection rates. The relative rates (RRs) of serious infection with 95% CIs for time actively using each medication category vs time not using that medication category were calculated.

Results

Of 11 641 new users of systemic therapy, 6114 (53%) were female, and the median (IQR) age was 71 (68-76) years. There were 1967 serious infections during a median (IQR) of 4.8 (2.3-8.4) years of follow-up. There were 2.7 serious infections per 100 person-years using methotrexate, 2.5 per 100 person-years using other older systemic drugs, 2.2 per 100 person-years using anti-TNF biologics, 1.4 per 100 person-years using other biologics, and 8.9 per 100 person-years using tofacitinib. In the multivariable-adjusted model, methotrexate (RR, 0.95 [95% CI, 0.85-1.07]), other older systemic medications (RR, 0.92 [95% CI, 0.79-1.07]), and anti-TNF biologics (RR, 0.87 [95% CI, 0.69-1.10]) were not associated with serious infection compared to person-time not using those respective medications. Other biologics (RR, 0.65 [95% CI, 0.48-0.88]) were associated with lower rates of serious infection, whereas tofacitinib (RR, 2.89 [95% CI, 1.14-7.34]) was associated with higher rates of serious infection.

Conclusions and Relevance

In this cohort study, biologics targeting IL-12, IL-23, or IL-17 were associated with a lower rate of serious infection among older adults with psoriatic disease. These biologics may have important safety benefits for older adults with higher infection risk.

Identifying emergency presentations of chronic liver disease using routinely collected administrative hospital data

Background & Aims

Patients with chronic liver disease (CLD) are often first diagnosed during an emergency hospital admission, when their disease is advanced and survival is very poor. Evaluating their care and outcomes is a clinical research priority, but methods are needed to identify them in routine data.

Methods

We analysed national administrative hospital data in the English National Health Service. We used existing literature, expert clinical opinion, and data-driven approaches to develop three algorithms to identify first-time emergency admissions in 2017-2018. We validated these in 2018-2019 data by assessing the distributions of predictive factors, treatments, and outcomes associated with CLD in the patients captured by each algorithm.

Results

Our most specific algorithm identified 10,719 patients with CLD who first presented through emergency hospital admission from April 2018 to March 2019. Alternative, less specific or more sensitive algorithms identified 12,867 or 20,828 patient, respectively. Additional patients identified by more sensitive algorithms had more comorbidities, were less likely to die from CLD, and were less likely to be treated by a gastroenterologist or hepatologist.

Conclusions

Three algorithms are provided that successfully identified patients in administrative hospital data with a first emergency admission for CLD. The choice of algorithm should reflect the aims of the research.

Impact and implications

The more and most sensitive algorithms are recommended in studies when it is important to minimise the number of patients with CLD erroneously missed from the cohort, such as studies measuring disease burden. The most specific algorithms might miss patients whose primary reason for admission is recorded as a sign, symptom, or complication of CLD, but is recommended when the interest is strictly in patients whose primary reason for emergency admission is CLD.

The association between cirrhosis and outcomes among female patients undergoing surgery for breast cancer in Ontario: a population-based study

BACKGROUND

The association between cirrhosis and post-operative breast cancer outcomes has not been explored. We evaluated the association between cirrhosis and surgical outcomes in female patients with breast cancer.

METHODS

We performed a retrospective population-based cohort study of female patients undergoing surgery for breast cancer between 2007 and 2018 using health administrative data from Ontario, Canada. Patients were stratified by cirrhosis status. Overall survival (OS) was described using the Kaplan-Meier method and the association between cirrhosis and long-term cancer-specific mortality (CSM) was evaluated using adjusted competing risks regression and subdistribution hazard ratios (sHR).

RESULTS

A total of 902 patients with breast cancer and cirrhosis were compared to 81,514 patients with breast cancer without cirrhosis. The median age at diagnosis was 65 years vs 61 years in patients with and without cirrhosis, respectively (p < .001). The most common etiologies of cirrhosis were metabolic dysfunction-associated steatotic liver disease (n = 595, 66%) and alcohol-associated (n = 143, 16%) liver disease. The median model for end-stage liver disease sodium score was 8 (IQR 6-11, n = 215). Furthermore, cirrhosis was associated with a twofold higher 90-day rate of post-operative mortality (RR 2.82; 95% CI 1.49-5.33). OS was lower in patients with cirrhosis (HR 1.41, 95% CI 1.26-1.58); however, there was no association with CSM (sHR 1.11, 95% CI 0.93-1.32).

CONCLUSION

This large population-based study demonstrates that patients with cirrhosis have lower OS compared to those without cirrhosis; however, there is no difference in CSM. Their outcomes remain favorable, and they should be considered for curative-intent therapies.

Clinical impact of Choosing Wisely Canada hepatology recommendations: an interrupted time-series analysis using data from GEMINI

INTRODUCTION

Choosing Wisely Canada (CWC) Hepatology published recommendations in 2017 aiming to reduce low-value care and testing, including serum ammonia tests for hepatic encephalopathy (HE) and transfusion of blood products for minor invasive procedures. We explored the impact of these recommendations in reducing rates of low-value testing and care.

METHODS

We included all medicine inpatients from 23 hospitals in Ontario, Canada from the GEMINI database between April 2015 and March 2022. Weekly rates of low-value care were measured before and after the CWC Hepatology recommendations (19 July 2017). Interrupted time-series regression models were used to assess time trends for rates of low-value care. Subgroup analysis was completed on hospitalisations under hepatology or gastroenterology services.

RESULTS

Of 59 155 patients identified with liver disease, 17 906 developed HE and 11 676 cirrhosis patients underwent minor invasive procedures. In the HE cohort, there was no immediate change in the rate of ammonia tests with recommendations, but the overall rate decreased by 0.002 tests per hospitalisation per week (95% CI -0.00413 to -0.000009). With recommendations, we observed an increase in the rate of 0.242 (95% CI 0.010 to 0.474 transfusions/hospitalisation), but no significant difference in the rate change nor in the rate of platelet and vitamin K transfusions. There was no significant change in the rate of platelet and vitamin K transfusions. Hospitalisations under hepatology or gastroenterology services also did not have a change in rates of low-value care overall, except for ammonia tests where the rate decreased by 0.012 tests (95% CI -0.0177 to -0.00626 tests/hospitalisation) per week after recommendations.

CONCLUSIONS

The CWC recommendations were associated with a reduction in the rate of serum ammonia tests, but not with transfusion of blood products. Thus, there remains an opportunity to reduce low-value care and application of clinical guidelines.

Bleeding and New Malignancy Diagnoses After Anticoagulation for Atrial Fibrillation: A Population-Based Cohort Study

BACKGROUND

Bleeding after starting anticoagulation for atrial fibrillation (AF) may be the first sign of malignancy, especially in elderly individuals. There are no recommendations to guide investigations for malignancy after new-onset bleeding after anticoagulation for AF. Our objective was to determine the association of bleeding after starting oral anticoagulation for AF with new diagnoses of malignancy in a population-wide sample.

METHODS

We conducted a population-based cohort study using linked administrative data sets of people ≥66 years of age who newly initiated warfarin or direct oral anticoagulants after diagnosis with AF between 2008 and 2022. Follow-up was 2 years after starting anticoagulation. We excluded patients with valvular disease, chronic dialysis, venous thromboembolism, previous cancer, or previously documented bleeding. Bleeding was identified from hospital/emergency department discharge records and physician billings, then handled as a time-varying covariate in cause-specific regression models while adjusting for baseline characteristics. The primary outcome was incident malignancy. We also determined the site of origin of the malignancy and the stage at diagnosis if indicated in the Ontario Cancer Registry. Analyses were repeated while limiting the exposure to specific bleeding sites.

RESULTS

Among 119 480 people (mean age, 77.4 years; 52% men) who started anticoagulants, 26 037 (21.8%) had documented bleeding, and 5800 (4.9%) were diagnosed with malignancy within the next 2 years. Bleeding was associated with a higher hazard of cancer diagnosis with a hazard ratio (HR) of 4.0 (95% CI, 3.8-4.3). The HRs for any malignancy were 5.0 (95% CI, 4.6-5.5) for gastrointestinal, 5.0 (95% CI, 4.4-5.7) for genitourinary, 4.0 (95% CI, 3.5-4.6) for respiratory, 1.8 (95% CI, 1.4-2.2) for intracranial, and 1.5 (95% CI, 1.2-2.0) for nasopharyngeal bleeds. The HRs were substantially higher for cancers concordant with the bleeding site (gastrointestinal, 15.4; genitourinary, 11.8; respiratory, 10.1). Cancers were diagnosed at an earlier stage after bleeding (27.6% stage 4 after bleeding versus 31.3% without bleeding; P=0.029).

CONCLUSIONS

In anticoagulated patients with AF, bleeding was strongly associated with new cancer diagnoses. Antecedent bleeding was associated with cancer diagnosis at an earlier stage. This highlights the importance of timely investigations in patients with bleeding after anticoagulation for AF, rather than attributing bleeding as an expected adverse effect.

Primary sclerosing cholangitis-inflammatory bowel disease: Epidemiology, mortality, and impact of diagnostic sequence

Background & Aims

Primary sclerosing cholangitis (PSC) carries significant morbidity and mortality compared with inflammatory bowel disease (IBD). We characterized epidemiology trends and outcomes in those with PSC-IBD and IBD, paying particular attention to the impact of PSC-IBD diagnostic sequence on outcomes.

Methods

Incidence and prevalence of PSC-IBD and IBD (2002-2018) were evaluated using validated health administrative data-derived cohorts from Ontario, Canada (population ∼15 million). Transplant and death outcomes were assessed, with PSC-IBD diagnostic sequence as the exposure of interest.

Results

Incidence of PSC-IBD and IBD was 0.46 and 24.6/100,000 person-years (PYs) respectively, whereas prevalence was 5.53 and 588/100,000 PY respectively. Incidence/prevalence of PSC-IBD increased over time, unlike for IBD. Age at IBD diagnosis was earlier among those with PSC-IBD compared with those with IBD alone. Higher socioeconomic status associated with high PSC-IBD incidence rates and fastest incidence rise. Those diagnosed with IBD before PSC had higher risk of transplant/death compared with PSC before IBD (hazard ratio [HR] 1.34, 95% CI 1.02-1.75), driven by an increased risk of death (HR 2.73, 95% CI 1.68-4.45). PSC-IBD had a 4.5-fold greater risk of transplant/death compared with IBD alone. Liver-related and luminal gastrointestinal disease, particularly hepatopancreatobiliary malignancy, were predominant causes of death among those with PSC-IBD, while cardiovascular and respiratory diseases were predominant among those with IBD.

Conclusions

Population-level data support distinct epidemiological patterns among people living with PSC-IBD compared with IBD, including a higher socioeconomic status and worse outcomes in those found to have IBD before PSC.

Impact and implications

Individuals with primary sclerosing cholangitis (PSC) face increased morbidity and mortality compared with the general population and those with inflammatory bowel disease (IBD); yet, most individuals with PSC are found to have concomitant IBD during their lifetime. This study describes the distinctive epidemiological differences and mortality trends at the population level between PSC-IBD and IBD. While PSC-IBD remains a rare condition, diagnoses are on the rise (particularly among higher socioeconomic status populations), with most patients being diagnosed with IBD before PSC; this group also experienced higher mortality post-PSC diagnosis compared with those diagnosed with PSC first, with a large proportion of deaths caused by liver- and gut-related causes. Practical applications of these findings include further studies to evaluate whether earlier identification of PSC-IBD affects disease outcomes, as well as educating patients, clinicians, and policymakers on the importance of recognizing PSC-IBD as a distinct entity from IBD alone.

