The 3-Month Readmission Rate Remains Unacceptably High in a Large North American Cohort of Patients With Cirrhosis

• Type of Material: Article
• Authors: Jasmohan S. Bajaj, Virginia Commonwealth University; K. Rajender Reddy, University of Pennsylvania; Puneeta Tandon, University of Alberta; Florence Wong, University of Toronto; Patrick S. Kamath, Mayo Clinic; Guadalupe Garcia-Tsao, Yale University; Benedict Maliakkal, University of Rochester; Scott W. Biggins, Univ Colorado; Paul J. Thuluvath, Mercy Medical Center; Michael B. Fallon, University of Texas; Ram Subramanian, Emory University; Hugo Vargas, Mayo Clinic; Leroy R. Thacker, Virginia Commonwealth University; Jacqueline G. O'Leary, Baylor University Medical Center
• Language: English
• Date: 2016-07-01
• Publisher: Wiley
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2015 by the American Association for the Study of Liver Diseases.
• Final Published Version (URL): http://dx.doi.org/10.1002/hep.28414
• Title of Journal or Parent Work: Hepatology
• ISSN: 0270-9139
• Volume: 64
• Issue: 1
• Start Page: 200
• End Page: 208
• Grant/Funding Information: The study was partly supported by Grifols pharmaceuticals through an investigator-initiated grant and partly through RO1DK089713 awarded to JSB.; None of the funders were involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript
• Keywords: BACTERIAL-INFECTIONS; RISK; HOSPITAL READMISSIONS; UNITED-STATES; PREDICT; HEALTH-CARE; PALLIATIVE CARE; MODEL; DECREASING MORTALITY; Science & Technology; LIVER; Gastroenterology & Hepatology; Life Sciences & Biomedicine
• Research Categories: Health Sciences, Medicine and Surgery; Health Sciences, Epidemiology

Abstract

In smaller single-center studies, patients with cirrhosis are at a high readmission risk, but a multicenter perspective study is lacking. We evaluated the determinants of 3-month readmissions among inpatients with cirrhosis using the prospective 14-center North American Consortium for the Study of End-Stage Liver Disease cohort. Patients with cirrhosis hospitalized for nonelective indications provided consent and were followed for 3 months postdischarge. The number of 3-month readmissions and their determinants on index admission and discharge were calculated. We used multivariable logistic regression for all readmissions and for hepatic encephalopathy (HE), renal/metabolic, and infection-related readmissions. A score was developed using admission/discharge variables for the total sample, which was validated on a random half of the total population. Of the 1353 patients enrolled, 1177 were eligible on discharge and 1013 had 3-month outcomes. Readmissions occurred in 53% (n = 535; 316 with one, 219 with two or more), with consistent rates across sites. The leading causes were liver-related (n = 333; HE, renal/metabolic, and infections). Patients with cirrhosis and with worse Model for End-Stage Liver Disease score or diabetes, those taking prophylactic antibiotics, and those with prior HE were more likely to be readmitted. The admission model included Model for End-Stage Liver Disease and diabetes (c-statistic = 0.64, after split-validation 0.65). The discharge model included Model for End-Stage Liver Disease, proton pump inhibitor use, and lower length of stay (c-statistic = 0.65, after split-validation 0.70). Thirty percent of readmissions could not be predicted. Patients with liver-related readmissions consistently had index-stay nosocomial infections as a predictor for HE, renal/metabolic, and infection-associated readmissions (odds ratio = 1.9-3.0). Conclusions: Three-month readmissions occurred in about half of discharged patients with cirrhosis, which were associated with cirrhosis severity, diabetes, and nosocomial infections; close monitoring of patients with advanced cirrhosis and prevention of nosocomial infections could reduce this burden.