Hospital resource intensity and cirrhosis mortality in United States

Abstract

AIMTo determine whether hospital characteristics predict cirrhosis mortality and how much variation in mortality is attributable to hospital differences.METHODSWe used data from the 2005-2011 Nationwide Inpatient Sample and the American Hospital Association Annual survey to identify hospitalizations for decompensated cirrhosis and corresponding facility characteristics. We created hospital-specific risk and reliability-adjusted odds ratios for cirrhosis mortality, and evaluated patient and facility differences based on hospital performance quintiles. We used hierarchical regression models to determine the effect of these factors on mortality.RESULTSSeventy-two thousand seven hundred and thirty-three cirrhosis admissions were evaluated in 805 hospitals. Hospital mean cirrhosis annual case volume was 90.4 (range 25-828). Overall hospital cirrhosis mortality rate was 8.00%. Hospital-adjusted odds ratios (aOR) for mortality ranged from 0.48 to 1.89. Patient characteristics varied significantly by hospital aOR for mortality. Length of stay averaged 6.0 ± 1.6 days, and varied significantly by hospital performance (P < 0.001). Facility level predictors of risk-adjusted mortality were higher Medicaid case-mix (OR = 1.00, P = 0.029) and LPN staffing (OR = 1.02, P = 0.015). Higher cirrhosis volume (OR = 0.99, P = 0.025) and liver transplant program status (OR = 0.83, P = 0.026) were significantly associated with survival. After adjusting for patient differences, era, and clustering effects, 15.3% of variation between hospitals was attributable to differences in facility characteristics.CONCLUSIONHospital characteristics account for a significant proportion of variation in cirrhosis mortality. These findings have several implications for patients, providers, and health care delivery in liver disease care and inpatient health care design.

Superior Performance of Teaching and Transplant Hospitals in the Management of Hepatic Encephalopathy from 2007 to 2014

“…That said, in a study by Volk et al ,15 proper titration of lactulose and diuretics along with failure to plan out-patient paracenteses were the greatest drivers of “preventable” readmissions. Of interest though, there have been multiple studies that have shown correlation between spending and improved morality, including cirrhosis,16–20 which is in line with this study’s results. However, another study by Fisher et al 21 demonstrated that greater spending driven by more specialists’ involvement and therapeutic interventions were not correlated with improved outcomes.…”

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

“…Liver disease severity, as assessed by MELD scores, was similar for the patients of the two hospitals. U1 and U2 were similar with regard to features considered advantageous, 14 including having high volumes of patients with cirrhosis, emergency and intensive care departments, academic hospital status, and advanced endoscopic and radiological facilities.…”

“…It is difficult to identify the specific aspect of the multifaceted care model most likely to have contributed to its positive effects, but the dedicated inpatient liver unit, staffed by gastroenterologists with a special interest and experience in hepatology and liver transplantation, may have been important, as specialist care has been associated with reduced mortality among patients with decompensated cirrhosis 15 . The presence of the state liver transplantation unit at U1 may have influenced outcomes, as transplantation centres are associated with lower in‐hospital mortality among patients with cirrhosis 14 . However, patients in U1 and U2 had equal access to the liver transplant facility.…”

Rural‐Urban Differences in In‐Hospital Mortality Among Admissions for End‐Stage Liver Disease in the United States

“…(34,35) Our findings support those of previous studies that demonstrated the importance of hospital-level characteristics to outcomes among patients with cirrhosis. (7,8) Mellinger et al found that patients admitted to rural hospitals had a 27% higher odds of in-hospital mortality than patients admitted to urban hospitals after accounting for patient-level factors. However, in their cohort, this effect was not statistically significant.…”

“…Characteristics of the treating hospital play a large role in the outcomes of patients with cirrhosis. Inpatient mortality varies substantially among hospitals and is partially attributable to differences in resource intensity at the hospital level . Little is known about treatment outcomes in rural hospitals, where outcomes for other conditions, such as acute myocardial infarction and congestive heart failure, are known to be inferior .…”