Background
Methods
Data source and study population
Outcome and independent variables
Risk adjustment models
Method | Variants | Description | |
---|---|---|---|
Comorbidity methods | CCI | CCI | Charlson individual comorbidities (binary variables) |
CCI categorized | number of Charlson comorbidities excluding liver disease (0, 1, 2, ≥3) | ||
CCI score | the score of Charlson comorbidities (weighted score) | ||
CCI score categorized | the score of CCI categorized as 0, 1–2, 3–4, ≥5 | ||
ECI | ECI | Elixhauser individual comorbidities (binary variables) | |
ECI categorized | number of Elixhauser comorbidities (0, 1, 2, ≥3) | ||
Liver specific severity methods | MELD | MELD score | calculated by total bilirubin, PT-INR, and creatinine |
MELDNa score | calculated by MELD score and serum sodium | ||
5vMELD score | calculated by MELDNa score and serum albumin | ||
CTP | CTP | the classification of Child-Turcotte-Pugh (including the individual binary variables of hepatic encephalopathy, ascites, total bilirubin, prothrombin time, and albumin) | |
CTP score | calculated by summing the weighted score of each CTP variable | ||
Comorbidity + Liver severity | MELDNa score + ECI | the score of MELDNa + individual binary variable of Elixhauser comorbidities | |
CTP + ECI | individual binary variables of CTP + individual binary variable of Elixhauser comorbidities |
Statistical analysis
Results
Characteristics | Median (interquartile range) or frequency |
---|---|
Na (mmol/L) | 138.4 (135.0–140.0) |
Creatinine (umol/L) | 66.3 (54.5–81.9) |
PT-INR | 1.2 (1.0–1.4) |
Total bilirubin (umol/L) | 27.2 (17.1–59.3) |
Albumin (g/dl) | 34.7 (29.4–40.0) |
CTP scorea
| 5.0 (5.0–6.0) |
MELD score | 8.0 (7.0–11.0) |
MELDNa score | 10.0 (8.0–14.0) |
5vMELD score | 13.0 (9.0–18.0) |
Charlson comorbidity score | 1 (0–2) |
LOS (day) | 13 (5–26) |
Age (year) | |
18–44 | 2576 (23.2%) |
45–64 | 6785 (61.0%) |
≥ 65 | 1761 (15.8%) |
Male | 7773 (69.9%) |
Urgent admission | 1219 (11.0%) |
Na < 135 mmol/L | 2764 (24.9%) |
Creatinine > 88.4 umol/L | 2190 (19.7%) |
PT-INR | |
< 1.7 (normal range) | 10071 (90.6%) |
1.7–2.2 | 724 (6.5%) |
> 2.2 | 327 (2.9%) |
Total bilirubin (umol/L) | |
< 34.2 (normal range) | 6564 (59.0%) |
34.2–51.3 | 1328 (11.9%) |
> 51.3 | 3230 (29.0%) |
Albumin (g/dl) | |
> 3.5 (normal range) | 5370 (48.3%) |
2.8–3.5 | 3660 (32.9%) |
< 2.8 | 2092 (18.8%) |
Hepatic encephalopathyb
| |
Grade I-II | 455 (4.1%) |
Grade III-IV (or refractory) | 109 (1.0%) |
Severity unknown | 1505 (13.5%) |
Ascitesb
| |
Mild | 522 (4.7%) |
Moderate to sever | 103 (0.9%) |
Severity unknown | 5853 (52.6%) |
CTP classificationb
| |
A (CTP score 5–6) | 3952 (35.5%) |
B (CTP score 7–9) | 1002 (9.0%) |
C (CTP score 10–15) | 80 (0.7%) |
Number of abnormal CTP variables | |
0 | 2803 (25.2%) |
1 | 2255 (20.3%) |
2 | 2390 (21.5%) |
≥ 3 | 3674 (33.0%) |
Number of Charlson comorbidities | |
0 | 3580 (32.2%) |
1 | 4564 (41.0%) |
2 | 2212 (19.9%) |
≥ 3 | 766 (6.9%) |
Number of Elixhauser comorbidities | |
0 | 2595 (23.3%) |
1 | 3239 (29.1%) |
2 | 2355 (21.2%) |
≥ 3 | 2933 (26.4%) |
Charlson comorbidities | |
Myocardial infarction | 62 (0.6%) |
Cerebrovascular disease | 371 (3.3%) |
Dementia | 6 (0.1%) |