Use of virtual care near the end of life before and during the COVID-19 pandemic: A population-based cohort study

BACKGROUND AND AIMS

The expanded use of virtual care may worsen pre-existing disparities in use and delivery of end-of-life care among certain groups of people. We measured the use of virtual care in the last three months of life before and after the introduction of virtual care fee codes that funded care delivery at the start of COVID-19 on March 14, 2020, and identified changes in the characteristics of people using it.

METHODS

We used linked clinical and administrative datasets to study use of virtual care in the last three months of life among 411,564 adults who died between January 25, 2018, and November 30, 2022. Modified Poisson regression was used to measure the association of the use of virtual care in the last three months of life with the pandemic study period and its association with each person- and physician-level factor.

RESULTS

14,261 people (8%) used virtual care in the last three months of life before the pandemic, and 161,000 people (69%) used it during the pandemic (relative risk [RR] 8.76; 95% CI 8.48-9.05). Several individual patient characteristics were associated with statistically significant increases in the use of virtual care after March 14, 2020 (following the introduction of virtual care fee codes), compared to before such as among older adults, ethnic minorities, multiple chronic comorbid health conditions and higher frailty groups.

CONCLUSIONS

The introduction of new fee codes broadening technology and funding for end-of-life care at the start of pandemic combined with pandemic-related effects was associated with a substantial increase in the use of virtual care near the end of life among certain groups and a general leveling of pre-existing disparities in its use. Virtual end-of-life care delivery may strengthen person-centredness for individuals with limited ability to attend in-person appointments and by providers who may not have previously engaged in such care.

Comparing the cost of cirrhosis to other common chronic diseases: A longitudinal study in a large national insurance database

BACKGROUND AND AIMS

Cirrhosis prevalence is increasing, yet costs associated with its chronic, complex care are poorly understood. The aim was to characterize the costs of care for patients with cirrhosis and compare them to other chronic diseases such as heart failure (HF) and chronic obstructive pulmonary disease (COPD), for which the public health burden is better recognized.

APPROACH AND RESULTS

Patients enrolled in Medicare Advantage plans from a large national insurer between 2011 and 2020 with cirrhosis, HF, and COPD were identified by ICD-9/-10 codes. Costs (USD) of care were calculated per patient-month and included inpatient medical, emergency medical, pharmacy, and other costs. In all, 93,308 patients with cirrhosis, 355,520 patients with HF, and 318,949 patients with COPD were analyzed. Patients with cirrhosis, HF, and COPD had a mean (SD) age of 69.6 (9.5), 75.9 (9.7), and 72.9 (9.8) years, respectively. The most frequent etiologies were metabolic dysfunction-associated steatohepatitis (37.7%) and alcohol-associated cirrhosis (22.1%). The total monthly cost of care for patients with cirrhosis, HF, and COPD was $3032.00, $2491.60, and $1955.60 respectively. The cost for patients with cirrhosis exceeded that for HF by $540.40 (21.7% higher) and COPD by $1076.30 (55.0% higher). The monthly cost of care for decompensated cirrhosis was $3969.30, which was 59.3% ($1477.70) higher than for HF and 103.0% ($1,955.60) higher than for COPD.

CONCLUSIONS

The cost of care for cirrhosis is high, significantly higher than HF and COPD. Interventions directed at optimizing care to prevent progression to cirrhosis and decompensation are likely to alleviate this public health burden.

Epidemiology and Outcomes of Alcohol-Associated Hepatitis in Adolescents and Young Adults

Importance

Alcohol-associated hepatitis (AH) has high mortality, and rates are increasing among adolescents and young adults (AYAs).

Objective

To define the sex-specific epidemiology of AH in AYAs and the association between female sex and liver-related outcomes after a first presentation of AH.

Design, Setting, and Participants

A retrospective, population-based cohort study of routinely collected health care data held at ICES from Ontario, Canada, was conducted. Data on AYAs (age, 13-39 years) with first presentation of AH without a history of cirrhosis and/or decompensation from January 1 to December 31, 2022, were included in the analysis.

Exposures

Study year and female sex.

Main Outcome and Measures

Overall and sex-specific yearly rates of AH were compared using Poisson regression and rate ratios (RRs). Associations between female sex and incident cirrhosis and/or decompensation were evaluated using competing risks regression, and liver-related mortality by sex was evaluated with cumulative incidence functions.

Results

A total of 3340 AYAs with AH were identified. Median age was 33 (IQR, 28-36) years, and the population included 1190 (36%) females and 2150 (64%) males. Rates of AH increased by 8% per year (RR, 1.08; 95% CI, 1.07-1.09), with yearly rates increasing faster among females (RR, 1.11; 95% CI, 1.09-1.12) than males (RR, 1.07; 95% CI, 1.06-1.07). A total of 2374 individuals (71%) were alive without cirrhosis 6 months after AH presentation. Of those, 527 (22%) developed incident cirrhosis and/or decompensation after a median follow-up of 4 (IQR, 2-9) years (37% females vs 29% males; P < .001). After adjustment, female sex was associated with a 47% higher subhazard of cirrhosis and/or decompensation compared with male sex (38%) (subhazard, 1.47; 95% CI, 1.23-1.76; P < .001). The cumulative incidence of liver-related mortality at 10 years was higher among females (11.0%; 95% CI, 8.3%-14.2%) than males (6.9%; 95% CI, 5.4%-8.6%) (P = .01).

Conclusions and Relevance

Over the past 2 decades, the rates of AH among AYAs increased significantly, with the greatest increase observed among females. The findings of this study suggest sex-specific interventions to prevent the development of AH and the progression to cirrhosis after an episode of AH are needed.

Health service utilization, substance use treatment response, and death in patients with opioid use disorder and comorbid hepatitis C findings from prospective cohort study with administrative database linkage

BACKGROUND

Among patients with opioid use disorder (OUD), high rates of overdose and death have been reported in subgroups with Hepatitis C Virus (HCV). Evidence on the comorbid effect of HCV on clinical and substance use trajectories has been limited by small sample sizes, short follow-up, and heavy reliance on administrative data which lacks granularity on important prognostic factors. Additionally, few studies include populations on substance use treatment.

AIM

To establish the impact of HCV exposure (antibody positivity) on health care utilization patterns, substance use treatment response, and death in a cohort of patients with OUD on opioid agonist therapy (OAT).

METHODS

This multi-center prospective cohort study recruited adult patients with OUD on OAT from 57 substance use treatment centers in Ontario, Canada. The study collected substance use outcomes, and classified patients with ≥50 % positive opioid urine screens over one year of follow-up as having poor treatment response. Additional data obtained via linkage with ICES administrative databases evaluated the relationship between HCV status, healthcare service utilization, and death over 3 years of follow-up. Multiple logistic regression models established the adjusted impact of HCV on various outcomes.

RESULTS

Among recruited participants (n = 3430), 44.10 % were female with a mean age of 38.64 years (Standard deviation: 10.96). HCV was prevalent in 10.6 % of the cohort (n = 365). Methadone was used most often (83.9 %, n = 2876), followed by sublingual buprenorphine (16.2 %, n = 554). Over the three-year follow-up, 5.3 % of patients died (n = 181). Unadjusted results reveal rates of hospitalization (all-cause, mental-health related, critical care) and emergency department visits (mental health-related), were significantly higher among HCV patients. Associations diminished in adjusted models. Active injection drug use exhibited the highest predictive risk for all outcomes.

CONCLUSION

A high degree of acute physical and mental illness and its resulting health service utilization burden is concentrated among patients with OUD and comorbid HCV. Future research should explore the role for targeted interventions and how best to implement integrated healthcare models to better address the complex health needs of HCV populations who inject drugs.

Trends in the incidence and prevalence of cirrhosis in Manitoba, Canada: A population-based study (2010-2019)

INTRODUCTION AND OBJECTIVES

The burden of chronic liver disease and cirrhosis continues to increase in North America. We sought to estimate the incidence and prevalence of cirrhosis in Manitoba, Canada over time and assess changes in trends between 2010-2019.

MATERIAL AND METHODS

We performed a population-based study using Manitoba administrative health care data, and two validated case-finding algorithms. Annual incidence and prevalence rates were estimated using a generalized linear model with generalized estimating equations, adjusting for age and sex. Changes in estimates were tested using linear trend regression models.

RESULTS

Two algorithms estimated the number of prevalent cirrhosis to be 16,140 and 29,943 respectively. The age- and sex-adjusted incidence rates increased over the study (from 149 to 264 cases per 100,000 population in 2010, to 177 to 388 cases per 100,000 population in 2019). Cirrhosis incidence increased annually by 2-6 %, with the largest increase (6-8 % 95 % CI 7-9 %, p <0.0001) in those aged 18-44 years. Irrespective of the algorithm used, females consistently exhibited higher cirrhosis incidence and prevalence compared to males over time (P <0.0001). Prevalence demonstrated an upward trend among all age groups over time for both algorithms (P < 0.0001).

CONCLUSIONS

This population-based study highlights concerning temporal trends in cirrhosis, characterized by rising annual incidence and prevalence estimates, particularly among young adults and females. These findings underscore the urgent need for comprehensive strategies that encompass prevention, early detection, and the delivery of high-quality healthcare and public health initiatives to effectively tackle this escalating health burden.

Impact of COVID-19 pandemic on hepatocellular carcinoma surveillance in British Columbia, Canada: An interrupted time series study

We assessed the impact of the COVID-19 pandemic on hepatocellular carcinoma (HCC) surveillance among individuals with HCV diagnosed with cirrhosis in British Columbia (BC), Canada. We used data from the British Columbia Hepatitis Testers Cohort (BC-HTC), including all individuals in the province tested for or diagnosed with HCV from 1 January 1990 to 31 December 2015, to assess HCC surveillance. To analyse the impact of the pandemic on HCC surveillance, we used pre-policy (January 2018 to February 2020) and post-policy (March to December 2020) periods. We conducted interrupted time series (ITS) analysis using a segmented linear regression model and included first-order autocorrelation terms. From January 2018 to December 2020, 6546 HCC screenings were performed among 3429 individuals with HCV and cirrhosis. The ITS model showed an immediate decrease in HCC screenings in March and April 2020, with an overall level change of -71 screenings [95% confidence interval (CI): -105.9, -18.9]. We observed a significant decrease in HCC surveillance among study participants, regardless of HCV treatment status and age group, with the sharpest decrease among untreated HCV patients. A recovery of HCC surveillance followed this decline, reflected in an increasing trend of 7.8 screenings (95% CI: 0.6, 13.5) per month during the post-policy period. There was no level or trend change in the number of individuals diagnosed with HCC. We observed a sharp decline in HCC surveillance among people living with HCV and cirrhosis in BC following the COVID-19 pandemic control measures. HCC screening returned to pre-pandemic levels by mid-2020.

Trends in the burden of hospitalised patients with cirrhosis in Switzerland: a cross-sectional study of cirrhosis-related hospitalisations between 1998 and 2020

OBJECTIVE

Liver cirrhosis is an increasing cause of morbidity and mortality worldwide with a heavy load on healthcare systems. We analysed the trends in hospitalisations for cirrhosis in Switzerland.

DESIGN

Cross-sectional study.

SETTING

Large nationwide inpatient database, years between 1998 and 2020.

PARTICIPANTS

Hospitalisations for cirrhosis of adult patients were selected.

