A prospective study of a protocol that reduces readmission after liver transplantation

Russo, Mark W.; Levi, David; Pierce, Ruth; Casingal, Vincent; Eskind, Lon; deLemos, Andrew S.; Schmeltzer, Paul; Zamor, Philippe J.

doi:10.1002/lt.24424

Cited by 22 publications

(41 citation statements)

References 7 publications

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“…We collected data on factors previously associated with readmission, including dialysis, prior abdominal surgery, diabetes, among others, and most of these variables were not associated with readmission. Weekend discharge was associated with fewer readmissions as we found in our prior study . In the current study, weekend discharges were less likely to have returned to the operating room after LT and have diabetes, so postoperative complications and comorbidities may partly explain higher weekday readmissions in our study.…”

Section: Discussionsupporting

confidence: 73%

“…In fact, the median length of stay for the index admission was shorter by a day after implementing the protocol. Our study demonstrated that the changes we made were sustained because the 30‐day readmission rate remained low at 16%, which is numerically better than 20% reported in our prior study . In addition, we did not shift readmissions to beyond 30 days because fewer patients were readmitted from 31‐90 days after implementation of the protocol.…”

Section: Discussionmentioning

confidence: 53%

“…We observed that the readmission rates within 30 days and 90 days after LT at our center were 40% and 56%, respectively, during the periods from 2012 to 2013, which were substantially higher than reported . To address the high readmission rate, in 2012, our quality improvement and process committee developed a quality improvement dashboard to collect information on readmissions and resource utilization . The process followed was a “plan‐do‐study‐act” cycle .…”

Section: Methodsmentioning

confidence: 88%

“…One approach to reducing resource utilization is to prevent readmissions. We have previously shown that 30‐day readmission rates after LT can be reduced by 50% by developing and implementing a protocol that included strategies designed to increase outpatient access and services . However, one concern was that after implementing the protocol, readmissions were simply delayed to beyond 30 days.…”

mentioning

confidence: 99%

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Strategies That Reduce 90‐Day Readmissions and Inpatient Costs After Liver Transplantation

Zeidan

Levi²,

Pierce³

et al. 2018

Liver Transpl

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Liver transplantation (LT) is hospital-resource intensive and associated with high rates of readmission. We have previously shown a reduction in 30-day readmission rates by implementing a specifically designed protocol to increase access to outpatient care. The aim of this work is to determine if the strategies that reduce 30-day readmission after LT were effective in also reducing 90-day readmission rates and costs. A protocol was developed to reduce inpatient readmissions after LT that expanded outpatient services and provided alternatives to readmission. The 90-day readmission rates and costs were compared before and after implementing strategies outlined in the protocol. Multivariable analysis was used to control for potential confounding factors. Over the study period, 304 adult primary LTs were performed on patients with a median biological Model for End-Stage Liver Disease of 22. There were 112 (37%) patients who were readmitted within 90 days of transplant. The readmission rates before and after implementation of the protocol were 53% and 26%, respectively (P < 0.001). The most common reason for readmission was elevated liver tests/rejection (24%). In multivariable analysis, the protocol remained associated with avoiding readmission (odds ratio, 0.33; 95% confidence interval, 0.20-0.55; P < 0.001). The median length of stay after transplant before and after protocol implementation was 8 days and 7 days, respectively. A greater proportion of patients were discharged to hospital lodging after protocol implementation (10% versus 19%; P = 0.03). The 90-day readmission costs were reduced by 55%, but the total 90-day costs were reduced by only 2.7% because of higher outpatient costs and index admission costs. In conclusion, 90-day readmission rates and readmission costs can be reduced by improving access to outpatient services and hospital-local lodging. Total 90-day costs were similar between the 2 groups because of higher outpatient costs after the protocol was introduced.

