Background and Aims Hepatic Encephalopathy (HE) leads to multiple hospitalizations in liver cirrhosis. This imposes a significant burden on patients caregivers, and the healthcare system. Rifaximin reduces HE recurrence and hospitalizations, but many patients are not able to receive Rifaximin promptly after hospitalizations due to gaps in the prior authorization process and insurance coverage. This study shows the results of the Quality Improvement (QI) project aimed at improving access to Rifaximin by utilization of hospital pharmacy to provide Rifaximin at bedside or soon after hospital discharge with HE. Methods A retrospective analysis of 124 patients admitted to our hospital with recurrent HE was performed. All selected patients had Rifaximin prescribed for the first time during a hospitalization (index hospitalization). Both 30-day and 60-day liver-related hospitalizations were recorded for these patients. 80 patients were included in the intervention group when the hospital pharmacy was notified of the Rifaximin prescription prior to discharge as part of a QI project (Group A). Control (Group-B) group included 44 patients who had admission and were prescribed Rifaximin at discharge, prior to initiation of our QI project. Results The number of patients who had a re-admission after index hospitalization with HE was lower in Group A compared to Group B (48% vs 73%, p=0.002 for re-admission within 30 days; 56% vs 73%, p=0.007 for re-admission within 60 days respectively). Total hospitalizations decreased in Group A (reduced by 32%, and 59% for the 30-day and 60-day time frame, respectively) compared to Group B. The median days to readmission in Group A was 32, compared to 10 in Group B after the index hospitalization. Conclusion Providing Rifaximin to patients with recurrent HE before or soon after discharge from HE-related hospitalization reduced readmission rates for liver-related admissions at our hospital. A significantly higher number of patients did not require early readmission when Rifaximin was provided by the hospital pharmacy. This intervention could lead to lower costs, fewer complications related to frequent hospitalization, and thus reduced healthcare burden.

Methods: We retrospectively analyzed charts of 137 patients who underwent SIRT with SS or TS at our center from April 2017 to January 2021, comprising 210 total procedures. Statistical analysis was performed using SAS. Results: Stratification by therapy type showed 70% of total Y-90 therapy procedures were with SS and 30% with TS. Table contains the demographic breakdown, liver disease etiology, tumor characteristics, MELD score, BCLC stage, pre-and post-SIRT symptoms, and Modified Response Evaluation Criteria in Solid Tumors (mRECIST) for SS and TS. There was a decrease in size, enhancement, or both size and enhancement in 85% of SS and 88% of TS patients. The median overall survival was 18 months for SS and 20 months for TS. Tumor recurrence occurred in 26% of non-transplanted patients while 3 transplanted patients (out of 15) showed recurrence. The median injected dose of Y-90 SS (24.9 mCi, range 5.7-81.8 mCi) was significantly lower than that of Y-90 TS (39.6 mCi, range 4.6-90.1 mCi). This is likely due to different dosimetry models for each type of bead, which evolve as imaging modalities allow more accurate representations of absorbed radiation per dose. The procedures were well tolerated. Conclusion: Our findings indicate that intermediate and advanced HCC patients have excellent response to Y-90 therapy with both SS and TS, as depicted by the decrease in size, enhancement, or both in 85% (SS) and 88% (TS) of patients, complete response in 37% (SS) and 49% (TS) of patients, and overall survival that ranges from 18 (SS) to 20 (TS) months, which is very favorable in this group of patients. Therapy is very well tolerated. Differences between SS and TS may possibly be explained by dosimetry; however, further comparative studies may be needed.

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