Incidence and Predictors of 30-Day Readmission Among Patients Hospitalized for Advanced Liver Disease

Berman, Kenneth; Tandra, Sweta; Forssell, Kate; Vuppalanchi, Raj; Burton, James R.; Nguyen, James; Mullis, Devonne; Kwo, Paul Y.; Chalasani, Naga

doi:10.1016/j.cgh.2010.10.035

Cited by 148 publications

(159 citation statements)

References 28 publications

(21 reference statements)

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“…Even after excluding the patients with very early readmissions (as we did in our primary analysis), 14% were readmitted in the subsequent 3 weeks. These results are broadly consistent with other data from patients with cirrhosis (1)(2)(3) and similar to those reported for patients with CHF. (4,11) In contrast, the mortality rate in the first 30 days after discharge-8.5% overall and 4.6% after excluding deaths that occurred within the first 7 days-was higher in our patients with cirrhosis than the rates reported for patients with CHF ( 4.0%), (27) underlining the higher burden of cirrhosis for patients as well as the health care system.…”

Section: Discussionsupporting

confidence: 92%

“…Approximately 20% of patients with cirrhosis who have been hospitalized get readmitted to the hospital within the first 30 days after discharge, with substantial implications for outcomes and cost of care. (1)(2)(3) Hospital readmission is a problem that is not unique to patients with cirrhosis. (4-6) Readmission rates and consequently readmission reduction programs have been a major focus of recent quality improvement initiatives across many chronic conditions.…”

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confidence: 99%

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Early outpatient follow‐up and 30‐day outcomes in patients hospitalized with cirrhosis

et al. 2016

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Preventing readmission has been the focus of numerous quality improvement efforts across many conditions. Early outpatient follow-up has been proposed as the best mechanism for reducing readmissions. The extent to which early outpatient follow-up averts readmission or improves outcomes in cirrhosis is not known. We evaluated the relationship between early outpatient follow-up and short-term readmission and mortality in patients with cirrhosis. We conducted a retrospective cohort study of patients with cirrhosis who were hospitalized with a liver-related diagnosis and discharged to home from 122 Veterans Administration hospitals between 2010 and 2013. We defined early follow-up as an outpatient visit with a clinician within 7 days after discharge. We propensity matched patients who received early visit with those who did not have any visit and examined the associations between early follow-up and all-cause readmission and mortality within 8-30 days after discharge. Of 25,217 patients hospitalized with cirrhosis, 8,123 (32.2%) had an early follow-up visit within 7 days of discharge. A total of 3,492 (13.8%) patients were readmitted and 1,185 (4.6%) died between 8 and 30 days after discharge. In the propensity-matched sample (N 5 16,238), patients with early outpatient follow-up visit had a slightly higher risk of readmission (15.3% vs. 13.8%; hazard ratio [HR] 51.10; 95% confidence interval [CI] 5 1.02-1.19), but significantly lower risk of mortality (3.2% vs. 5.2%; HR 5 0.60; 95% CI 5 0.51-0.70) than those without early visit. The findings persisted in several subgroup and sensitivity analyses. Conclusions: Early outpatient follow-up after discharge was associated with a small increase in readmissions but lower overall mortality in patients with cirrhosis. Transitional care may be effective in improving short-term outcomes in patients with cirrhosis, but readmission performance measures would miss this effect. (HEPATOLOGY 2016;64:569-581) C irrhosis is a common and costly condition.Most patients with cirrhosis require frequent hospitalizations. Approximately 20% of patients with cirrhosis who have been hospitalized get readmitted to the hospital within the first 30 days after discharge, with substantial implications for outcomes and cost of care. (1)(2)(3) Hospital readmission is a problem that is not unique to patients with cirrhosis. (4-6) Readmission rates and consequently readmission reduction programs have been a major focus of recent quality improvement initiatives across many chronic conditions. In 2012, the Centers for Medicare and Medicaid Services (CMS) began to invoke penalties for readmissions of patients who have been discharged after hospitalizations for congestive heart failure (CHF), pneumonia, and acute myocardial infarction. (7) Recently, the CMS also started to reimburse for early transitional care as a

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Section: Discussionsupporting

confidence: 92%

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confidence: 99%

Early outpatient follow‐up and 30‐day outcomes in patients hospitalized with cirrhosis

et al. 2016

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“…Our readmission rates of 32% are consistent with those of previous studies from single tertiary‐care centers 1, 2. A report of a multistate population‐based cohort study showed the 30‐day rate of readmission to be only 12.9% 4.…”

Section: Discussionsupporting

confidence: 90%

“…The unscheduled readmission rates for patients with cirrhosis are reported to range from 20% to 37% at 30 days and up to 53% at 90 days 1, 2, 3. A high readmission rate is believed to be predicted by the severity of liver disease as determined by the Model for End‐Stage Liver Disease (MELD) score and comorbidities 1, 2, 3. These data, however, come from tertiary care referral centers where readmissions may occur outside the tertiary care health system.…”

Section: Introductionmentioning

confidence: 99%

Incidence and cost analysis of hospital admission and 30‐day readmission among patients with cirrhosis

