Introduction: Liver cirrhosis (LC) is a major cause of mortality and morbidity in the United States. American Association for the Study of Liver Disease (AASLD) has developed guidelines for the management of patients with LC. Methods: We conducted a one-year retrospective chart review study of patients admitted with LC related complication. Our primary outcome was adherence to AASLD guidelines for the management of variceal bleeding (VB), fluid overload and hepatocellular carcinoma (HCC) screening, and secondary outcome was re-admission rate within 30 days of discharge. Results: A total of 139 patients were reviewed. Majority were males (65%) and Caucasians (65%). The admission indication was mainly for fluid overload (39%), hepatic encephalopathy (36%) and VB (27%). The one-month readmission rate was 31%, of those 47% and 37% were admitted for hepatic encephalopathy and fluid overload respectively. Periodic screening for HCC was done in only 40% of patients. Ninety-five percent of patients admitted with VB received PPI, octreotride and antibiotics. Diet education was only documented in 9% of patients on discharge. Significant predictors for 30-day readmission included high MELD score, elevated creatinine, and taking diuretics/lactulose before hospitalization in addition to shorter length of stay. Conclusion: Compliance with AASLD guidelines was optimal for patients with VB. Further optimization is required for HCC screening and patient education. Multiple factors play a role in readmissions for patients with cirrhosis; this model helps to identify patients at risk for readmission and opens an area for quality improvement measures to avoid unnecessary hospitalizations.
Liver cirrhosis (LC) is a major cause of mortality and morbidity in the United States. More than 100,000 patients are discharged each year with chronic liver disease and cirrhosis as the first-listed diagnosis [
Liver fibrosis results from the perpetuation of the normal wound healing response resulting in an abnormal continuation of fibrogenesis (connective tissue production and deposition). Fibrosis progresses at variable rates depending on the cause of liver disease, environmental and host factors [
Ascites is the most common major complication of cirrhosis; other major complications include: hepatic encephalopathy (HE) and variceal hemorrhage [
Variceal bleeding is considered the most dangerous and life threatening consequence of portal hypertension [
Primary liver cancer (hepatocellular carcinoma, HCC) is a serious late complication of chronic hepatic injury, particularly in cirrhosis due to Hepatitis B Virus, Hepatitis C Virus, and hemochromatosis. The incidence of HCC has increased by 70% in the United States over the past 20 years, particularly among younger patients [
Hospital readmissions among patients with decompensated liver cirrhosis are common, costly, moderately predictable―in some cases possibly preventable―and independently associated with mortality [
The aim of this study was to evaluate the adherence to AASLD guidelines at a tertiary teaching center and to assess for predictors of re-hospitalization within 30 days after discharge.
We conducted a retrospective chart review for patients with decompensated LC admitted to University of Texas Medical Branch (UTMB) at Galveston from June 2012 to June 2013. Cases were identified using International Classification of Diseases, 9th revision (ICD-9) codes: 571.2 (alcoholic cirrhosis), 571.5 (non-alcoholic cirrhosis), 572.3 (portal hypertension), 572.2 (hepatic encephalopathy), 456.0 to 456.2 (esophageal varices with and without bleeding), 789.5 (ascites), 789.59 (nonmalignant ascites), 567.23 (spontaneous bacterial peritonitis), and 572.4 (hepatorenal syndrome). Electronic medical records were reviewed by the authors MM and AZ. Liver cirrhosis was confirmedeither by histology if liver biopsy was done and showed grade 4 fibrosis, or by imaging if ultrasound (US), Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) showed typical features of advanced liver disease; recanalization of umbilical vein, nodularity of the liver, presence of vascular collaterals and reversal of portal blood flow. We included patients with LC who were admitted for: fluid overload, HE, variceal bleeding, hepatorenal syndrome, SBP or abdominal pain. We excluded patients who were admitted for any other reasons including infection other than SBP, patients who left the hospital against medical advice and hospice patients. For patients with multiple admissions, the latest admission that meets the inclusion criteria was included.
Our primary outcome was adherence to AASLD guidelines for the management of variceal hemorrhage, fluid overload and hepatocellular carcinoma screening. Adherence to AASLD guidelines for the management of variceal hemorrhage was defined as: use of proton pump inhibitor, somatostatin analogues and antibiotic therapy for SBP prophylaxis at the time of admission. Adherence to AASLD guidelines for the management of fluid overload was defined as: use of diuretics, salt restriction and patient education. Adherence to AASLD guidelines for the screening of HCC was defined as: Liver ultrasound or CT scan every 6 - 12 months. Our secondary outcome was re-admission rate within 30 days of discharge with the exclusion of elective admissions.
