Coordinated care for patients with cirrhosis: fewer liver‐related emergency admissions and improved survival

Abstract

Objectives: To compare the incidence of liver‐related emergency admissions and survival of patients after hospitalisation for decompensated cirrhosis at two major hospitals, one applying a coordinated chronic disease management model (U1), the other standard care (U2); to examine predictors of mortality for these patients. Design: Retrospective observational cohort study. Setting: Two major tertiary hospitals in an Australian capital city. Participants: Patients admitted with a diagnosis of decompensated cirrhosis during October 2013 – October 2014, identified on the basis of International Classification of Diseases (ICD‐10) codes. Main outcome measures: Incident rates of liver‐related emergency admissions; survival (to 3 years). Results: Sixty‐nine patients from U1 and 54 from U2 were eligible for inclusion; the median follow‐up time was 530 days (range, 21–1105 days). The incidence of liver‐related emergency admissions was lower for U1 (mean, 1.14 admissions per person‐year; 95% CI, 0.95–1.36) than for U2 (mean, 1.55 admissions per person‐year; 95% CI, 1.28–1.85; adjusted incidence rate ratio [U1 v U2], 0.52; 95% CI, 0.28–0.98; P = 0.042). The adjusted probabilities of transplantation‐free survival at 3 years were 67.7% (U1) and 37.2% (U2) (P = 0.009). Independent predictors of reduced transplantation‐free free survival were Charlson comorbidity index score (per point: hazard ratio [HR], 1.27; 95% CI, 1.05–1.54, P = 0.014), liver‐related emergency admissions within 90 days of discharge (HR, 3.60; 95% CI, 1.87–6.92; P < 0.001), and unit (U2 v U1: HR, 2.54, 95% CI, 1.26–5.09; P = 0.009). Conclusions: A coordinated care model for managing patients with decompensated cirrhosis was associated with improved survival and fewer liver‐related emergency admissions than standard care.

Validation of a Dynamic Risk Classification System for in-Hospital Death, Based on Electronic Records of Non-Surgical Admissions to General Hospitals

“…Hepatic cirrhosis and lung infections were the other most relevant diagnostic risk factors. Admissions for hepatic cirrhosis generally occur in terminal stages of the disease (RAMACHANDRAN et al, 2018). Respiratory infections, however, are amongst the top reasons for hospital admissions in Brazil (GOMES et al, 2010), many times as complications of other major underlying disease (BAHLIS et al, 2018).…”

Improving Medication‐Related Outcomes in Chronic Liver Disease

“…(7,(89)(90)(91)(92)(93)(94) Most involved implementation of new multidisciplinary "chronic disease management" models or "patient care management" programs to improve postdischarge care and prevent readmission. Three studies delivered face-to-face interventions (89,92,93) and two studies used modern technologies (90,91) to assist with remote management of medications and liver disease complications. While outcome measures varied, most studies reported reduced readmission rates (including for potentially medication-preventable complications, like ascites and HE) but not medication-specific outcome measures, like adherence or MRPs.…”

“…(99,100) Given the degree of frailty that is commonly present in people Wigg et al (89) Single-center prospective, randomized, controlled, parallel-group study design; al. (93) Retrospective observational cohort study between two tertiary hospitals (unit 1 vs. unit 2);…”

“…A small number of patient‐oriented interventions that mention a dedicated medication component have been conducted in people with cirrhosis (Table 3). ( 7,89‐94 ) Most involved implementation of new multidisciplinary “chronic disease management” models or “patient care management” programs to improve postdischarge care and prevent readmission. Three studies delivered face‐to‐face interventions ( 89,92,93 ) and two studies used modern technologies ( 90,91 ) to assist with remote management of medications and liver disease complications.…”

Patient‐centred care for cirrhosis: a key role for chronic disease management

“…In this issue of the MJA , Ramachandran and colleagues 10 report the results of a retrospective study in which they compared the rates of liver‐related emergency admissions and survival for patients hospitalised for decompensated cirrhosis at two major metropolitan hospitals, one of which had implemented chronic disease management for patients with liver disease. This comprehensive liver failure program was a nurse‐led model of care with support from specialist hepatologists.…”