MAIN OUTCOMES AND MEASURES

Hospitalisations with either a primary diagnosis of cirrhosis or a cirrhosis-related primary diagnosis with a mandatory presence of cirrhosis as a secondary diagnosis were considered following the 10th revision of the International Statistical Classification of Diseases and Related Health Problems codes. Trends in demographic and clinical characteristics, in-hospital mortality and length of stay were analysed. Causes and costs of cirrhosis-related hospitalisations were available from 2012 onwards.

RESULTS

Cirrhosis-related hospitalisations increased from 1631 in 1998 to 4052 in 2020. Of the patients, 68.7% were men. Alcohol-related liver disease was the leading cause, increasing from 44.1% (95% CI, 42.4% to 45.9%) in 2012 to 47.9% (95% CI, 46.4% to 49.5%) in 2020. Assessed by exclusion of other coded causes, non-alcoholic fatty liver disease was the second cause at 42.7% (95% CI, 41.2% to 44.3%) in 2020. Hepatitis C virus-related cirrhosis decreased from 12.3% (95% CI, 11.2% to 13.5%) in 2012 to 3.2% (95% CI, 2.7% to 3.8%) in 2020. Median length of stay decreased from 11 to 8 days. Hospitalisations with an intensive care unit stay increased from 9.8% (95% CI, 8.4% to 11.4%) to 15.6% (95% CI, 14.5% to 16.8%). In-hospital mortality decreased from 12.1% (95% CI, 10.5% to 13.8%) to 9.7% (95% CI, 8.8% to 10.7%). Total costs increased from 54.4 million US$ (51.4 million €) in 2012 to 92.6 million US$ (87.5 million €) in 2020.

CONCLUSIONS

Cirrhosis-related hospitalisations and related costs increased in Switzerland from 1998 to 2020 but in-hospital mortality decreased. Alcohol-related liver disease and non-alcoholic fatty liver disease were the most prevalent and preventable aetiologies of cirrhosis-related hospitalisations.

Validating new coding algorithms to improve identification of alcohol-associated and nonalcohol-associated cirrhosis hospitalizations in administrative databases

BACKGROUND

Alcohol (AC) and nonalcohol-associated cirrhosis (NAC) epidemiology studies are limited by available case definitions. We compared the diagnostic accuracy of previous and newly developed case definitions to identify AC and NAC hospitalizations.

METHODS

We randomly selected 700 hospitalizations from the 2008 to 2022 Canadian Discharge Abstract Database with alcohol-associated and cirrhosis-related International Classification of Diseases 10th revision codes. We compared standard approaches for AC (ie, AC code alone and alcohol use disorder and nonspecific cirrhosis codes together) and NAC (ie, NAC codes alone) case identification to newly developed approaches that combine standard approaches with new code combinations. Using electronic medical record review as the reference standard, we calculated case definition positive and negative predictive values, sensitivity, specificity, and AUROC.

RESULTS

Electronic medical records were available for 671 admissions; 252 had confirmed AC and 195 NAC. Compared to previous AC definitions, the newly developed algorithm selecting for the AC code, alcohol-associated hepatic failure code, or alcohol use disorder code with a decompensated cirrhosis-related condition or NAC code provided the best overall positive predictive value (91%, 95% CI: 87-95), negative predictive value (89%, CI: 86-92), sensitivity (81%, CI: 76-86), specificity (96%, CI: 93-97), and AUROC (0.88, CI: 0.85-0.91). Comparing all evaluated NAC definitions, high sensitivity (92%, CI: 87-95), specificity (82%, CI: 79-86), negative predictive value (96%, CI: 94-98), AUROC (0.87, CI: 0.84-0.90), but relatively low positive predictive value (68%, CI: 62-74) were obtained by excluding alcohol use disorder codes and using either a NAC code in any diagnostic position or a primary diagnostic code for HCC, unspecified/chronic hepatic failure, esophageal varices without bleeding, or hepatorenal syndrome.

CONCLUSIONS

New case definitions show enhanced accuracy for identifying hospitalizations for AC and NAC compared to previously used approaches.

Hepatocellular Carcinoma in Metabolic Dysfunction-Associated Steatotic Liver Disease

Importance

In the US, hepatocellular carcinoma (HCC) has been the most rapidly increasing cancer since 1980, and metabolic dysfunction-associated steatotic liver disease (MASLD) is expected to soon become the leading cause of HCC.

Objective

To develop a prediction model for HCC incidence in a cohort of patients with MASLD.

Design, Setting, and Participants

This prognostic study was conducted among patients aged at least 18 years with MASLD, identified using diagnosis of MASLD using International Classification of Diseases, Ninth Revision (ICD-9) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis codes; natural language processing of radiology imaging report text, which identified patients who had imaging evidence of MASLD but had not been formally diagnosed; or the Dallas Steatosis Index, a risk equation that identifies individuals likely to have MASLD with good precision. Patients were enrolled from Kaiser Permanente Northern California, an integrated health delivery system with more than 4.6 million members, with study entry between January 2009 and December 2018, and follow-up until HCC development, death, or study termination on September 30, 2021. Statistical analysis was performed during February 2023 and January 2024.

Exposure

Data were extracted from the electronic health record and included 18 routinely measured factors associated with MASLD.

Main Outcome and Measures

The cohort was split (70:30) into derivation and internal validation sets; extreme gradient boosting was used to model HCC incidence. HCC risk was divided into 3 categories, with the cumulative estimated probability of HCC 0.05% or less classified as low risk; 0.05% to 0.09%, medium risk; and 0.1% or greater, high risk.

Results

A total of 1 811 461 patients (median age [IQR] at baseline, 52 [41-63] years; 982 300 [54.2%] female) participated in the study. During a median (range) follow-up of 9.3 (5.8-12.4) years, 946 patients developed HCC, for an incidence rate of 0.065 per 1000 person-years. The model achieved an area under the curve of 0.899 (95% CI, 0.882-0.916) in the validation set. At the medium-risk threshold, the model had a sensitivity of 87.5%, specificity of 81.4%, and a number needed to screen of 406. At the high-risk threshold, the model had a sensitivity of 78.4%, a specificity of 90.1%, and a number needed to screen of 241.

Conclusions and Relevance

This prognostic study of more than 1.8 million patients with MASLD used electronic health record data to develop a prediction model to discriminate between individuals with and without incident HCC with good precision. This model could serve as a starting point to identify patients with MASLD who may need intervention and/or HCC surveillance.

COVID-19 hospitalization, mortality and pre-mature mortality by a history of immigration in Ontario, Canada: a population-based cohort study

Background

Immigrants in high-income countries experienced inequities in COVID-19 severe outcomes. We examined hospitalization and death throughout the pandemic, and change during the vaccine era, in Ontario, Canada.

Methods

We conducted a population-based study using linked immigration and health data, following two cohorts for 20 months from January 1, 2020 (pre-vaccine) and September 1, 2021 (vaccine era). We used multivariable Poisson generalized estimating equation regression to estimate adjusted rate ratios (aRR) with 95% confidence intervals (CI), accounting for age, sex and co-morbidities. We calculated age-standardized years of life lost (ASYRs) rates by immigrant category.

Findings

Of 11,692,387 community-dwelling adults in the pre-vaccine era cohort and 11,878,304 community-dwelling adults in the vaccine era cohort, 21.6% and 21.4% of adults in each era respectively were immigrants. Females accounted for 57.9% and 57.8% of sponsored family, and 68.4% and 67.6% of economic caregivers, in each era respectively. Compared to other Ontarians in the pre-vaccine era cohort, hospitalization rates were highest for refugees (aRR [95% CI] 3.41 [3.39-3.44]) and caregivers (3.13 [3.07-3.18]), followed by sponsored family and other economic immigrants. Compared to other Ontarians, aRRs were highest for immigrants from Central America (5.00 [4.92-5.09]), parts of South Asia (3.95 [3.89-4.01]) and Jamaica (3.56 [3.51-3.61]) with East Asians having lower aRRs. Mortality aRRs were similar to hospitalization aRRs. In the vaccine era, all aRRs were attenuated and most were similar to or lower than other Ontarians, with refugees and a few regions maintaining higher rates. In the pre-vaccine era ASYRs were higher for all immigrant groups. ASYRs dropped in the vaccine era with only refugees continuing to have higher rates.

Interpretation

Immigrants, particularly refugees, experienced greater premature mortality. aRRs for most immigrant groups dropped substantially after high vaccine coverage was achieved. Vaccine outreach and improvements in the social determinants of health are needed.

Funding

Canadian Institutes of Health Research, Canada Research Chairs Program.

Impact of new direct-acting antiviral therapy on the prevalence and undiagnosed proportion of chronic hepatitis C infection

BACKGROUND

Patients with chronic hepatitis C (CHC) can be cured with the new highly effective interferon-free combination treatments (DAA) that were approved in 2014. However, CHC is a largely silent disease, and many individuals are unaware of their infections until the late stages of the disease. The impact of wider access to effective treatments and improved awareness of the disease on the number of infections and the number of patients who remain undiagnosed is not known in Canada. Such evidence can guide the development of strategies and interventions to reduce the burden of CHC and meet World Health Organization's (WHO) 2030 elimination targets. The purpose of this study is to use a back-calculation framework informed by provincial population-level health administrative data to estimate the prevalence of CHC and the proportion of cases that remain undiagnosed in the three most populated provinces in Canada: British Columbia (BC), Ontario and Quebec.

METHODS

We have conducted a population-based retrospective analysis of health administrative data for the three provinces to generate the annual incidence of newly diagnosed CHC cases, decompensated cirrhosis (DC), hepatocellular carcinoma (HCC) and HCV treatment initiations. For each province, the data were stratified in three birth cohorts: individuals born prior to 1945, individuals born between 1945 and 1965 and individuals born after 1965. We used a back-calculation modelling approach to estimate prevalence and the undiagnosed proportion of CHC. The historical prevalence of CHC was inferred through a calibration process based on a Bayesian Markov chain Monte Carlo (MCMC) algorithm. The algorithm constructs the historical prevalence of CHC for each cohort by comparing the model-generated outcomes of the annual incidence of the CHC-related health events against the data set of observed diagnosed cases generated in the retrospective analysis.

RESULTS

The results show a decreasing trend in both CHC prevalence and undiagnosed proportion in BC, Ontario and Quebec. In 2018, CHC prevalence was estimated to be 1.23% (95% CI: .96%-1.62%), .91% (95% CI: .82%-1.04%) and .57% (95% CI: .51%-.64%) in BC, Ontario and Quebec respectively. The CHC undiagnosed proportion was assessed to be 35.44% (95% CI: 27.07%-45.83%), 34.28% (95% CI: 26.74%-41.62%) and 46.32% (95% CI: 37.85%-52.80%) in BC, Ontario and Quebec, respectively, in 2018. Also, since the introduction of new DAA treatment in 2014, CHC prevalence decreased from 1.39% to 1.23%, .97% to .91% and .65% to .57% in BC, Ontario and Quebec respectively. Similarly, the CHC undiagnosed proportion decreased from 38.78% to 35.44%, 38.70% to 34.28% and 47.54% to 46.32% in BC, Ontario and Quebec, respectively, from 2014 to 2018.

CONCLUSIONS

We estimated that the CHC prevalence and undiagnosed proportion have declined for all three provinces since the new DAA treatment has been approved in 2014. Yet, our findings show that a significant proportion of HCV cases remain undiagnosed across all provinces highlighting the need to increase investment in screening. Our findings provide essential evidence to guide decisions about current and future HCV strategies and help achieve the WHO goal of eliminating hepatitis C in Canada by 2030.