Study data were collected and managed using REDCap electronic data capture tools hosted at UTMB [
The institutional review board (IRB) approved our study. Variables collected include demographics (age, sex, and race), etiology of cirrhosis, and presence of hepatocellular carcinoma, comorbid conditions and reason for hospitalization. Laboratory values of interest included white blood cell count, platelet count, sodium level, creatinine level, albumin level, total bilirubin, and international normalized ratioon admission. Model for End-stage Liver Disease (MELD) score and Child’s Pugh score were both calculated. Data regarding whether the patient required intensive level of care or was readmitted within 30 days of discharge was also gathered.
Descriptive statistics was conducted using STATA software for the primary outcome. For the secondary outcome Multivariate Adaptive Regression Splines (MARS) model was developed on 80% of the data (training), and tested on the remaining 20% (testing). MARS is a nonparametric regression procedure that seeks to create a classification model based on piecewise linear regressions. This algorithm has the ability to search through a large number of candidate predictor variables to determine those most relevant to the classification model. We used five variables as input, and created a model with the ability to correctly predict hospital readmission with an 81.2% success rate in the training population and a 72.73% success rate in the testing population based on these five variables.
A total of 139 patients met the inclusion criteria. The baseline characteristics of these patients are summarized in
One third of patients required Intensive Care Unit (ICU) level of care. A hepatologist, either as a consult service or as a primary service, was involved in 84.2% of patients’ care. Only 31% of patients followed up with hepatology or gastroenterology clinic within 1 month after discharge. Physical exam findings and laboratory values on presentation are shown in
N = 139 | |
---|---|
Age-year | 54.6 ± 9.9 |
Male sex―n. (%) | 90 (64.8) |
Race―n. (%) | |
African American | 16 (11.5) |
Caucasian | 91 (65.5) |
Hispanic | 32 (23.0) |
Etiology of cirrhosis―n. (%)* | |
HCV | 69 (49.6) |
Alcohol | 86 (61.2) |
HBV | 2 (1.4) |
NAFLD | 11 (7.9) |
Autoimmune | 6 (4.3) |
Other† | 9 (6.5) |
Reason for admission―n. (%)* | |
Variceal Bleeding | 37 (26.6) |
Ascites | 54 (38.9) |
Hepatic Encephalopathy | 50 (36.0) |
Coagulopathy | 4 (2.9) |
SBP | 7 (5.0) |
Abdominal Pain | 16 (11.5) |
Other‡ | 12 (8.6) |
Hepatologist involved in patients’ care―n. (%)§ | 117 (84.2) |
30 day re-admission―n. (%) | 43 (31.0) |
Procedures―n. (%)* | |
Paracentesis | 54 (38.9) |
EGD | 45 (32.3) |
Colonoscopy | 5 (3.6) |
TIPS | 6 (4.3) |
Liver Biopsy | 3 (2.2) |
ICU level of care―n. (%) | 46 (33.1) |
Mortality―n. (%) | 12 (8.6) |
Comorbidity―n. (%) | |
Heart Disease | 16 (11.5) |
Diabetes | 27 (19.4) |
Renal Failure¶ | 44 (31.7) |
COPD | 5 (3.6) |
HIV | 2 (1.4) |
Malignancy‖ | 35 (25.2) |
*Patients may have more than one reason to be admitted, etiology of cirrhosis or procedure performed. †Include: Hemochromatosis (1), Wilson Disease (0), PBC (2), PSC (1), Alpha 1 Anti Trypsin Deficiency (1), Secondary Liver Cancer (1) and Cryptogenic (3). ‡Include: AKI, Alcoholic hepatitis, Cholangitis, HCC, Hepatic hydrothorax, Jaundice, Umbilical hernia. §Either as admitted to liver service or as a consult service when admitted to non-liver service. ¶Includes: AKI (30), CKD (9) and ESRD (5). ‖Includes HCC (22) and other (13). Abbreviations: HCV: Hepatitis C Virus; HBV: Hepatitis B Virus; NAFLD: Non Alcoholic Fatty Liver Disease; PBC: Primary Biliary Cirrhosis; PSC: Primary Sclerosing Cholangitis; AKI: Acute Kidney Injury; CKD: Chronic Kidney Disease; ESRD: End Stage Renal Disease; HCC: Hepatocellular Cancer; EGD: Esophagogastroduodenoscopy; TIPS: Transjugular Intrahepatic Portosystemic Shunt; ICU: Intensive Care Unit; COPD: Chronic Obstructive Pulmonary Disease; HIV: Human Immunodeficiency Virus
N = 139 | |
---|---|
Systolic Blood Pressure > 100 mm Hg―n. (%) | 122 (87.8) |
Heart Rate, rate/min―n. (%) | |
<50 | 4 (2.9) |
50 - 59 | 4 (2.9) |
60 - 99 | 87 (62.6) |
≥100 | 44 (31.4) |
Mental Status―n. (%) | |
Alert | 99 (71.2) |
Disoriented | 20 (14.4) |
Stuporous | 13 (9.4) |
Comatose | 7 (5.0) |
Flapping Tremor―n. (%) | 24 (17.3) |
Ascites―n. (%) | 81 (58.3) |
Bilateral Lower Extremity Edema―n. (%) | 68 (49.0) |
Jaundice―n. (%) | 56 (40.3) |
Value (±SD) | |
---|---|
Hgb, g/dL | 10.3 (±2.3) |
WBC count, 106 cells/dL | 8.0 (±5.2) |
Platelet count, 103 cells/µL | 120 (±86) |
INR | 1.8 (±2.0) |
Albumin, g/dL | 2.8 (±0.6) |
Total Bilirubin, U/L | 4.9 (±6.8) |
Sodium, mEq/L | 136 (±6) |
Potassium, mEq/L | 4.3 (±0.8) |
Creatinine, mg/dL | 1.4 (±1.4) |
MELD score | 18 (±8) |
Child Pugh Score | 9 (±2) |
Abbreviations: SD: Standard Deviation; Hgb: Hemoglobin; WBC: White Blood Cell; INR: International Normalized Ratio; MELD: Model for End Stage Liver Disease.
