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Current Gastroenterology Reports

Erschienen in:

01.01.2017 | Liver (S Cotler and E Kallwitz, Section Editors)

Strategies to Reduce 30-Day Readmissions in Patients with Cirrhosis

verfasst von: Elliot B. Tapper, Michael Volk

Erschienen in: Current Gastroenterology Reports | Ausgabe 1/2017

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Abstract

Purpose of Review

Approximately, one quarter of patients discharged after a hospitalization for decompensated cirrhosis will be readmitted within 30 days. These readmissions have been associated with increased morbidity and mortality, can be financially harmful to the health system, and may be partially preventable. This review summarizes the literature on readmissions, providing clinicians with tools for risk prediction and a taxonomy for preventative interventions.

Recent Findings

Readmission strategies can be categorized according to complexity (simple versus complex) and specificity (focused versus broad). The literature thus far provides the following generalizable inferences: 1) Interventions should be integrated in the clinical workflow, 2) default options are more powerful than voluntary actions, 3) knowledge improvement should focus on the front line clinicians, 4) process improvements do not always translate into better outcomes, and 5) any successful intervention must include viable alternatives to hospitalization.

Summary

A growing body of literature provides concrete and actionable guidance for interventions to reduce readmissions in patients with cirrhosis.

• Tapper EB. Building effective quality improvement programs in liver disease: a systematic review of quality improvement initiatives. Clin Gastroenterol Hepatol. 2016. A systematic review of quality improvement initiatives for patients with cirrhosis highlights the common features of successful and unsuccessful programs.

Volk ML, Tocco RS, Bazick J, Rakoski MO, Lok AS. Hospital readmissions among patients with decompensated cirrhosis. Am J Gastroenterol. 2012;107(2):247–52.CrossRefPubMed

•• Tapper EB, Halbert B, Mellinger J. Rates of and reasons for hospital readmissions in patients with cirrhosis: a multistate population-based cohort study. Clin Gastroenterol Hepatol. 2016. The first population-based cohort study on readmsisions. It established that readmission risk is proportional to the number of hepatic decompensations, most linked to hepatic encephalopathy overall and substance abuse-related admissions among non-decompensated patients with alcoholic cirrhosis.

Bajaj JS, O’Leary JG, Reddy KR, Wong F, Olson JC, Subramanian RM, et al. Second infections independently increase mortality in hospitalized patients with cirrhosis: the North American consortium for the study of end‐stage liver disease (NACSELD) experience. Hepatology. 2012;56(6):2328–35.CrossRefPubMedPubMedCentral

Tapper EB, Risech-Neyman Y, Sengupta N. Psychoactive medications increase the risk of falls and fall-related injuries in hospitalized patients with cirrhosis. Clin Gastroenterol Hepatol. 2015;13(9):1670–5.CrossRefPubMed

Tapper EB. Challenge accepted: confronting readmissions for our patients with cirrhosis. Hepatology. 2016.

•• Bajaj JS, Reddy KR, Tandon P, Wong F, Kamath PS, Garcia-Tsao G, et al. The three-month readmission rate remains unacceptably high in a large north american cohort of cirrhotic patients. Hepatology. 2015. The first multicenter evaluation of readmissions. This cohort of complex patients with decompensated cirrhosis have a >50% 90-day readmission rate. Independent associations with readmission risk include hepatic encephalopathy and proton-pump inhibitor use.

Singal AG, Rahimi RS, Clark C, Ma Y, Cuthbert JA, Rockey DC, et al. An automated model using electronic medical record data identifies patients with cirrhosis at high risk for readmission. Clin Gastroenterol Hepatol. 2013;11(10):1335–41.e1.CrossRefPubMed

Tapper EB, Finkelstein D, Mittleman MA, Piatkowski G, Lai M. Standard assessments of frailty are validated predictors of mortality in hospitalized patients with cirrhosis. Hepatology. 2015.

10.

Li R, Tierney A, Carr R. The impact of Peri-discharge interventions on 30-day readmission and 90-day mortality rates for patients admitted with hepatic encephalopathy. Am J Gastroenterol. 2014;109:S131.CrossRef

11.

•• Morando F, Maresio G, Piano S, Fasolato S, Cavallin M, Romano A, et al. How to improve care in outpatients with cirrhosis and ascites: a new model of care coordination by consultant hepatologists. J Hepatol. 2013;59(2):257–64. The most significant publication on care redesign for patients with cirrhosis. This Italian group enrolled a small cohort of post-discharge patients to receive as-needed multidisciplinary management at day-hospitals equipped to perform testing and procedures. They significantly reduced readmissions and overall costs.

12.

•• Tapper EB, Finkelstein D, Mittleman MA, Piatkowski G, Chang M, Lai M. A quality improvement initiative reduces 30-day rate of readmission for patients with cirrhosis. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2015. An online decision aid built into the electronic ordering system used default options to standardize care for patients with decompensated cirrhosis, particularly those with hepatic encephalopathy and reduced readmissions by 40%. A prior checklist intervention failed to reduce readmissions.

13.