Validation of case-ascertainment algorithms using health administrative data to identify people who inject drugs in Ontario, Canada

OBJECTIVES

Health administrative data can be used to improve the health of people who inject drugs by informing public health surveillance and program planning, monitoring, and evaluation. However, methodological gaps in the use of these data persist due to challenges in accurately identifying injection drug use (IDU) at the population level. In this study, we validated case-ascertainment algorithms for identifying people who inject drugs using health administrative data in Ontario, Canada.

STUDY DESIGN AND SETTING

Data from cohorts of people with recent (past 12 months) IDU, including those participating in community-based research studies or seeking drug treatment, were linked to health administrative data in Ontario from 1992 to 2020. We assessed the validity of algorithms to identify IDU over varying look-back periods (ie, all years of data [1992 onwards] or within the past 1-5 years), including inpatient and outpatient physician billing claims for drug use, emergency department (ED) visits or hospitalizations for drug use or injection-related infections, and opioid agonist treatment (OAT).

RESULTS

Algorithms were validated using data from 15,241 people with recent IDU (918 in community cohorts and 14,323 seeking drug treatment). An algorithm consisting of ≥1 physician visit, ED visit, or hospitalization for drug use, or OAT record could effectively identify IDU history (91.6% sensitivity and 94.2% specificity) and recent IDU (using 3-year look back: 80.4% sensitivity, 99% specificity) among community cohorts. Algorithms were generally more sensitive among people who inject drugs seeking drug treatment.

CONCLUSION

Validated algorithms using health administrative data performed well in identifying people who inject drugs. Despite their high sensitivity and specificity, the positive predictive value of these algorithms will vary depending on the underlying prevalence of IDU in the population in which they are applied.

Organizational and Implementation Factors Associated with Cirrhosis Care in the Veterans Health Administration

BACKGROUND

The Veterans Health Administration provides care to more than 100,000 Veterans with cirrhosis.

AIMS

This implementation evaluation aimed to understand organizational resources and barriers associated with cirrhosis care.

METHODS

Clinicians across 145 Department of Veterans Affairs (VA) medical centers (VAMCs) were surveyed in 2022 about implementing guideline-concordant cirrhosis care. VA Corporate Data Warehouse data were used to assess VAMC performance on two national cirrhosis quality measures: HCC surveillance and esophageal variceal surveillance or treatment (EVST). Organizational factors associated with higher performance were identified using linear regression models.

RESULTS

Responding VAMCs (n = 124, 86%) ranged in resource availability, perceived barriers, and care processes. In multivariable models, factors independently associated with HCC surveillance included on-site interventional radiology and identifying patients overdue for surveillance using a national cirrhosis population management tool ("dashboard"). EVST was significantly associated with dashboard use and on-site gastroenterology services. For larger VAMCs, the average HCC surveillance rate was similar between VAMCs using vs. not using the dashboard (47% vs. 41%), while for smaller and less resourced VAMCs, dashboard use resulted in a 13% rate difference (46% vs. 33%). Likewise, higher EVST rates were more strongly associated with dashboard use in smaller (55% vs. 50%) compared to larger (57% vs. 55%) VAMCs.

CONCLUSIONS

Resources, barriers, and care processes varied across diverse VAMCs. Smaller VAMCs without specialty care achieved HCC and EVST surveillance rates nearly as high as more complex and resourced VAMCs if they used a population management tool to identify the patients due for cirrhosis care.

Emergency Colorectal Surgery in Those with Cirrhosis: A Population-based Study Assessing Practice Patterns, Outcomes and Predictors of Mortality

Background

Those with cirrhosis who require emergency colorectal surgery are at risk for poor outcomes. Although risk predictions models exists, these tools are not specific to colorectal surgery, nor were they developed in a contemporary setting. Thus, the objective of this study was to assess the outcomes in this population and determine whether cirrhosis etiology and/or the Model for End Stage Liver Disease (MELD-Na) is associated with mortality.

Methods

This population-based study included those with cirrhosis undergoing emergent colorectal surgery between 2009 and 2017. All eligible individuals in Ontario were identified using administrative databases. The primary outcome was 90-day mortality.

Results

Nine hundred and twenty-seven individuals (57%) (male) were included. The most common cirrhosis etiology was non-alcoholic fatty liver disease (NAFLD) (50%) and alcohol related (32%). Overall 90-day mortality was 32%. Multivariable survival analysis demonstrated those with alcohol-related disease were at increased risk of 90-day mortality (hazards ratio [HR] 1.53, 95% confidence interval [CI] 1.2-2.0 vs. NAFLD [ref]). Surgery for colorectal cancer was associated with better survival (HR 0.27, 95%CI 0.16-0.47). In the subgroup analysis of those with an available MELD-Na score (n = 348/927, 38%), there was a strong association between increasing MELD-Na and mortality (score 20+ HR 6.6, 95%CI 3.9-10.9; score 10-19 HR 1.8, 95%CI 1.1-3.0; score <10 [ref]).

Conclusion

Individuals with cirrhosis who require emergent colorectal surgery have a high risk of postoperative complications, including mortality. Increasing MELD-Na score is associated with mortality and can be used to risk stratify individuals.

Patients with early-stage alcohol-associated liver disease are at increased risk of hospital readmission and death

BACKGROUND AND AIMS

Patients with alcohol use disorder (AUD) can develop alcohol-associated fatty liver disease (AFLD). However, the impact of AFLD on outcomes remains unclear. We studied the impact of AFLD on readmission, 30-day mortality, and overall mortality in patients admitted with AUD.

METHODS

Hospitalized patients with AUD between 2011 and 2019 at a tertiary medical center were retrospectively evaluated. Our population included patients with AUD with AFLD: AST and ALT elevation and serum bilirubin <3 mg/dl. Patients with AUD without evidence of liver disease served as control and were labeled as no ALD. Patients with alcohol-associated cirrhosis (AC) and alcohol-associated hepatitis (AH) were included for comparison. Kaplan-Meier survival analysis and multivariable regression for predictors of mortality and survival were performed.

RESULTS

There were 7522 patients of which 32.44% were female with mean age of 51.86 ± 14.41 years. Patient distribution included no ALD (n = 3775), AFLD (n = 2192), AC (n = 1017) and AH (n = 538) groups. Compared to no ALD group, AFLD group was associated with significantly higher 30-day mortality [4.43% vs. 1.56%, hazard ratio (HR): 2.84; P  < 0.001], overall mortality [15.97% vs. 12.69%, HR 1.40, P  < 0.001], and 30-day readmission [21.85% vs. 18.49%, odds ratio: 1.21; P  < 0.01].

CONCLUSION

We demonstrated that AFLD is not a benign entity and poses significant mortality risk. Our results suggest that AFLD may be under-recognized and highlight the need for focused management and close follow-up after discharge.

Patterns of multiple chronic conditions in pregnancy: Population-based study using latent class analysis

BACKGROUND

Adults with multiple chronic conditions (MCC) are a heterogeneous population with elevated risk of future adverse health outcomes. Yet, despite the increasing prevalence of MCC globally, data about MCC in pregnancy are scarce.

OBJECTIVES

To estimate the population prevalence of MCC in pregnancy and determine whether certain types of chronic conditions cluster together among pregnant women with MCC.

METHODS

We conducted a population-based cohort study in Ontario, Canada, of all 15-55-year-old women with a recognised pregnancy, from 2007 to 2020. MCC was assessed from a list of 22 conditions, identified using validated algorithms. We estimated the prevalence of MCC. Next, we used latent class analysis to identify classes of co-occurring chronic conditions in women with MCC, with model selection based on parsimony, clinical interpretability and statistical fit.

RESULTS

Among 2,014,508 pregnancies, 324,735 had MCC (161.2 per 1000, 95% confidence interval [CI] 160.6, 161.8). Latent class analysis resulted in a five-class solution. In four classes, mood and anxiety disorders were prominent and clustered with one additional condition, as follows: Class 1 (22.4% of women with MCC), osteoarthritis; Class 2 (23.7%), obesity; Class 3 (15.8%), substance use disorders; and Class 4 (22.1%), asthma. In Class 5 (16.1%), four physical conditions clustered together: obesity, asthma, chronic hypertension and diabetes mellitus.

CONCLUSIONS

MCC is common in pregnancy, with sub-types dominated by co-occurring mental and physical health conditions. These data show the importance of preconception and perinatal interventions, particularly integrated care strategies, to optimise treatment and stabilisation of chronic conditions in women with MCC.

Identifying patients with diagnosed cirrhosis in administrative health databases: a validation study

Objectives

Case ascertainment algorithms were developed and validated to identify people living with cirrhosis in administrative health data in Manitoba, Canada using primary care electronic medical records (EMR) to define the reference standards.

Methods

We linked provincial administrative health data to primary care EMR data. The validation cohort included 116,675 Manitobans aged >18 years with at least one primary care visit between April 1998 and March 2015. Hospital records, physician billing claims, vital statistics, and prescription drug data were used to develop and test 93 case-finding algorithms. A validated case definition for primary care EMR data was the reference standard. We estimated sensitivity, specificity, positive and negative predictive values (PPV, NPV), Youden's index, area under the receiver operative curve, and their 95% confidence intervals (CIs).

Results

A total of 116,675 people were in the validation cohort. The prevalence of cirrhosis was 1.4% (n = 1593). Algorithm sensitivity estimates ranged from 32.5% (95% CI 32.2-32.8) to 68.3% (95% CI 68.0-68.9) and PPV from 17.4% (95% CI 17.1-17.6) to 23.4% (95% CI 23.1-23.6). Specificity (95.5-98.2) and NPV (approximately 99%) were high for all algorithms. The algorithms had slightly higher sensitivity estimates among men compared with women, and individuals aged ≥45 years compared to those aged 18-44 years.

Conclusion

Cirrhosis algorithms applied to administrative health data had moderate validity when a validated case definition for primary care EMRs was the reference standard. This study provides algorithms for identifying diagnosed cirrhosis cases for population-based research and surveillance studies.

Development and validation of a case definition to estimate the prevalence and incidence of cirrhosis in pan-Canadian primary care databases

Aims

To develop and validate case definitions to identify patients with cirrhosis and alcohol-related cirrhosis using primary care electronic medical records (EMRs) and to estimate cirrhosis prevalence and incidence in pan-Canadian primary care databases, between 2011 and 2019.

Methods

A total of 689,301 adult patients were included with ≥1 visit to a primary care provider within the Canadian Primary Care Sentinel Study Network between January 1, 2017, and December 31, 2018. A subsample of 17,440 patients was used to validate the case definitions. Sensitivity, specificity, predictive values were calculated with their 95% CIs and then determined the population-level prevalence and incidence trends with the most accurate case definition.

Results

The most accurate case definition included: ≥1 health condition, billing, or encounter diagnosis for International Classification of Diseases, Ninth Revision codes 571.2, 571.5, 789.59, or 571. Sensitivity (84.6; 95% CI 83.1%-86.%), specificity (99.3; 95% CI 99.1%-99.4%), positive predictive values (94.8; 95% CI 93.9%-95.7%), and negative predictive values (97.5; 95% CI 97.3%-97.7%). Application of this definition to the overall population resulted in a crude prevalence estimate of (0.46%; 95% CI 0.45%-0.48%). Annual incidence of patients with a clinical diagnosis of cirrhosis nearly doubled between 2011 (0.05%; 95% CI 0.04%-0.06%) and 2019 to (0.09%; 95% CI 0.08%-0.09%).