Renal disease | 1228 (11.0%) |
Any malignancyc
| 645 (5.8%) |
Charlson and Elixhauser shared comorbidities | |
Congestive heart failure | 25 (0.2%) |
Peripheral vascular disease | 7 (0.1%) |
Chronic pulmonary disease | 191 (1.7%) |
Rheumatologic disease | 62 (0.6%) |
Peptic ulcer disease | 1234 (11.1%) |
Diabetes complicated | 130 (1.2%) |
Diabetes uncomplicated | 3957 (35.6%) |
Hemiplegia or paraplegia | 8 (0.1%) |
Metastatic solid tumorc
| 275 (2.5%) |
AIDS | 40 (0.4%) |
Elixhauser comorbiditiesd
| |
Cardiac arrhythmias | 447 (4.0%) |
Valvular disease | 30 (0.3%) |
Hypertension uncomplicated | 2008 (18.1%) |
Hypertension complicated | 1156 (10.4%) |
Hypothyroidism | 95 (0.9%) |
Lymphoma | 20 (0.2%) |
Solid tumor without metastasisc
| 178 (1.6%) |
Coagulopathy | 5 (0.04%) |
Blood loss anemia | 335 (3.0%) |
Deficiency anemia | 959 (8.6%) |
Depression | 41 (0.4%) |
Fluid and electrolyte disorders | 1707 (15.4%) |
Alcohol abuse | 2780 (25.0%) |
Psychoses | 19 (0.2%) |
Renal failure | 236 (2.1%) |
Outcome measure and independent variables
Variables | Mortality % (n) |
P-value1
| |
---|---|---|---|
Age (year) | 18–44 | 4.9 (125) | <0.0001 |
45–64 | 8.0 (543) | ||
≥65 | 14.3 (252) | ||
Sex | male | 9.1 (704) | <0.0001 |
female | 6.5 (216) | ||
Admission status | non-urgent | 6.3 (627) | <0.0001 |
urgent | 24.0 (293) | ||
Hepatic encephalopathy | no | 4.0 (360) | <0.0001 |
yes | 27.1 (560) | ||
Ascites | no | 1.8 (85) | <0.0001 |
yes | 12.9 (835) | ||
PT-INR | <1.7 | 6.2 (628) | <0.0001 |
1.7–2.3 | 23.2 (168) | ||
>2.3 | 37.9 (124) | ||
Total bilirubin (umol/L) | <34.2 | 4.1 (271) | <0.0001 |
34.2–51.3 | 7.1 (94) | ||
>51.3 | 17.2 (555) | ||
Albumin (g/dl) | >35 | 3.2 (170) | <0.0001 |
28–35 | 10.0 (367) | ||
<28 | 18.3 (383) | ||
Creatinine (umol/L) | ≤88.4 | 5.0 (445) | <0.0001 |
>88.4 | 21.7 (475) | ||
Na | ≥135 | 4.4 (364) | <0.0001 |
<135 | 20.1 (556) | ||
MELD score | <7.0 | 1.9 (54) | <0.0001 |
7.0–8.0 | 3.6 (100) | ||
8.0–10.0 | 7.0 (195) | ||
>10.0 | 20.5 (571) | ||
MELDNa score | <8.0 | 0.7 (19) | <0.0001 |
8.0–10.0 | 2.7 (74) | ||
10.0–14.0 | 6.6 (184) | ||
>14.0 | 23.1 (643) | ||
5vMELD score | <9.0 | 0.5 (15) | <0.0001 |
9.0–13.0 | 2.3 (65) | ||
13.0–18.0 | 8.0 (223) | ||
>18.0 | 22.2 (617) | ||
CTP classification | A (CTP score 5–6) | 0.9 (34) | <0.0001 |
B (CTP score 7–9) | 3.2 (32) | ||
C (CTP score 10–15) | 11.3 (9) | ||
Number of abnormal CTP variables | 0 | 0.5 (13) | <0.0001 |
1 | 2.3 (52) | ||
2 | 6.2 (147) | ||
≥3 | 19.3 (708) | ||
Myocardial infarction | no | 8.2 (902) | <0.0001 |
yes | 29.0 (18) | ||
Cerebrovascular disease | no | 7.9 (846) | <0.0001 |
yes | 20.0 (74) | ||
Renal disease | no | 5.9 (586) | <0.0001 |
yes | 27.2 (334) | ||
Any malignancya
| no | 8.0 (841) | <0.0001 |
yes | 12.2 (79) | ||
Congestive heart failure | no | 8.3 (10) | <0.0001 |
yes | 40.0 (10) | ||
Chronic pulmonary disease | no | 8.1 (888) | <0.0001 |
yes | 16.8 (32) | ||
Rheumatologic disease | no | 8.3 (913) | 0.39 |
yes | 11.3 (7) | ||
Peptic ulcer disease | no | 8.1 (801) | 0.06 |
yes | 9.6 (119) | ||
Diabetes complicated | no | 8.3 (907) | 0.47 |
yes | 10.0 (13) | ||
Diabetes uncomplicated | no | 5.2 (374) | <0.0001 |
yes | 13.8 (546) | ||
Hemiplegia or paraplegia | no | 8.3 (919) | 0.66 |
