Targets to improve quality of care for patients with hepatic encephalopathy: data from a multi-centre cohort

• Type of Material: Article
• Authors: Jasmohan S. Bajaj, Virginia Commonwealth University; Jacqueline G. O'Leary, Dallas VA Medical Center; Puneeta Tandon, University of Alberta; Florence Wong, University of Toronto; Patrick S. Kamath, Mayo Clinic; Scott W. Biggins, University of Washington; Guadalupe Garcia-Tsao, Yale University; Jennifer Lai, University of California San Francisco; Michael B. Fallon, University of Arizona; Paul J. Thuluvath, Mercy Medical Center; Hugo E. Vargas, Mayo Clinic; Benedict Maliakkal, University of Tennessee; Ram Subramanian, Emory University; Leroy R. Thacker, McGuire VA Medical Center; K. Rajender Reddy, University of Pennsylvania
• Language: English
• Date: 2019-06-01
• Publisher: Wiley
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2019 John Wiley & Sons Ltd.
• Final Published Version (URL): http://dx.doi.org/10.1111/apt.15265
• Title of Journal or Parent Work: Alimentary Pharmacology & Therapeutics
• Volume: 49
• Issue: 12
• Start Page: 1518
• End Page: 1527
• Grant/Funding Information: This study was funded in part by VA Merit Review Grant I0CX001076 and NCATS R21TR002024 to JSB and institutions of NACSELD members have received research funding from Grifols and Valeant Pharmaceuticals as part of investigator-initiated grants.; Supported by VA Merit I0CX00176, NCATS R21TR002024 and investigator-initiated grants from Grifols and Valeant Pharmaceuticals
• Keywords: Risk; Science & Technology; Pharmacology & Pharmacy; Life Sciences & Biomedicine; Rifaximin treatment; Chronic liver failure; Mortality; Article; Health; Cirrhotic patients; Economic burden; Gastroenterology & Hepatology; Hospital readmissions; Medications
• Research Categories: Health Sciences, Pharmacy; Biology, Biostatistics; Health Sciences, Health Care Management

Abstract

Background: Hepatic encephalopathy (HE) can adversely affect outcomes in both in-patients and out-patients with cirrhosis. Aim: To define targets for improving quality of care in HE management in the multi-centre North American Consortium for End-Stage Liver Disease (NACSELD) cohort. Method: NACSELD in-patient cohort was analysed for (a) medication-associated precipitants, (b) aspiration pneumonia development, (c) HE medication changes, and (d) 90-day HE recurrence/readmissions. Comparisons were made between patients on no-therapy, lactulose only, rifaximin only or both. Ninety-day HE-readmission analysis was adjusted for MELD score. Results: Two thousand eight hundred and ten patients (1102 no-therapy, 659 lactulose, 154 rifaximin, 859 both) were included. HE on admission, and HE rates during hospitalisation were highest in those on lactulose only or dual therapy compared to no-therapy or rifaximin only (P < 0.001). Medications were the most prevalent precipitants (32%; 21% lactulose over/underuse, 5% benzodiazepines, 4% opioids, 1% rifaximin underuse, 1% hypnotics). Patients with medication-associated precipitants had a better prognosis compared to other precipitants. A total of 23% (n = 217) reached grade 3/4 HE, of which 16% developed HE-related aspiration pneumonia. Two thousand four hundred and twenty patients were discharged alive without liver transplant (790 no-therapy, 639 lactulose, 136 rifaximin, 855 both); 12.5% (n = 99) of no-therapy patients did not receive a discharge HE therapy renewal. Ninety-day HE-related readmissions were seen in 16% of patients (9% no-therapy, 9% rifaximin only, lactulose only 18%, dual 21%, <0.001), which persisted despite MELD adjustment (P = 0.009). Conclusion: Several targets to improve HE management were identified in a large cohort of hospitalised cirrhotic patients. Interventions to decrease medication-precipitated HE, prevention of aspiration pneumonia, and optimisation of HE medications are warranted.