Conclusions

The EMR-based case definition accurately captured patients diagnosed with cirrhosis in primary care. Future work to characterize patients with cirrhosis and their primary care experiences can support improvements in identification and management in primary care settings.

Colorectal Cancer in Individuals with Cirrhosis: A Population-Based Study Assessing Practice Patterns, Outcomes, and Predictors of Survival

Those with cirrhosis who develop colorectal cancer (CRC) are an understudied group who may tolerate treatments poorly and are at risk of worse outcomes. This is a retrospective cohort study of 842 individuals from Ontario, Canada, with a pre-existing diagnosis of cirrhosis who underwent surgery for CRC between 2009 and 2017. Practice patterns, overall survival, and short-term morbidity and mortality were assessed. The most common cirrhosis etiology was non-alcoholic fatty liver disease (NAFLD) (52%) and alcohol-associated liver disease (29%). The model for end-stage liver disease score (MELD-Na) was available in 42% (median score of 9, IQR7-11). Preoperative radiation was used in 62% of Stage II/III rectal cancer patients, while postoperative chemotherapy was used in 42% of Stage III colon cancer patients and 38% of Stage II/III rectal cancer patients. Ninety-day mortality following surgery was 12%. Five-year overall survival was 53% (by Stages I-IV, 66%, 55%, 50%, and 11%, respectively). Those with alcohol-associated cirrhosis (HR 1.8, 95% CI 1.5-2.2) had lower survival than those with NAFLD. Those with a MELD-Na of 10+ did worse than those with a lower MELD-Na score (HR 1.9, 95% CI 1.4-2.6). This study reports poor survival in those with cirrhosis who undergo treatment for CRC. Caution should be taken when considering aggressive treatment.

Liver Cirrhosis Increases the Risk of Herpes Zoster: A Nationwide Population-Based Cohort Study

INTRODUCTION

Limited data are available regarding the association between liver cirrhosis (LC) and the risk of herpes zoster (HZ). This study aimed to determine the risk of HZ in patients with LC.

METHODS

HZ was defined as the presence of the International Classification of Diseases-10th revision code for HZ and concomitant prescription of antiviral medication. The incidence rates and standardized incidence ratios (SIRs) of HZ in patients with LC were analyzed using data from the Health Insurance Review and Assessment Service in Korea claims database from 2009 to 2019.

RESULTS

A total of 504,986 Korean patients with LC were included. The mean age was 52.4 years, and 60.8% were men. Chronic hepatitis B was the most common cause of LC. The incidence rates for HZ and HZ-related hospitalization were 21.6 of 1,000 and 1.81 of 1,000 person-years, respectively. The SIRs for HZ and HZ-related hospitalization were 1.09 (95% confidence interval [CI]: 1.08-1.09) and 1.48 (95% CI: 1.44-1.52), respectively, which were significantly higher than those in the general population. Patients with LC aged 20-29, 30-39, and 40-49 years had SIRs for HZ of 1.41 (95% CI: 1.33-1.48), 1.16 (1.13-1.19), and 1.17 (1.13-1.19), respectively. In multivariable analysis, woman (adjusted hazard ratio [AHR]: 1.48), steroid (AHR: 1.20), immunosuppressant use (AHR: 1.26), and combined comorbidities were associated with an increased risk of HZ among patients with LC.

DISCUSSION

Patients with LC, particularly those who are not currently recommended for HZ vaccination, were at an increased risk of HZ and HZ-related hospitalization compared with the general Korean population.

Physical disability and venous thromboembolism during pregnancy and the postpartum period: a population-based cohort study

BACKGROUND

Pregnancy and the postpartum period are a high-risk time for venous thromboembolism (VTE). Decreased mobility is also a major risk factor. However, the risk of peripregnancy VTE among individuals with physical disabilities is unknown.

OBJECTIVES

To compare the risk of peripregnancy VTE between people with a physical disability and those without a physical disability.

METHODS

This population-based cohort study comprised all births in Ontario, Canada, from 2007 to 2018. Physical disability was defined as a condition diagnosed before conception that was likely to result in restricted mobility. Modified Poisson regression was used to compare the risk of VTE during pregnancy and up to 6 weeks postpartum between people with a physical disability and those without a physical disability. Adjusted relative risks (aRRs) were calculated, controlling for demographics, history of VTE, thrombophilia, and other comorbidities. An additional analysis was used to evaluate the risk of peripregnancy VTE among people with physical disabilities who used a mobility aid.

RESULTS

Of 1 220 822 eligible people, 13 791 (1.1%) had a physical disability. VTE occurred during pregnancy or up to 6 weeks of the postpartum period in 0.85% of the individuals with a physical disability and 0.47% of those without a physical disability (aRR, 1.52; 95% CI, 1.26-1.83). The rate of VTE was notably higher in those with a physical disability requiring a mobility aid (3.0%), generating an aRR of 3.05 (95% CI, 1.45-6.41), than in those without a physical disability.

CONCLUSION

Pregnant people with a physical disability, especially those using a mobility aid, are at an increased risk of VTE. Anticoagulant prophylaxis could be considered in this group, especially in the presence of additional risk factors.

Cause-specific mortality among patients with cirrhosis in a population-based cohort study in Ontario (2000-2017)

BACKGROUND

Although patients with cirrhosis are at increased risk of death, the exact causes of death have not been reported in the contemporary era. This study aimed to describe cause-specific mortality in patients with cirrhosis in the general population.

METHODS

Retrospective cohort study using administrative health care data from Ontario, Canada. Adult patients with cirrhosis from 2000-2017 were identified. Cirrhosis etiologies were defined as HCV, HBV, alcohol-associated liver disease (ALD), NAFLD, or autoimmune liver disease/other with validated algorithms. Patients were followed until death, liver transplant, or end of study. Primary outcome was the cause of death as liver-related, cardiovascular disease, non-hepatic malignancy, and external causes (accident/self-harm/suicide/homicide). Nonparametric analyses were used to describe the cumulative incidence of cause-specific death by cirrhosis etiology, sex, and compensation status.

RESULTS

Overall, 202,022 patients with cirrhosis were identified (60% male, median age 56 y (IQR 46-67), 52% NAFLD, 26% alcohol-associated liver disease, 11% HCV). After a median follow-up of 5 years (IQR 2-12), 81,428 patients died, and 3024 (2%) received liver transplant . Patients with compensated cirrhosis mostly died from non-hepatic malignancies and cardiovascular disease (30% and 27%, respectively, in NAFLD). The 10-year cumulative incidence of liver-related deaths was the highest among those with viral hepatitis (11%-18%) and alcohol-associated liver disease (25%), those with decompensation (37%) and/or HCC (50%-53%). Liver transplant occurred at low rates (< 5%), and in men more than women.

CONCLUSIONS

Cardiovascular disease and cancer-related mortality exceed liver-related mortality in patients with compensated cirrhosis.

The Association of Sodium-Glucose Cotransporter 2 Inhibitors With Cardiovascular Outcomes in Anthracycline-Treated Patients With Cancer

Background

Sodium glucose cotransporter-2 inhibitors (SGLT2is) are hypothesized to reduce the risk of anthracycline-associated cardiotoxicity.

Objectives

This study sought to determine the association between SGLT2is and cardiovascular disease (CVD) after anthracycline-containing chemotherapy.

Methods

Using administrative data sets, we conducted a population-based cohort study of people >65 years of age with treated diabetes and no prior heart failure (HF) who received anthracyclines between January 1, 2016, and December 31, 2019. After estimating propensity scores for SGLT2i use, the average treatment effects for the treated weights were used to reduce baseline differences between SGLT2i-exposed and -unexposed controls. The outcomes were hospitalization for HF, incident HF diagnoses (in- or out-of-hospital), and documentation of any CVD in future hospitalizations. Death was treated as a competing risk. Cause-specific HRs for each outcome were determined for SGLT2i-treated people relative to unexposed controls.

Results

We studied 933 patients (median age 71.0 years, 62.2% female), 99 of whom were SGLT2i treated. During a median follow-up of 1.6 years, there were 31 hospitalizations for HF (0 in the SGLT2i group), 93 new HF diagnoses, and 74 hospitalizations with documented CVD. Relative to controls, SGLT2i exposure was associated with HR of 0 for HF hospitalization (P < 0.001) but no significant difference in incident HF diagnosis (HR: 0.55; 95% CI: 0.23-1.31; P = 0.18) or CVD diagnosis (HR: 0.39; 95% CI: 0.12-1.28; P = 0.12). There was no significant difference in mortality (HR: 0.63; 95% CI: 0.36-1.11; P = 0.11).

Conclusions

SGLT2is may reduce the rate of HF hospitalization after anthracycline-containing chemotherapy. This hypothesis warrants further testing in randomized controlled trials.

Liver-related mortality among people with hepatitis B and C: Evaluation of definitions based on linked healthcare administrative datasets

Routinely collected and linked healthcare administrative datasets could be used to monitor mortality among people with hepatitis B (HBV) and C (HCV). This study aimed to evaluate the concordance in records of liver-related mortality among people with an HBV or HCV notification, between data on hospitalization for end-stage liver disease (ESLD) and death certificates. In New South Wales, Australia, HBV and HCV notifications (1993-2017) were linked to hospital admissions (2001-2018), all-cause mortality (1993-2018) and cause-specific mortality (1993-2016) datasets. Hospitalization for ESLD was defined as a first-time hospital admission due to decompensated cirrhosis (DC) or hepatocellular carcinoma (HCC). Consistency of liver death definition of mortality following hospitalization for ESLD was compared with two death certificate-based definitions of liver deaths coded among primary and secondary cause-specific mortality data, including ESLD-related (deaths due to DC and HCC) and all-liver deaths (ESLD-related and other liver-related causes). Of 63,292 and 107,430 individuals with an HBV and HCV notification, there were 4478 (2.6%) post-ESLD hospitalization deaths, 5572 (3.3%) death certificate liver disease deaths and 2910 (1.7%) death certificate ESLD deaths. Between 2001 and 2016, among HBV post-ESLD hospitalization deaths (n = 891), 63% (562) had death certificate ESLD recorded, and 83% (741) had death certificate liver disease recorded. Between 2001 and 2016, among HCV post-ESLD hospitalization deaths (n = 3587), 58% (2082) had death certificate ESLD recorded, and 87% (3135) had death certificate liver disease recorded. At least one-third of death certificates with DC and HCC as cause of death had no mention of HBV, HCV or viral hepatitis. Our study identified limitations in estimating and tracking HBV and HCV liver disease mortality using death certificate-based data only. The optimum data for this purpose is either ESLD hospitalisations with vital status information or a combination of these with cause-specific death certificate data.

Accurate Identification of Patients with Cirrhosis and Its Complications in the Electronic Health Record

BACKGROUND

Cirrhosis represents a significant health burden; administrative data provide an important tool for research studies.

AIMS

We aimed to understand the validity of current ICD-10 codes compared to previously used ICD-9 codes to identify patients with cirrhosis and its complications.

METHODS

We identified 1981 patients presenting to MUSC between 2013 and 2019 with a diagnosis of cirrhosis. To validate the sensitivity of ICD codes, we reviewed the medical records of 200 patients for each associated ICD 9 and 10 codes. Sensitivity, specificity, and positive predictive value for each ICD code (individually or when combined) were calculated and univariate binary logistic models, for cirrhosis and its complications, predicted probabilities were used to calculate C-statistics.