For patients admitted with fluid overload (n = 54), 31.7% of them were diuretics naïve, and dose adjustment
on discharge was done in 57.6%. Eighty seven percent of them were discharged on low sodium diet but patient education was only documented in 7.4%.
For patients admitted with variceal bleeding (n = 37), prior to admission screening esophagogastroduodenoscopy was done in 74.8% of them. Proton pump inhibitors, octreotide and SBP prophylaxis were given on admissionto 94.6% of patients.
Hepatocellular cancer screening modalities included liver ultrasound (manufacturer General Electric) (56.1%), CT (manufacturer General Electric) with triple phase contrast (62.6%) and MRI (manufacturer General Electric) of the liver (6.5%). For patients who are eligible for HCC screening, interval screening every 6 to 12 months was done in only 40.3%.Primary study outcomes are summarized in
Thirty-day readmission rate was 31.0%, of those 47% and 37% were admitted for HE and fluid overload respectively. Significant predictors for 30-day readmission included high MELD score and elevated creatinine. These results are similar to results found by Volk et al. [
Patients with chronic liver disease presenting with acute decompensation are often seriously ill. The AASLD proposed guidelines for the management of such events like variceal bleeding [
N = 139 | |
---|---|
Variceal Bleeding―n. (%) | 37 (26.6) |
PPI | 35 (94.6) |
Somatostatin Analogues | 35 (94.6) |
Antibiotic therapy for SBP prophylaxis | 35 (94.6) |
Ascites and Volume Overload―n. (%) | 54 (38.9) |
Diuretics | 41 (75.9) |
Salt Restriction | 47 (87.0) |
Patient Education | 4 (7.4) |
HCC screening―n. (%)* | 56 (40.3) |
*Every 6 to 12 month; Abbreviations: PPI: Proton Pump Inhibitor; SBP: Spontaneous Bacterial Peritonitis.
40.3%. Acute medical management with proton pump inhibitors, somatostatin analogues and antibiotics for SBP prophylaxis for patients admitted with bleeding varices was optimal (94.6%).
The 30-day readmission rate was 31%. It is lower than what Volk et al. reported (37%) [
This study shows another predictive role of MELD score; patients with a higher MELD score were found more likely to be readmitted; this was also reported by Berman et al. [
Johnson et al. [
Shu et al. [
Cirrhosis is a complex disease with multiple complications that are overwhelming for patients and their care providers. Our current episodic and uncoordinated system of healthcare delivery is poorly structured for such patients with chronic disease [
The limitations of our study include: 1) It’s retrospective; 2) It was done in a single center; 3) The sample size is relatively small. Also re-admissions could have happened to other hospitals in the area.
In summary, compliance with AASLD guidelines was optimal for patients with variceal bleeding. Further optimization is required for HCC screening and patient education for ascites. We believe that this study will add to the literature in several ways. First, it helps identifying gaps in treating patients with LC. Second, it outlines predictors of 30-day readmission that can help identifying patients that might benefit from post discharge care. Further prospective studies are needed to better identify and possibly implement quality measures that might improve patients’ outcome and avoid unnecessary hospitalizations.
Maen M. Masadeh,Ali Zaied,Feroze Hussain,Heidi Spratt,Roger Soloway, (2015) Adherence to American Association for the Study of Liver Diseases (AASLD) Guidelines and Predictors of Readmission in Cirrhotic Patients: A Single Center Experience. Open Access Library Journal,02,1-8. doi: 10.4236/oalib.1101593
LC: Liver cirrhosis
AASLD: American Association for the Study of Liver Disease
VB: Variceal Bleeding
HCC: Hepatocellular Carcinoma
HE: Hepatic Encephalopathy
SBP: Spontaneous Bacterial peritonitis
MELD: Model for End Stage Liver Disease
MARS: Multivariate Adaptive Regression Splines
LOS: Length of Stay
CT: Computed Tomography
MRI: Magnetic Resonance Imaging