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Section: Discussionsupporting

confidence: 73%

Section: Discussionmentioning

confidence: 53%

Section: Methodsmentioning

confidence: 88%

mentioning

confidence: 99%

See 2 more Smart Citations

Strategies That Reduce 90‐Day Readmissions and Inpatient Costs After Liver Transplantation

Zeidan

Levi²,

Pierce³

et al. 2018

Liver Transpl

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“…Unlike many other markers of severity of illness, the readmission risk in patients with ESLD is modifiable 8, 27–29 . Volk et al demonstrated that 22% of re-hospitalizations in patients with ESLD are potentially preventable 2 , and others have reduced post-LT healthcare utilization through alternatives to hospital admission 30 . The observed center variability in post-LT outcomes here highlight the need for centers to re-assess processes of care for recipients pre- and post-LT. Steps for further improvement are likely to be different according to center volume, where smaller centers may benefit more from greater coordination of care, while some larger centers may need to re-evaluate their risk-taking practices.…”

Section: Discussionmentioning

confidence: 99%

Healthcare utilization after liver transplantation is highly variable among both centers and recipients

Bittermann

Hubbard

Serper

et al. 2018

American Journal of Transplantation

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The relationship between healthcare utilization before and after liver transplantation (LT), and its association with center characteristics, is incompletely understood. This was a retrospective cohort study of 34 402 adult LTs between 2002 and 2013 using Vizient inpatient claims data linked to the United Network for Organ Sharing (UNOS) database. Multivariable mixed-effects linear regression models evaluated the association between hospitalization 90 days pre-LT and the number of days alive and out of the hospital (DAOH) 1 year post-LT. Of those patients alive at LT discharge, 24.7% spent ≥30 days hospitalized during the first year. Hospitalization in the 90 days pre-LT was inversely associated with DAOH (β = -3.4 DAOH/week hospitalized pre-LT; P = .002). Centers with >30% of their liver transplant recipients hospitalized ≥30 days in the first LT year were typically smaller volume and/or transplanting higher risk recipients (Model for End-Stage Liver Disease [MELD] score ≥35, inpatient or ventilated pre-LT). In conclusion, pre-LT hospitalization predicts 1-year post-LT hospitalization independent of MELD score at the patient-level, whereas center-specific post-LT healthcare utilization is associated with certain center behaviors and selection practices.

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Medication‐Related Problems in Outpatients With Decompensated Cirrhosis: Opportunities for Harm Prevention

et al. 2019

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People with decompensated cirrhosis are often prescribed a complex regimen of therapeutic and prophylactic medications. In other chronic diseases, polypharmacy increases the risk of medication misadventure and medication‐related problems (MRPs), with associated increased morbidity, mortality, and health care costs. This study examined MRPs in a cohort of ambulatory patients with a history of decompensated cirrhosis who were enrolled in a randomized controlled trial of a pharmacist‐led, patient‐oriented medication education intervention and assessed the association between MRPs and patient outcomes. A total of 375 MRPs were identified among 57 intervention patients (median, 6.0; interquartile range, 3.5‐8.0 per patient; maximum 17). Nonadherence (31.5%) and indication issues (29.1%) were the most prevalent MRP types. The risk of potential harm associated with MRPs was low in 18.9% of instances, medium in 33.1%, and high in 48.0%, as categorized by a clinician panel using a risk matrix tool. Patients had a greater incidence rate of high‐risk MRPs if they had a higher Child‐Pugh score (incidence rate ratio [IRR], 1.31; 95% confidence interval [CI], 1.09‐1.56); greater comorbidity burden (IRR, 1.15; 95% CI, 1.02‐1.29); and were taking more medications (IRR, 1.12; 95% CI, 1.04‐1.22). A total of 221 MRPs (58.9%) were resolved following pharmacist intervention. A greater proportion of high‐risk MRPs were resolved compared to those of low and medium risk (68.9% versus 49.7%; P < 0.001). During the 12‐month follow‐up period, intervention patients had a lower incidence rate of unplanned admissions compared to usual care (IRR, 0.52; 95% CI, 0.30‐0.92). Conclusion : High‐risk MRPs are prevalent among adults with decompensated cirrhosis. Pharmacist intervention facilitated identification and resolution of high‐risk MRPs and was associated with reduced incidence rate of unplanned hospital admissions in this group.

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A prospective study of a protocol that reduces readmission after liver transplantation

Cited by 22 publications

References 7 publications

Strategies That Reduce 90‐Day Readmissions and Inpatient Costs After Liver Transplantation

Strategies That Reduce 90‐Day Readmissions and Inpatient Costs After Liver Transplantation

Healthcare utilization after liver transplantation is highly variable among both centers and recipients

Medication‐Related Problems in Outpatients With Decompensated Cirrhosis: Opportunities for Harm Prevention

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