RESULTS

Single ICD 9 and 10 codes were similarly insensitive for detection of cirrhosis, with sensitivity ranging from 5 to 94%. However, ICD-9 code combinations (when used as either/or) had high sensitivity and specificity for the detection of cirrhosis, with the combination of either 571.5 (or 456.21) or 571.2 codes having a C-statistic of 0.975. Combinations of ICD-10 codes were only slightly less sensitive and specific than ICD-9 codes for detection of cirrhosis (K76.6, or K70.31, plus K74.60 or K74.69, and K70.30 had a C-statistic of 0.927).

CONCLUSIONS

ICD-9 and ICD-10 codes when used alone were inaccurate for identifying cirrhosis. ICD-10 and ICD-9 codes had similar performance characteristics. Combinations of ICD codes exhibited the greatest sensitivity and specificity for detection of cirrhosis, and thus should be used to accurately identify cirrhosis.

Characterizing the cascade of care for hepatitis C virus infection among Status First Nations peoples in Ontario: a retrospective cohort study

BACKGROUND

As First Nations Peoples are a priority focus of Canada's commitment to eliminating hepatitis C virus (HCV) as a public health threat, understanding individuals' progression from diagnosis to cure can guide prioritization of elimination efforts. We sought to characterize and identify gaps in the HCV care cascade for Status First Nations peoples in Ontario.

METHODS

In this retrospective cohort study, a partnership between the Ontario First Nations HIV/AIDS Education Circle and academic researchers, HCV testing records (1999-2018) for Status First Nations peoples in Ontario were linked to health administrative data. We defined the cascade of care as 6 stages, as follows: tested positive for HCV antibody, tested for HCV RNA, tested positive for HCV RNA, HCV genotyped, initiated treatment and achieved sustained viral response (SVR). We mapped the care cascade from 1999 to 2018, and estimated the number and proportion of people at each stage. We stratified analyses by sex, diagnosis date and location of residence. We used Cox regression to analyze the secondary outcomes, namely the associations between undergoing HCV RNA testing and initiating treatment, and demographic and clinical predictors.

RESULTS

By Dec. 31, 2018, 4962 people tested positive for HCV antibody. Of those testing positive, 4118 (83.0%) were tested for HCV RNA, with 2480 (60.2%) testing positive. Genotyping was completed in 2374 (95.7%) of those who tested positive for HCV RNA, with 1002 (42.2%) initiating treatment. Nearly 80% (n = 801, 79.9%) of treated people achieved SVR, with 34 (4.2%) experiencing reinfection or relapse. Undergoing testing for HCV RNA was more likely among people in older age categories (within 1 yr of antibody test; adjusted hazard ratio [HR] 1.30, 95% confidence interval [CI] 1.19-1.41, among people aged 41-60 yr; adjusted HR 1.47, 95% CI 1.18-1.81, among people aged > 60 yr), those living in rural areas (adjusted HR 1.20, 95% CI 1.10-1.30), those with an index date after Dec. 31, 2013 (era of treatment with direct-acting antiviral regimens) (adjusted HR 1.99, 95% CI 1.85-2.15) and those with a record of substance use or addictive disorders (> 1 yr after antibody test; adjusted HR 1.38, 95% CI 1.18-1.60). Treatment initiation was more likely among people in older age categories at index date (adjusted HR 1.32, 95% CI 1.15-1.50, among people aged 41-60 yr; adjusted HR 2.62, 95% CI 1.80-3.82, among people aged > 60 yr) and those with a later diagnosis year (adjusted HR 2.71, 95% CI 2.29-3.22).

INTERPRETATION

In comparison with HCV testing and diagnosis, a substantial gap in treatment initiation remains among Status First Nations populations in Ontario. Elimination efforts that prioritize linkage to care and integration with harm reduction and substance use services are needed to close gaps in HCV care among First Nations populations in Ontario.

An AI Approach for Identifying Patients With Cirrhosis

GOAL

The goal of this study was to evaluate an artificial intelligence approach, namely deep learning, on clinical text in electronic health records (EHRs) to identify patients with cirrhosis.

BACKGROUND AND AIMS

Accurate identification of cirrhosis in EHR is important for epidemiological, health services, and outcomes research. Currently, such efforts depend on International Classification of Diseases (ICD) codes, with limited success.

MATERIALS AND METHODS

We trained several machine learning models using discharge summaries from patients with known cirrhosis from a patient registry and random controls without cirrhosis or its complications based on ICD codes. Models were validated on patients for whom discharge summaries were manually reviewed and used as the gold standard test set. We tested Naive Bayes and Random Forest as baseline models and a deep learning model using word embedding and a convolutional neural network (CNN).

RESULTS

The training set included 446 cirrhosis patients and 689 controls, while the gold standard test set included 139 cirrhosis patients and 152 controls. Among the machine learning models, the CNN achieved the highest area under the receiver operating characteristic curve (0.993), with a precision of 0.965 and recall of 0.978, compared with 0.879 and 0.981 for the Naive Bayes and Random Forest, respectively (precision 0.787 and 0.958, and recalls 0.878 and 0.827). The precision by ICD codes for cirrhosis was 0.883 and recall was 0.978.

CONCLUSIONS

A CNN model trained on discharge summaries identified cirrhosis patients with high precision and recall. This approach for phenotyping cirrhosis in the EHR may provide a more accurate assessment of disease burden in a variety of studies.

Influence of hepatitis C viral parameters on pregnancy complications and risk of mother-to-child transmission

BACKGROUND & AIMS

With the World Health Organization plan for hepatitis C elimination by the year 2030, and recent guideline recommendations to screen all women during pregnancy for HCV, data on HCV in pregnancy are needed to determine the association of HCV viremia with adverse pregnancy outcomes and mother-to-child transmission (MTCT).

METHODS

This retrospective cohort study was performed in Ontario, Canada, using population-based administrative healthcare data. Individuals were stratified based on whether they had active HCV viremia during pregnancy or resolved viremia at time of pregnancy. Peak HCV viral load was determined. Logistic regression was used to determine the association of viremia with adverse pregnancy outcomes; maternal HCV RNA levels were evaluated as a predictor of MTCT.

RESULTS

We identified a total of 2,170 pregnancies in 1,636 women who were HCV RNA positive prior to pregnancy; 1,780 (82%) pregnancies occurred in women who were HCV RNA positive during pregnancy. Patients who were HCV RNA positive during pregnancy were more likely to have preterm delivery (18% vs. 12%, p = 0.002), intrahepatic cholestasis of pregnancy (4% vs. <2%, p = 0.003), and post-partum hemorrhage (9% vs. 5%, p = 0.013), and less likely to have gestational diabetes (6% vs. 10%, p = 0.008) than those with resolved infection. Only 511 (29%) infants had screening consistent with guidelines after birth; there was an estimated 3.5% risk of MTCT. HCV RNA ≥6.0 log₁₀ IU/ml was significantly associated with MTCT (exact odds ratio 3.4, p = 0.04).

CONCLUSION

Active HCV viremia among individuals with a history of HCV infection significantly increases adverse pregnancy outcomes. Few infants are screened for MTCT. Higher HCV RNA is associated with increased risk of MTCT.

LAY SUMMARY

The prevalence of hepatitis C has increased in women of child-bearing age and has important implications for women who become pregnant and their infants. We evaluated the effect that hepatitis C has on pregnancy outcomes as well as the rate of hepatitis C transmission to infants in a large database with linked mother-infant records. We found that active hepatitis C during pregnancy increased the risk of pregnancy complications. We also identified very low rates of testing of infants born to mothers with hepatitis C, but found higher rates of hepatitis C transmission to infants in mothers with higher virus levels.

Identifying Ascites in Patients with Cirrhosis Using Administrative Codes and Diuretic Use: A Multicenter Study

BACKGROUND

Ascites is associated with significantly increased morbidity, mortality, and health care costs. Large population studies are necessary to determine the burden and impact of ascites; however, ascites ICD-10 codes perform poorly in the identification of patients.

METHODS

We utilized three independent retrospective cohorts at the University of Michigan (cohorts 1 and 2) and Duke University (cohort 3). Cohort 1: Child A5-6 patients followed up to 10 years (n = 150); cohort 2: Child A5-B7 patients with portal hypertension followed for up to 1 year (n = 65); cohort 3: cross-sectional cohort of patients evaluated for liver transplant (n = 100). We computed performance characteristics for ascites-related ICD-10 codes (K70.31, K70.11, K71.51, R18.8), as well as loop and/or potassium-sparing diuretics.

RESULTS

A total of 315 patients were included across three cohorts. Algorithms including any ascites code provided better sensitivity and equivalent specificity to R18.8 alone for all cohorts. In cohort 2, we found that loop diuretics, potassium-sparing diuretics, and a combination of both with a cirrhosis code were highly sensitive (82.3% for each) and specific (89.1-93.5%). In contrast, ascites codes were insensitive. In patients with moderate-severe ascites, a combination of recorded diuretics showed high sensitivity and specificity (95.2% and 86.8%). In Cohort 3's transplant evaluation patients, we found that loop diuretics, potassium-sparing diuretics, and a combination of both with a cirrhosis code were highly sensitive (90.4%, 78.8% and 75.0%, respectively) and specific (85.0%, 90.0% and 95.0%, respectively). For moderate-severe cirrhosis, loop diuretics and R18.8 showed higher sensitivity (77.8%) and specificity (88.9%), respectively.

CONCLUSION

Diuretic records with a cirrhosis code improve the identification of ascites. This method for identifying ascites should be used in future large dataset studies.

Association between social determinants of health and rates of liver transplantation in individuals with cirrhosis

BACKGROUND AND AIMS

This study evaluated the association between neighborhood-level social determinants of health (SDOH) and liver transplantation (LT) among patients with cirrhosis who have universal access to health care.

APPROACH AND RESULTS

This was a retrospective population-based cohort study from 2000-2019 using administrative health care data from Ontario, Canada. Adults aged 18-70 years with newly decompensated cirrhosis and/or HCC were identified using validated coding. The associations between five neighborhood level SDOH quintiles and LT were assessed with multivariate Fine-Gray competing risks regression to generate subdistribution HRs (sHRs) where death competes with LT. Overall, n = 38,719 individuals formed the cohort (median age 57 years, 67% male), and n = 2788 (7%) received LT after a median of 23 months (interquartile range 3-68). Due to an interaction, results were stratified by sex. After multivariable regression and comparing those in the lowest versus highest quintiles, individuals living in the most materially resource-deprived areas (female sHR, 0.61; 95% CI, 0.49-0.76; male sHR, 0.55; 95% CI, 0.48-0.64), most residentially unstable neighborhoods (female sHR, 0.61; 95% CI, 0.49-0.75; male sHR, 0.56; 95% CI, 0.49-0.65), and lowest-income neighborhoods (female sHR, 0.57; 95% CI, 0.46-0.7; male sHR, 0.58; 95% CI, 0.50-0.67) had ~40% reduced subhazard for LT (p < 0.01 for all). No associations were found between neighborhoods with the most diverse immigrant or racial minority populations or age and labor force quintiles and LT.

CONCLUSIONS

This information highlights an urgent need to evaluate how SDOH influence rates of LT, with the overarching goal to develop strategies to overcome inequalities.

External Validation of the FIPS Score for Post-TIPS Mortality in a National Veterans Affairs Cohort

BACKGROUND

The Freiburg index of post-TIPS survival (FIPS) score was recently demonstrated to improve prediction of post-TIPS mortality relative to existing standards. As this score was derived from a German cohort over an extended time period, it is unclear if performance will translate well to other settings. This study aimed to externally validate the FIPS score in a large Veterans Affairs (VA) cohort over two separate eras of TIPS-related care.

