Exploring opportunities to prevent cirrhosis admissions in the emergency department: A multicenter multidisciplinary survey

Abstract

Patients with cirrhosis have high admission and readmission rates, and it is estimated that a quarter are potentially preventable. Little data are available regarding nonmedical factors impacting triage decisions in this patient population. This study sought to explore such factors as well as to determine provider perspectives on low‐acuity clinical presentations to the emergency department, including ascites and hepatic encephalopathy. A survey was distributed in four liver transplant centers to both emergency medicine and hepatology providers, who included attending physicians, house staff, and advanced practitioners; 196 surveys were returned (estimated response rate 50.6%). Emergency medicine providers identified several influential nonmedical factors impacting inpatient triage decisions, including input from a hepatologist (77.7%), inadequate patient access to outpatient specialty care (68.6%), and patient need for diagnostic testing for a procedure (65.6%). When given patient‐based scenarios of low‐acuity cases, such as ascites requiring paracentesis, only 7.0% believed patients should be hospitalized while 48.9% said these patients would be hospitalized at their institution (P < 0.0001). For mild hepatic encephalopathy, the comparable numbers were 19.5% and 55.2%, respectively (P < 0.001). Several perceived barriers were cited for this discrepancy, including limited resources both in the outpatient setting and emergency department. Most providers believed that an emergency department observation unit protocol would influence triage toward an emergency department observation unit visit instead of inpatient admission for both ascites requiring large volume paracentesis (83.2%) and mild hepatic encephalopathy (79.4%). Conclusion: Many nonmedical factors that influence inpatient triage for patients with cirrhosis could be targeted for quality improvement initiatives. In some scenarios, providers are limited by resource availability, which results in triage to an inpatient admission even when they believe this is not the most appropriate disposition. (Hepatology Communications 2018;2:237‐244)

Hepatic Encephalopathy is a Strong Predictor of Early Hospital Readmission Among Cirrhosis Patients

“…13,14 Similar to previous studies, our present study also demonstrated that the presence of hepatic encephalopathy was the strongest predictor of early readmission to the hospital. 4,6,7,9,11 This consistent observation across studies and across different cohorts is important for several reasons. First, it validates the important predictive ability of hepatic encephalopathy on recurrent hospitalizations.…”

“…These observations highlight the potential for a systematic targeted quality improvement program to significantly improve hepatic encephalopathy management and overall cirrhosis-related outcomes. 5,11 Another important factor influencing hospital readmission rates among cirrhosis patients involves suboptimal patient awareness and understanding of their disease process. A study by Volk et al 7 reported that 22% of readmissions can be attributed to inadequate patient education about medication dosing (especially in regards to adjusting lactulose) or lack of prompt follow-up labs or clinic visits to adjust diuretics.…”

“…Similar findings were reported in additional cohorts of decompensated cirrhosis patients, all concluding that not only were rates of readmission high but presence of cirrhosis-related complications were strong predictors of risk of readmission. 4,7,11 Cirrhosis patients among underserved safety-net health systems are even more vulnerable populations. Although inherent system barriers already contribute to impaired access to care, cirrhosis patients among this complex safety-net system are even more disadvantaged, and we hypothesize that these populations will have high rates of hospital readmission as well.…”

A Smartphone App to Manage Cirrhotic Ascites Among Outpatients: Feasibility Study

“…In a recent interview study of patients with an early readmission for decompensated cirrhosis, the majority stated that they would use a smartphone to manage their condition, particularly if it was able to transmit weight data to their provider [ 13 ]. Retrospective and survey studies suggest that programs with enhanced outpatient care can improve outcomes for patients with ascites [ 14 , 15 ].…”

A Smartphone App to Manage Cirrhotic Ascites Among Outpatients: Feasibility Study (Preprint)

“…Retrospective and survey studies suggest that programs with enhanced outpatient care can improve outcomes for patients with ascites [14,15].…”