Variation by center and economic burden of readmissions after liver transplantation

Abstract

The rate and causes of hospital readmissions after liver transplantation (LT) remain largely unknown in the United States. Adult patients (n 5 11,937; 43.1% of all LT cases) undergoing LT from 2007 to 2011 were examined with a linkage of the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases to determine the incidence and risk factors for 30-day readmissions and utilization metrics 90 days after LT. The overall 30-day hospital readmission rate after LT was 37.9%, with half of patients admitted within 7 days after discharge. Readmitted patients had worse overall graft and patient survival with a 2-year follow-up. Multivariate analysis identified risk factors associated with 30-day hospital readmission, including a higher Model for End-Stage Liver Disease score, diabetes at LT, dialysis dependence, a high donor risk index allograft, and discharge to a rehabilitation facility. After adjustments for donor, recipient, and geographic factors in a hierarchical model, we found significant variation in readmission rates among hospitals ranging from 26.3% to 50.8% (odds ratio, 0.53-1.90). In the 90-day analysis after LT, readmissions accounted for $43,785 of added costs in comparison with patients who were not readmitted in the first 90 days. This is the first national report showing that more than one-third of LT recipients are readmitted to their center within 30 days and that readmissions are associated with center variation and increased resource utilization. Liver Transpl 21:953-960, 2015. V C 2015 AASLD.

Readmission following liver transplantation: an unwanted occurrence but an opportunity to act

“…Furthermore, given the safety and efficacy of new direct acting antiviral (DAA) therapies, treatment prior to transplant as well as preemptively after transplant may ultimately help decrease readmissions in these patients although the impact is unknown at this time. 9,10 Although the additional finding of increased length of stay during index hospitalization was concordant with prior investigations, 7 the protective factors noted in the current study including age and male sex, have not been identified by others. Although speculative, it is possible that these factors may be protective due to differences in social support structures upon discharge.…”

“…8 Although there are multiple factors that contribute to these expenses in the postoperative period, readmissions remain a significant cost driver. 7 This is not surprising given that in the current study of patients from a single center in a Region with a prolonged waitlist time, nearly half of all patients were readmitted within 90 days. After adjusting for various donor and recipient factors, age and male gender were found to be protective whereas length of stay after liver transplant and hepatitis C as a primary cause of liver failure were found to significantly increase risk of readmission.…”

“…3 As neither of these large database multicenter studies evaluated those undergoing liver transplant, and given that single center reports have demonstrated high readmission rates of 30-41% [4][5][6] in this patient population, Wilson et al conducted a large linkage study using the University HealthSystem Consortium and Scientific Registry of Transplant Recipient Databases. 7 Results from this multi-institutional study demonstrated significant variation in readmission rates among hospitals, but was unable to identify marked differences between low-risk and high-risk centers even after accounting for difference in center volume, as well as donor and recipient characteristics. 7 As readmission risk after transplant appears to be center specific, and reports evaluating readmissions in liver transplant patients remain inconclusive in their identification of risk factors and opportunities for risk reduction, further study in this specific group of surgical patients remains of utmost importance.…”

“…7 Results from this multi-institutional study demonstrated significant variation in readmission rates among hospitals, but was unable to identify marked differences between low-risk and high-risk centers even after accounting for difference in center volume, as well as donor and recipient characteristics. 7 As readmission risk after transplant appears to be center specific, and reports evaluating readmissions in liver transplant patients remain inconclusive in their identification of risk factors and opportunities for risk reduction, further study in this specific group of surgical patients remains of utmost importance. Thus, the current study aims to assess readmission in liver transplant patients in a region with high patient acuity from prolonged waitlist times in order to identify predictors and to evaluate the impact of readmission on recipient survival.…”

Liver transplant readmissions: The cost of the revolving door

“…The study by Wilson et al 2 is timely because it is one of the first to quantify the burden of early post-LT readmissions and associated costs by merging 2 national data sources: the University HealthSystem Consortium, which is an administrative claims database that captures data from 50% of transplant centers, and the Scientific Registry of Transplant Recipients (SRTR). Their 5-year analysis of more than 12,000 LT recipients demonstrated 30-day readmission rates of 38% and 90-day readmission rates of 48%-strikingly, approximately one-half of all readmissions occurred within 7 days of discharge.…”