METHODS

This was a retrospective cohort study of patients with cirrhosis who underwent TIPS placement in the VA from 2008 to 2020. Cox regression models for post-TIPS survival were constructed using FIPS, MELD, MELD-Na, or CTP scores as predictors. Discrimination (Harrell's C) and calibration (joint tests of calibration curve slope and intercept) were evaluated for each score. A stratified analysis was performed for time periods between 2008-2013 and 2014-2020.

RESULTS

The cohort of 1,274 patients was 97.3% male with mean age 60.9 years and mean MELD-Na 14. The FIPS score demonstrated the highest overall discrimination versus MELD, MELD-Na, and CTP (0.634 vs. 0.585, 0.626, 0.612, respectively). However, in the modern treatment era (2014-2020), the FIPS score performed similarly to MELD-Na. Additionally, the FIPS score demonstrated poor calibration at one-month and six-month post-TIPS timepoints (joint p = 0.04 and 0.004, respectively). MELD, MELD-Na, and CTP were well-calibrated at each timepoint (each joint p > 0.05).

CONCLUSION

The FIPS score performed similarly to MELD-Na in the modern TIPS treatment era and demonstrated regions of poor calibration. Future models derived with contemporary data may improve prediction of post-TIPS mortality.

Accuracy of International Classification of Diseases-10 Codes for Cirrhosis and Portal Hypertensive Complications

BACKGROUND AND AIMS

International Classification of Diseases (ICD)-10 codes may correspond to cirrhosis diagnosis. However, these codes have not been as well studied as ICD-9 codes. We aimed to evaluate the positive predictive value (PPV) and specificity of ICD-10 codes for cirrhosis.

METHODS

We conducted a single-center retrospective study of patients in Michigan Medicine (Ann Arbor, MI, USA). We evaluated patients with at least one of 28 ICD-10 codes for cirrhosis and randomly selected controls for the presence of cirrhosis and/or portal hypertensive complications.

RESULTS

Among 1317 patients with at least one ICD-10 code consistent with cirrhosis and/or portal hypertension, 796 had confirmed cirrhosis. After excluding ICD-10 codes found in < 10 patients, we evaluated the PPV of the 19 remaining codes. Of these, 15 had a high PPV for cirrhosis (> 80%), including codes for cirrhosis itself, gastroesophageal varices, hepatic encephalopathy, and other portal hypertensive complications. Specificity of ICD codes for cirrhosis for these 15 codes was high (> 94% for all). PPV and specificity were high across liver disease etiologies. Among patients without portal hypertension, PPVs of ICD-10 codes for cirrhosis were lower but still > 80% for the most common codes. PPVs of most codes for portal hypertensive complications were > 70%. Defining cirrhosis based on the presence of any of the 15 codes resulted in a PPV of 86% and by two different codes, a PPV 94%.

CONCLUSIONS

ICD-10 codes for cirrhosis can accurately identify patients with cirrhosis with or without portal hypertensive complications.

Trends in decompensated cirrhosis and hepatocellular carcinoma among people with a hepatitis B notification in New South Wales

Background & Aims

Population-level trends and factors associated with HBV-related decompensated cirrhosis (DC), hepatocellular carcinoma (HCC), and liver-related mortality are crucial to evaluate the impacts of therapeutic interventions.

Methods

Trends in HBV-DC and -HCC diagnoses and liver-related mortality in New South Wales, Australia, were determined through linkage of HBV notifications (1993-2017) to hospital admissions (2001-2018), mortality (1993-2018), and cancer registry (1994-2014) databases. Late HBV notification was defined as notification at or within 2 years of a DC or HCC diagnosis. Cox proportional-hazards regression and multivariable logistic regression analyses were performed to evaluate associated factors.

Results

Among 60,660 people with a HBV notification, 1,276 (2.0%) DC and 1,087 (1.8%) HCC diagnoses, and 1,219 (2.0%) liver-related deaths were documented. Since the early 2000s, the number of DC and HCC diagnoses increased; however, age-standardised incidence decreased from 2.64 and 1.95 in 2003 to 1.14 and 1.09 per 1,000 person-years in 2017, respectively. Similarly, age-standardised liver mortality decreased from 2.60 in 2003 to 1.14 per 1,000 person-years in 2017. Among people with DC and HCC diagnoses, late HBV notification declined from 41% and 40% between 2001-2009 to 29% and 25% in 2010-2018, respectively. Predictors of DC diagnosis included older age (birth <1944, adjusted hazard ratio [aHR] 2.06, 95% CI 1.57–2.69), alcohol use disorder (aHR 4.82, 95% CI 3.96–5.87) and HCV co-infection (aHR 1.88, 95% CI 1.53–2.31). Predictors of HCC diagnosis included older age (birth <1944, aHR 3.94, 95% CI 2.91–5.32) and male sex (aHR 3.79, 95% CI 3.05–4.71).

Conclusion

In an era of improved antiviral therapies, the risk of HBV-related liver morbidity and mortality has declined. HCV co-infection and alcohol use disorder are key modifiable risk factors associated with the burden of HBV.

Lay summary

Rising hepatitis B-related morbidity and mortality is a major public health concern. However, the development of highly effective medicines against hepatitis B virus (HBV) has brought renewed optimism for its elimination by 2030. This study shows a steady decline in HBV-related liver morbidity and mortality in New South Wales, Australia. Moreover, late hepatitis notification has also declined, allowing individuals with HBV to have access to timely antiviral treatment. Despite this, hepatitis C co-infection and alcohol use disorder are key modifiable risk factors associated with HBV disease burden. To attain the desired benefits from highly effective antiviral treatment, managing comorbidities, including hepatitis C and high alcohol use, must improve among individuals with hepatitis B.

•

The World Health Organization has set a 65% HBV mortality reduction target by 2030.

•

Since the early 2000s, diagnoses of decompensated cirrhosis and HCC increased, but age-standardised incidence rates decreased.

•

Age-standardised liver mortality rates decreased from 2.64 in 2003 to 0.97 per 1,000 person-years in 2017.

•

Late HBV notification declined from 41% and 40% during 2001-2009 to 28% and 26% in 2010-2018, respectively.

•

Hepatitis C co-infection and alcohol-use disorder are key modifiable risk factors associated with HBV disease burden.

Core implementation strategies for improving cirrhosis care in the Veterans Health Administration

BACKGROUND AND AIMS

The Veterans Health Administration (VHA) provides care for more than 80,000 veterans with cirrhosis. This longitudinal, multimethod evaluation of a cirrhosis care quality improvement program aimed to (1) identify implementation strategies associated with evidence-based, guideline-concordant cirrhosis care over time, and (2) use qualitative interviews to operationalize strategies for a manualized intervention.

APPROACH AND RESULTS

VHA providers were surveyed annually about the use of 73 implementation strategies to improve cirrhosis care in fiscal years 2018 (FY18) and 2019 (FY19). Implementation strategies linked to guideline-concordant cirrhosis care were identified using bivariate statistics and comparative configurational methods. Semistructured interviews were conducted with 12 facilities in the highest quartile of cirrhosis care to specify the successful implementation strategies and their mechanisms of change. A total of 106 VHA facilities (82%) responded at least once over the 2-year period (FY18, n = 63; FY19, n = 100). Facilities reported using a median of 12 (interquartile range [IQR] 20) implementation strategies in FY18 and 10 (IQR 19) in FY19. Of the 73 strategies, 35 (48%) were positively correlated with provision of evidence-based cirrhosis care. Configurational analysis identified multiple strategy pathways directly linked to more guideline-concordant cirrhosis care. Across both methods, a subset of eight strategies was determined to be core to cirrhosis care improvement and specified using qualitative interviews.

CONCLUSIONS

In a national cirrhosis care improvement initiative, a multimethod approach identified a core subset of successful implementation strategy combinations. This process of empirically identifying and specifying implementation strategies may be applicable to other implementation challenges in hepatology.

Morbimortality Associated with Liver Cirrhosis in Peru: An Ecological Analysis for the Period of 2004-2016

Liver cirrhosis (LC) is an irreversible, chronic disease and constitutes the last clinical stage of many different liver diseases. The main cause of death is upper gastrointestinal bleeding caused by esophageal variceal rupture. We aim to depict the trend and estimate the morbimortality. For this, we conducted an ecological study and analyzed data from 2004-2016 using the public information provided by the Peruvian Ministry of Health (Ministerio de Salud del Perú, MINSA). Morbidity and mortality were presented according to 5-year groups. Regions were divided according to age quintiles for each studied year, and standardized morbidity and mortality rates were calculated for each natural geographic region; we found that LC-related morbidity per 100,000 people was 52.3 in 2004 and 117.9 in 2016. LC-related mortality had increased from 13.6 deaths per 100,000 people in 2004-2005 to 16.8 deaths per 100,000 people in 2015-2016. Morbidity showed an upward trend in Peru, especially in the departments of Callao, Ica, and Tumbes, whereas mortality showed an upward trend in the departments of Lambayeque, Ica, and Callao.

Pregnancy Is Not Associated with an Increased Risk of Decompensation, Transplant, or Death in Compensated Cirrhosis

BACKGROUND AND AIMS

Childbirth in women with cirrhosis is increasing and associated with a higher risk of perinatal outcomes compared to the general population. Whether pregnancy influences the risk of liver-related events compared to nonpregnant women with cirrhosis is unclear. This study evaluates the association between pregnancy and liver-related outcomes in women with compensated cirrhosis. Approach and Results. Population-based retrospective matched cohort study in Ontario, Canada, using routinely collected healthcare data. Pregnant women with compensated cirrhosis and without prior history of decompensation between 2000 and 2016 were identified and matched to nonpregnant women with compensated cirrhosis on age, etiology of cirrhosis, and socioeconomic status in a 1 : 2 ratio. The association between pregnancy and the composite outcome of nonmalignant decompensation, liver transplant (LT), and death up to two years after cohort entry was estimated using the multivariate Cox proportional hazard regression adjusting for potential confounders. Overall, 5,403 women with compensated cirrhosis were included (1,801 pregnant; 3,602 nonpregnant; median age 31 years (IQR 27-34); 60% nonalcoholic fatty liver disease, 34% viral hepatitis). After two years of follow-up, only 19 (1.1%) pregnant women had a liver-related event compared to 319 (8.9%) nonpregnant women. Pregnant women with compensated cirrhosis had a lower hazard of a liver-related event compared to nonpregnant women (aHR 0.14, 95% CI 0.09-0.22, P < .001).

CONCLUSIONS

Pregnancy in women with compensated cirrhosis is not associated with increased liver-related events compared to nonpregnant women. These results can facilitate counselling women with cirrhosis of child-bearing age and suggests that pregnancy may not accelerate liver disease progression.

