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

• 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
• Journal Title: Alimentary Pharmacology & Therapeutics
• Volume: Volume 49, Number 12
• Publisher: Wiley | 2019-06-01, Pages 1518-1527
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1111/apt.15265
• Subjects: Health Sciences, Pharmacy; Health Sciences, Health Care Management; Biology, Biostatistics
• Keywords: Science & Technology; Life Sciences & Biomedicine; Gastroenterology & Hepatology; Pharmacology & Pharmacy; Chronic liver failure; Cirrhotic patients; Hospital readmissions; Rifaximin treatment; Economic burden; Mortality; Health; Risk; Medications; Article

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.