Chirapongsathorn¹,

Krittanawong

Enders

et al. 2018

Hepatology Communications

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We examined risks for first hospitalization and the rate, risk factors, costs, and 1‐year outcome of 30‐day readmission among patients admitted for complications of cirrhosis. Data were retrospectively analyzed for adult patients with cirrhosis residing in Minnesota, Iowa, or Wisconsin and admitted from 2010 through 2013 at both campuses of the Mayo Clinic Hospital in Rochester, MN. Readmission was captured at the two hospitals as well as at community hospitals in the tristate area within the Mayo Clinic Health System. The incidence of hospitalization for complications of cirrhosis was 100/100,000 population, with increasing age and male sex being the strongest risks for hospitalization. For the 2,048 hospitalized study patients, the overall 30‐day readmission rate was 32%; 498 (24.3%) patients were readmitted to Mayo Clinic hospitals and 157 (7.7%) to community hospitals, mainly for complications of portal hypertension (52%) and infections (30%). Readmission could not be predicted accurately. There were 146 deaths during readmission and an additional 105 deaths up to 1 year of follow‐up (50.4% total mortality). Annual postindex hospitalization costs for those with a 30‐day readmission were substantially higher ($73,252) than those readmitted beyond 30 days ($62,053) or those not readmitted ($5,719). At 1‐year follow‐up, only 20.4% of patients readmitted within 30 days were at home. In conclusion, patients with cirrhosis have high rates of hospitalization, especially among men over 65 years, and of unscheduled 30‐day readmission. Readmission cannot be accurately predicted. Postindex hospitalization costs are high; nationally, the annual costs are estimated to be more than $4.45 billion. Only 20% of patients readmitted within 30 days are home at 1 year. (Hepatology Communications 2018;2:188–198)

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“…(1)(2)(3) Hospitalization is a marker for a variety of poor outcomes including readmission and death. Although we are gaining a better understanding of risk factors for readmission in discharged patients, (1,(4)(5)(6) we lack a practical prognostic model to identify those at highest risk for 3-month postdischarge mortality.Identifying this group would facilitate interventions that include more intensive follow-up and consideration of early liver transplant when available. Moreover, an estimation of the probability of survival can help to inform the type of integrated palliative support that is provided to patients.…”

mentioning

confidence: 99%

A Karnofsky performance status–based score predicts death after hospital discharge in patients with cirrhosis

et al. 2016

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Identification of patients with cirrhosis at risk for death within 3 months of discharge from the hospital is essential to individualize postdischarge plans. The objective of the study was to identify an easy-to-use prognostic model based on the Karnofsky Performance Status (KPS). The North American Consortium for the Study of End-Stage Liver Disease consists of 16 tertiary-care hepatology centers that prospectively enroll nonelectively admitted cirrhosis patients. Patients enrolled had KPS assessed 1 week postdischarge. KPS was categorized into low (score 10-40), intermediate , and high (80-100). Of 954 middle-aged patients (57 6 10 years, 63% men) with a median Model for End-Stage Liver Disease (MELD) score of 17 (interquartile range 13-21), the mortality rates for the low, intermediate, and high performance status groups were 23% (36/ 159), 11% (55/489), and 5% (15/306), respectively. Low, intermediate, and high performance status was seen in 17%, 51%, and 32% of the cohort, respectively. Low performance status was associated with older age, dialysis, hepatic encephalopathy, longer length of stay, and higher white blood cell count or MELD score at discharge. A model was derived using the three independent predictors of 3-month mortality: KPS, age, and MELD score. This score had better discrimination (area under the receiver operating characteristic curve 5 0.74) than a model using MELD (area under the receiver operating characteristic curve 5 0.62) or MELD and age (area under the receiver operating characteristic curve 5 0.67) to predict 3-month mortality. Conclusions: Cirrhosis patients at risk for 3-month postdischarge mortality can be identified using a novel KPS-based score; this score may be adopted in practice to guide postdischarge early interventions, including the integrated provision of active and palliative management strategies. (HEPATOLOGY 2017;65:217-224).P atients with cirrhosis can experience sudden deteriorations in health that lead to increased morbidity, repeated hospitalizations, and mortality. (1)(2)(3) Hospitalization is a marker for a variety of poor outcomes including readmission and death. Although we are gaining a better understanding of risk factors for readmission in discharged patients, (1,(4)(5)(6) we lack a practical prognostic model to identify those at highest risk for 3-month postdischarge mortality.Identifying this group would facilitate interventions that include more intensive follow-up and consideration of early liver transplant when available. Moreover, an estimation of the probability of survival can help to inform the type of integrated palliative support that is provided to patients.To date, mortality prediction in patients with cirrhosis has been predominated by liver-specific and kidney-specific prognostic indicators such as the Abbreviations: AUC, area under the receiver operating characteristic curve; CI, confidence interval; HE, hepatic encephalopathy; KAM, KPS, age, MELD (model); KPS, Karnofsky Performance Status; MELD, Model for End-Stage Liver Disease; OR, odd...

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Incidence and Predictors of 30-Day Readmission Among Patients Hospitalized for Advanced Liver Disease

Cited by 148 publications

References 28 publications

Early outpatient follow‐up and 30‐day outcomes in patients hospitalized with cirrhosis

Early outpatient follow‐up and 30‐day outcomes in patients hospitalized with cirrhosis

Incidence and cost analysis of hospital admission and 30‐day readmission among patients with cirrhosis

A Karnofsky performance status–based score predicts death after hospital discharge in patients with cirrhosis

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