Association of the presence of allergic disease with subsequent risk of liver cancer in a nationwide retrospective cohort among Koreans

A number of studies have proposed an inverse association between allergic diseases and risk of cancer, but only a few studies have specifically investigated the risk of primary liver cancer, including hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). The aim of this study was to evaluate the association of allergic diseases with risk of primary liver cancer. We conducted a retrospective cohort study of the Korean National Health Insurance Service database consisted of 405,512 Korean adults ages 40 and above who underwent health screening before January 1st, 2005. All participants were followed up until the date of liver cancer, death, or December 31st, 2013, whichever happened earliest. Those who died before the index date or had pre-diagnosed cancer were excluded from the analyses. Cox proportional hazards regression was used to determine the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for risk of primary liver cancer according to the presence of allergic diseases, including atopic dermatitis, asthma, and allergic rhinitis. The aHR (95% CI) for overall liver cancer among allergic patients was 0.77 (0.68–0.87) compared to those without allergic disease. Allergic patients had significantly reduced risk of HCC (aHR, 0.72; 95% CI 0.62–0.85) but not ICC (aHR, 0.95; 95% CI 0.73–1.22). The presence of allergies was associated with significantly lower risk of liver cancer among patients whose systolic blood pressure is lower than 140 mmHg (aHR, 0.64; 95% CI 0.62–0.78 for overall liver cancer; aHR, 0.64; 95% CI 0.52–0.78 for HCC) but this effect was not observed among patients whose systolic blood pressure is higher than 140 mmHg (aHR, 0.91; 95% CI 0.71–1.18 for overall liver cancer; aHR, 0.91; 95% CI 0.71–1.18 for HCC) The aHR (95% CI) for overall liver cancer of allergic patients with and without chronic hepatitis virus infection were 0.60 (95% CI 0.44–0.81) and 0.77 (95% CI 0.64–0.93), respectively. In addition, allergic patients without cirrhosis showed significantly lower risk of overall liver cancer (aHR, 0.73; 95% CI 0.63–0.83). Patients with allergic diseases have significantly lower risk of primary liver cancer compared to those without allergic diseases, which supports the rationale for immunotherapy as an effective treatment for liver cancer.

International Classification of Diseases Codes are Useful in Identifying Cirrhosis in Administrative Databases

BACKGROUND

Health administrative databases are essential to define patient populations, make socioeconomic predictions, and facilitate medical research and healthcare planning. The accuracy of this data is dependent on valid codes/coding algorithms.

AIMS

The aim of this study was to systematically identify and summarize the validity of International Classification of Diseases (ICD) codes for identifying patients with cirrhosis in administrative data.

METHODS

Electronic databases, MEDLINE (via Ovid), EMBASE (via Ovid), the Web of Science, and CINAHL (via EBSCOhost), were searched for validation studies which compared ICD codes related to cirrhosis to a clinical reference standard, and reported statistical measures of performance.

RESULTS

Fourteen studies were included in the review. There was a large variation in the algorithms used to validate ICD codes to diagnose cirrhosis. Despite the variation, the positive predictive value (PPV) was greater than 84% and the specificity was greater than 75% in the majority of the studies. The negative predictive value (NPV) was lower, but still was associated with values greater than 70% in the majority of studies. Sensitivity data varied significantly with values ranging from 0.27 to 99%.

CONCLUSIONS

Evaluated ICD codes for cirrhosis, including codes for chronic liver disease, cirrhosis-specific codes, and cirrhosis-related complications, have demonstrated variable sensitivity and reasonable specificity for the identification of cirrhosis. Additional research is needed to maximize the identification of persons with cirrhosis to avoid underestimating the burden of disease.

The Impact of Cirrhosis on Outcomes of Patients Admitted With Diabetic Ketoacidosis: A Nationwide Study

Introduction Diabetic ketoacidosis (DKA) is the most common acute hyperglycemic emergency in people with diabetes mellitus (DM). Cirrhosis is a consequence of chronic inflammation that is followed by hepatic fibrosis. It has been noted that cirrhosis is associated with an increased risk of developing type II DM due to altered glucose homeostasis. The prognostic value of DM in cirrhotic patients has been studied before and was found to be associated with lower survival. However, the risk of mortality and adverse events in cirrhotic patients admitted with DKA needs further evaluation. The aim of this study is to compare outcomes in patients with cirrhosis admitted to the hospital with DKA compared to non-cirrhotic patients. Methods The data for this study were extracted from the National Inpatient Sample (NIS) 2016-2019. The NIS was queried for all patients who had a discharge diagnosis of DKA. Patients with cirrhosis were identified and subclassified into compensated and decompensated cirrhosis using the International Classification of Diseases 10th revision, Clinical Modification (ICD-10-CM) codes. Patients without cirrhosis were the control group. ICD-10-CM codes that have been validated for cirrhosis were utilized. The primary outcome was in-hospital mortality. Secondary outcomes were hospital charges, length of stay (LOS), and in-hospital complications, including shock, mechanical ventilation, and acute kidney injury (AKI) requiring dialysis. Results We included 1,098,875 hospitalizations with a discharge diagnosis of DKA. Overall, 9,190 patients had compensated cirrhosis and 4,355 had decompensated cirrhosis. Cirrhotic patients had overall worse outcomes compared to non-cirrhotics. Decompensated cirrhotics had the highest mortality (11.26%; 95% confidence interval [CI]: 9.36% to 13.49%) compared to compensated cirrhotics (3.54%; 95% CI: 2.79% to 4.48%) and non-cirrhotics (2.15%; 95% CI: 1.89% to 2.43%). Similarly, decompensated cirrhotics also had the highest LOS, total charges, and in-hospital complications among the groups. On multivariate analysis, decompensated cirrhosis, rather than compensated cirrhosis, was an independent predictor of higher mortality (adjusted odds ratio [AOR]: 2.30; 95% CI: 1.81 to 2.92), LOS (regression coefficient: +1.82 days; 95% CI: +1.19 to +2.44 days), hospital charges (regression coefficient: +$28,497; 95% CI: +$18,107 to +$38,887), shock (AOR: 2.31; 95% CI: 1.68 to 3.18), mechanical ventilation (AOR: 1.91; 95% CI: 1.58 to 2.29), and AKI requiring dialysis (AOR: 2.31; 95% CI: 1.68 to 3.18). Conclusion This study showed that patients with decompensated liver cirrhosis who were admitted with DKA had the worst in-hospital outcomes. Additionally, only decompensated cirrhosis was an independent predictor of worse outcomes. Decompensated cirrhotics who develop DKA should be approached with more caution with a probable lower threshold for intensive care unit admission for a higher level management.

Rising Healthcare Costs and Utilization among Young Adults with Cirrhosis in Ontario: A Population-Based Study

OBJECTIVES

Chronic diseases account for the majority of healthcare spending. Cirrhosis is a chronic disease whose burden is rising, especially in young adults. This study aimed at describing the direct healthcare costs and utilization in young adults with cirrhosis compared to other chronic diseases common to this age group.

METHODS

Retrospective population-based study of routinely collected healthcare data from Ontario for the fiscal years 2007-2016 and housed at ICES. Young adults (aged 18-40 years) with cirrhosis, inflammatory bowel disease (IBD), and asthma were identified based on validated case definitions. Total and annual direct healthcare costs and utilization were calculated per individual across multiple healthcare settings and compared based on the type of chronic disease. For cirrhosis, the results were further stratified by etiology and decompensation status.

RESULTS

Total direct healthcare spending from 2007 to 2016 increased by 84% for cirrhosis, 50% for IBD, and 41% for asthma. On a per-patient basis, annual costs were the highest for cirrhosis ($6,581/year) compared to IBD ($5,260/year), and asthma ($2,934/year) driven by acute care in cirrhosis and asthma, and drug costs in IBD. Annual costs were four-fold higher in patients with decompensated versus compensated cirrhosis ($20,651/year vs. $5,280/year). Patients with cirrhosis had greater use of both ICU and mental health services.

CONCLUSION

Healthcare costs in young adults with cirrhosis are rising and driven by the use of acute care. Strategies to prevent the development of cirrhosis and to coordinate healthcare in this population through the development of chronic disease prevention and management strategies are urgently needed.

Impact of the COVID-19 Pandemic on Hospitalizations for Alcoholic Hepatitis or Cirrhosis in Alberta, Canada

BACKGROUND & AIMS

Coronavirus disease 2019 (COVID-19) pandemic lockdown and restrictions had significant disruption to patient care. We aimed to evaluate the impact of COVID-19 restrictions on hospitalizations of patients with alcoholic and nonalcoholic cirrhosis as well as alcoholic hepatitis (AH) in Alberta, Canada.

METHODS

We used validated International Classification of Diseases (ICD-9 and ICD-10) coding algorithms to identify liver-related hospitalizations for nonalcoholic cirrhosis, alcoholic cirrhosis, and AH in the province of Alberta between March 2018 and September 2020. We used the provincial inpatient discharge and laboratory databases to identify our cohorts. We used elevated alanine aminotransferase or aspartate aminotransferase, elevated international normalized ratio, or bilirubin to identify AH patients. We compared COVID-19 restrictions (April-September 2020) with prior study periods. Joinpoint regression was used to evaluate the temporal trends among the 3 cohorts.

RESULTS

We identified 2916 hospitalizations for nonalcoholic cirrhosis, 2318 hospitalizations for alcoholic cirrhosis, and 1408 AH hospitalizations during our study time. The in-hospital mortality rate was stable in relation to the pandemic for alcoholic cirrhosis and AH. However, nonalcoholic cirrhosis patients had lower in-hospital mortality rate after March 2020 (8.5% vs 11.5%; P = .033). There was a significant increase in average monthly admissions in the AH cohort (22.1/10,000 admissions during the pandemic vs 11.6/10,000 admissions before March 2020; P < .001).

CONCLUSIONS

Before and during COVID-19 monthly admission rates were stable for nonalcoholic and alcoholic cirrhosis; however, there was a significant increase in AH admissions. Because alcohol sales surged during the pandemic, future impact on alcoholic liver disease could be detrimental.

Pregnancies With Cirrhosis Are Rising and Associated With Adverse Maternal and Perinatal Outcomes

INTRODUCTION

Cirrhosis incidence in pregnancies from outside the United States (US) is rising, although contemporary data including maternal and perinatal outcomes within the United States are lacking.

METHODS

Using discharge data from the racially diverse US National Inpatient Sample, temporal trends of cirrhosis in pregnancies were compared with noncirrhotic chronic liver disease (CLD) or no CLD. Outcomes included preterm birth, postpartum hemorrhage, hypertensive complications (preeclampsia, eclampsia, and/or hemolysis, elevated liver enzymes, and low platelets syndrome), and maternal or fetal death. Logistic regression was adjusted for age, race, multiple gestation, insurance status, and prepregnancy metabolic comorbidities.

RESULTS

Among 18,573,000 deliveries from 2012 to 2016, 895 had cirrhosis, 119,875 had noncirrhotic CLD, and 18,452,230 had no CLD. Pregnancies with cirrhosis increased from 2.5/100,000 in 2007 to 6.5/100,000 in 2016 (P = 0.01). On adjusted analysis, cirrhosis was associated with hypertensive complications (vs no CLD, OR 4.9, 95% confidence intervals [CI] 3.3-7.4; vs noncirrhotic CLD, OR 4.4, 95% CI 3.0-6.7), postpartum hemorrhage (vs no CLD, OR 2.8, 95% CI 1.6-4.8; vs noncirrhotic CLD, OR 2.0, 95% CI 1.2-3.5), and preterm birth (vs no CLD, OR 3.1, 95% CI 1.9-4.9; vs noncirrhotic CLD, OR 2.0, 95% CI 1.3-3.3, P ≤ 0.01). Cirrhosis was statistically associated with maternal mortality, although rarely occurred (≤ 1%).

DISCUSSION

In this racially diverse, US population-based study, pregnancies with cirrhosis more than doubled over the past decade. Cirrhosis conferred an increased risk of several adverse events, although maternal and perinatal mortality was uncommon. These data underscore the need for reproductive counseling and multidisciplinary pregnancy management in young women with cirrhosis.