yes | 12.5 (1) | ||
Metastatic solid tumor | no | 7.8 (844) | <0.0001 |
yes | 27.6 (76) | ||
Cardiac arrhythmias | no | 7.9 (840) | <0.0001 |
yes | 17.9 (80) | ||
Valvular disease | no | 8.3 (916) | 0.31 |
yes | 13.3 (4) | ||
Hypertension uncomplicated | no | 7.8 (708) | <0.0001 |
yes | 10.6 (212) | ||
Hypertension complicated | no | 7.9 (784) | <0.0001 |
yes | 11.8 (136) | ||
Hypothyroidism | no | 8.3 (911) | 0.67 |
yes | 9.5 (9) | ||
Lymphoma | no | 8.3 (918) | 0.78 |
yes | 10.0 (2) | ||
Solid tumor without metastasisa
| no | 8.1 (886) | 0.31 |
yes | 19.2 (34) | ||
Coagulopathy | no | 8.3 (918) | 0.01 |
yes | 40.0 (2) | ||
Blood loss anemia | no | 7.6 (818) | <0.0001 |
yes | 30.5 (102) | ||
Deficiency anemia | no | 7.4 (755) | <0.0001 |
yes | 17.2 (165) | ||
Depression | no | 8.2 (913) | <0.0001 |
yes | 17.1 (7) | ||
Fluid and electrolyte disorders | no | 5.5 (519) | <0.0001 |
yes | 23.5 (401) | ||
Psychoses | no | 8.3 (918) | 0.72 |
yes | 10.5 (2) | ||
Renal failure | no | 7.4 (803) | <0.0001 |
yes | 49.6 (117) | ||
AIDS | no | 8.3 (920) | 0.06 |
yes | 0.0 (0) | ||
Peripheral vascular disease | no | 8.3 (920) | 0.43 |
yes | 0.0 (0) | ||
Alcohol abuse | no | 7.49 (625) | <0.0001 |
yes | 10.62 (295) | ||
Number of Charlson comorbidities | 0 | 2.6 (92) | <0.0001 |
1 | 6.0 (272) | ||
2 | 14.2 (315) | ||
≥3 | 31.5 (241) | ||
Charlson comorbidity score categorized | 0 | 2.6 (92) | <0.0001 |
1–2 | 6.2 (310) | ||
3–4 | 16.75 (325) | ||
≥5 | 30.4 (193) | ||
Number of Elixhauser comorbidities | 0 | 2.1 (54) | <0.0001 |
1 | 3.9 (126) | ||
2 | 7.4 (175) | ||
≥3 | 19.3 (565) |
Performance of risk adjustment models
Model | Mean c-statistic (95% CI)b
| Bias-corrected c-statisticc
|
---|---|---|
CCI | 0.809 (0.792–0.822) | 0.816 |
CCI categorized | 0.786 (0.771–0.801) | 0.784 |
CCI score | 0.785 (0.769–0.799) | 0.787 |
CCI score categorized | 0.786 (0.770–0.801) | 0.783 |
ECI | 0.825 (0.749–0.848) | 0.827 |
ECI categorized | 0.794 (0.743–0.841) | 0.773 |
MELDNa score | 0.849 (0.838–0.861) | 0.849 |
5vMELD score | 0.845 (0.833–0.858) | 0.847 |
MELD score | 0.818 (0.805–0.833) | 0.817 |
CTP | 0.851 (0.839–0.864) | 0.847 |
CTP score | 0.793 (0.736–0.844) | 0.803 |
MELDNa score + ECI | 0.882 (0.826–0.898) | 0.882 |
CTP + ECI | 0.887 (0.846–0.901) | 0.885 |
Model | Viral hepatitis | PLC | Alcoholic hepatitis | Decompensated | No-procedurec
|
---|---|---|---|---|---|
Number of cases (%) | 8132 (73.1) | 3824 (34.4) | 2778 (25.0) | 7183 (64.6) | 5433 (48.9) |
CCI | 0.807 (0.789–0.825) | 0.788 (0.764–0.812) | 0.791 (0.761–0.817) | 0.788 (0.771–0.805) | 0.796 (0.778–0.815) |
ECI | 0.821 (0.756–0.846) | 0.828 (0.805–0.849) | 0.837 (0.809–0.860) | 0.807 (0.786–0.825) | 0.834 (0.817–0.852) |
MELDNa score | 0.848 (0.835–0.863) | 0.846 (0.828–0.861) | 0.853 (0.833–0.873) | 0.827 (0.810–0.841) | 0.845 (0.831–0.860) |
CTP | 0.856 (0.842–0.869) | 0.869 (0.851–0.885) | 0.847 (0.827–0.867) | 0.822 (0.806–0.838) | 0.852 (0.837–0.867) |
MELDNa score + ECI | 0.878 (0.836–0.897) | 0.888 (0.871–0.903) | 0.896 (0.876–0.914) | 0.863 (0.846–0.877) | 0.889 (0.876–0.902) |
CTP + ECI | 0.887 (0.847–0.905) | 0.907 (0.891–0.920) | 0.897 (0.878–0.914) | 0.864 (0.848–0.877) | 0.892 (0.878–0.904) |