•• Wigg AJ, McCormick R, Wundke R, Woodman RJ. Efficacy of a chronic disease management model for patients with chronic liver failure. Clin Gastroenterol Hepatol. 2013;11(7):850–8.e4. An intervention consisting of case management and nursing home-visits failed to reduce readmissions for patients with decompensated cirrhosis. This is likely because the identification of early decompensations does not itself prevent the need for hospitalization.

14.

•• Russo MW, Levi DM, Pierce R, Casingal V, Eskind L, deLemos A, et al. A Prospective study of a protocol that reduces readmission after liver transplantation. Liver Transpl. 2016. A classic example of quality improvement processes was employed to determine and address the root causes for post-transplant readmissions. The authors were successful in reducing 30-day readmissions.

15.

Volk ML, Kanwal F. Quality of care in the cirrhotic patient. Clin Transl Gastroenterol. 2016;7(4):e166.CrossRefPubMedPubMedCentral

16.

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17.

Johnson EA, Spier BJ, Leff JA, Lucey MR, Said A. Optimising the care of patients with cirrhosis and gastrointestinal haemorrhage: a quality improvement study. Aliment Pharmacol Ther. 2011;34(1):76–82.CrossRefPubMed

18.

Wundke R, Altus R, Sandford J, Wigg A. Improving management of oesophageal varices in patients with cirrhosis. Qual Saf Health Care. 2010;19(6):536–41.PubMed

19.

• Kanwal F, Asch SM, Kramer JR, Cao Y, Asrani S, El‐Serag HB. Early outpatient follow‐up and 30‐day outcomes in patients hospitalized with cirrhosis. Hepatology. 2016. This is an important paper that demonstrates how early clinical follow-up after discharge improves mortality and increases readmission rates, highlighting that there is both a hierarchy of outcomes (readmissions are secondary) and the need for care-coordination of alternatives to rehospitalization.

20.

• Ghaoui R, Friderici J, Desilets DJ, Lagu T, Visintainer P, Belo A, et al. Outcomes associated with a mandatory gastroenterology consultation to improve the quality of care of patients hospitalized with decompensated cirrhosis. J Hosp Med. 2015;10(4):236–41. In the absence of a standardized care protocol, mandatory gastroenterology consults did not improve outcomes and only slightly improved adherence to quality indicators.CrossRefPubMed

21.

Desai AP, Satoskar R, Appannagari A, Reddy KG, Te HS, Reau N, et al. Co-management between hospitalist and hepatologist improves the quality of care of inpatients with chronic liver disease. J Clin Gastroenterol. 2014;48(4):e30–6.CrossRefPubMed

22.

Tapper EB, Lai M. Factors affecting adherence to a quality improvement checklist on an inpatient hepatology service. Proc (Baylor Univ Med Cent). 2014;27(2):100.

23.

Bradley EH, Curry L, Horwitz LI, Sipsma H, Wang Y, Walsh MN, et al. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ Cardiovasc Qual Outcomes. 2013;6(4):444–50.CrossRefPubMedPubMedCentral

24.

Burke RE, Coleman EA. Interventions to decrease hospital readmissions: keys for cost-effectiveness. JAMA Intern Med. 2013;173(8):695–8.CrossRefPubMed

25.

Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520–8.CrossRefPubMed

26.

Halpern SD, Ubel PA, Asch DA. Harnessing the power of default options to improve health care. N Engl J Med. 2007;357(13):1340–4.CrossRefPubMed

27.

Mellinger JL, Volk ML. Multidisciplinary management of patients with cirrhosis: a need for care coordination. Clin Gastroenterol Hepatol. 2013;11(3):217–23.CrossRefPubMed

28.

• Mellinger JL, Moser S, Welsh DE, Yosef MT, Van T, McCurdy H, et al. Access to subspecialty care and survival among patients with liver disease. Am J Gastroenterol. 2016. Highlighting the benefits of multisciplinary care coordination, these authors demonstrate that access to gastroenterology care improves all-cause mortality in patients with liver disease.

29.

Bini EJ, Weinshel EH, Generoso R, Salman L, Dahr G, Pena‐Sing I, et al. Impact of gastroenterology consultation on the outcomes of patients admitted to the hospital with decompensated cirrhosis. Hepatology. 2001;34(6):1089–95.CrossRefPubMed

30.

• Mayorga CA, Rockey DC. Clinical utility of a standardized electronic order set for the management of acute upper gastrointestinal hemorrhage in patients with cirrhosis. Clin Gastroenterol Hepatol. 2013;11(10):1342–8. The authors create an online decision aid to facilitate guideline-based care for variceal bleeding. Uptake was 50% among clinicians caring for bleeding patients.

31.

Bass NM, Mullen KD, Sanyal A, Poordad F, Neff G, Leevy CB, et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med. 2010;362(12):1071–81.CrossRefPubMed

Titel: Strategies to Reduce 30-Day Readmissions in Patients with Cirrhosis
verfasst von: Elliot B. Tapper
Michael Volk
Publikationsdatum: 01.01.2017
Verlag: Springer US
Erschienen in: Current Gastroenterology Reports / Ausgabe 1/2017
Print ISSN: 1522-8037
Elektronische ISSN: 1534-312X
DOI: https://doi.org/10.1007/s11894-017-0543-3

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