A Quality Improvement Initiative Reduces 30-Day Rate of Readmission for Patients With Cirrhosis

Tapper, Elliot B.; Finkelstein, Daniel; Mittleman, Murray A.; Piatkowski, Gail; Chang, Matthew S.; Lai, Michelle

doi:10.1016/j.cgh.2015.08.041

Cited by 135 publications

(131 citation statements)

References 28 publications

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“…Their individual risk is commensurate with disease severity, burden of comorbidities, and strength of social support. Few interventions aside from the use of rifaximin for HE have been linked with reduced readmissions . In our study, we observed a reduced rate of 30‐day readmissions in patients managed by APPs.…”

Section: Discussionsupporting

confidence: 50%

The Quality and Outcomes of Care Provided to Patients with Cirrhosis by Advanced Practice Providers

et al. 2019

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Cirrhosis is morbid and increasingly prevalent, yet the U.S. health care system lacks enough physicians and specialists to adequately manage patients with cirrhosis. Although advanced practice providers (APPs) can expand access to cirrhosis‐related care, their impact on the quality of care remains unknown. We sought to determine the effect on care quality and outcomes for patients managed by APPs using a retrospective analysis of a nationally representative American commercial claims database (Optum), which included 389,257 unique adults with cirrhosis. We evaluated a complication of process measures (i.e., rates of hepatocellular carcinoma [HCC] screening, endoscopic varices screening, and use of rifaximin after hospitalization for hepatic encephalopathy) and outcomes (30‐day readmissions and survival). Compared with patients without APP care, patients with APP care had higher rates of HCC screening (adjusted odds ratio [OR] 1.23, 95% confidence interval 1.19, 1.27), varices screening (OR 1.20 [1.13, 1.27]), use of rifaximin after a discharge for hepatic encephalopathy (OR 2.09 [1.80, 2.43]), and reduced risk of 30‐day readmission (OR 0.68 [0.66, 0.70]). Gastroenterology/hepatology consultation was also associated with improved quality metric performance compared with primary care; however, shared visits between gastroenterologists/hepatologists and APPs were associated with the best performance and lower 30‐day readmissions compared with subspecialty consultation without an APP (OR 0.91 [0.87, 0.95]. Multivariate analysis adjusting for comorbidities, liver disease severity, and other factors including gastroenterology/hepatology consultation showed that patients seen by APPs were more likely to receive consistent HCC and varices screening over time, less likely to experience 30‐day readmissions, and had lower mortality (adjusted hazard ratio 0.57, 95% confidence interval 0.55, 0.60). Conclusion: APPs, particularly when working with gastroenterologists/hepatologists, are associated with improved quality of care and outcomes for patients with cirrhosis.

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Section: Discussionsupporting

confidence: 50%

The Quality and Outcomes of Care Provided to Patients with Cirrhosis by Advanced Practice Providers

et al. 2019

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“…10 Tapper et al 10 implemented a checklist for patients with liver failure to ensure timely and appropriate care to prevent spontaneous bacterial peritonitis and hepatic encephalopathy used in both hand-held and electronic fashions throughout the admission. Our checklist, in contrast, was designed to be implemented at the time of discharge and addresses previous research on the causes and preventability of PCI readmissions.…”

Section: During Hospitalizationmentioning

confidence: 99%

Clinical Interventions to Reduce Preventable Hospital Readmission After Percutaneous Coronary Intervention

Tanguturi

Temin

Yeh

et al. 2016

Circ: Cardiovascular Quality and Outcomes

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Abstract-Hospital readmissions are common and costly and, in some cases, may be related to problems with care processes. We sought to reduce readmissions after percutaneous coronary intervention (PCI) in a large tertiary care facility through programs to target vulnerabilities predischarge, after discharge, and during re-presentation to the emergency department. During initial hospitalization, we assessed patients' readmission risk with a validated risk score and used a discharge checklist to ensure access to appropriate medications and close follow-up for high-risk patients. We also developed patient education videos about chest discomfort and heart failure. After discharge, we established a new follow-up clinic with cardiology fellows. A computerized system was developed to automatically notify cardiologists when patients presented to the emergency department within 30 days of PCI to enhance patient access to cardiology care in the emergency department. Early cardiologist assessment and assistance with triage was encouraged, and the emergency department used a risk stratification algorithm derived from a local database of patients to triage patients presenting with chest discomfort after PCI. We tracked the number of patients readmitted after PCI to our hospital. With our interventions, from 2011 to 2015, the index hospital readmission rate has declined from 9.6% to 5.3%. This program could provide tangible structural changes that can be implemented in other healthcare centers, both reducing the cost of care and improving the quality of care for patients with PCI. (Circ Cardiovasc Qual Outcomes. 2016;9:600-604.

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“…Although the inpatient mortality or hospice referral rates were similar between groups, we found a significant reduction in 90‐day readmissions in the prospective cohort compared with the retrospective cohort. There are multiple reasons behind readmissions, some of which can be modulated by active interventions compared with others . Although the rate of follow‐up visits between those who got readmitted in the prospective versus retrospective arms was similar, significantly fewer patients in the prospective arm who saw an RD were readmitted compared with those who did not see an RD.…”

Section: Discussionmentioning

confidence: 99%

Nutritional Assessment in Inpatients With Cirrhosis Can Be Improved After Training and Is Associated With Lower Readmissions

et al. 2019

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Malnutrition is widely prevalent in cirrhosis patients, which can worsen sarcopenia, hepatic encephalopathy (HE), and overall prognosis. We aimed to define the frequency of nutritional assessments of patients with cirrhosis in retrospective and prospective (after educational training) cohorts and to evaluate prospective changes along with their effects on 90‐day readmissions. This study was conducted in 2 phases. Retrospectively, records of hospitalized patients with cirrhosis from the university and Veterans Affairs Medical Center (VAMC) settings were reviewed to assess nutritional status, if a nutrition consultation occurred, the number of days patients were nil per os (npo) and received inadequate nutrition, and if nutritional management was guideline directed. In the prospective phase, after dedicated educational efforts directed at the stakeholders regarding nutritional guidelines for patients with cirrhosis, subsequently hospitalized cirrhosis patients had nutritional and 90‐day readmission data collected for comparison between groups. In total, 279 patients were included in the retrospective phase (150 university/129 VAMC), and 102 VAMC patients were in the prospective phase. Cirrhosis severity, reason for admission, and hospital course were similar between groups regardless of cohort, ie, prospective versus retrospective or VAMC versus university. The prospective group had significantly more nutritional consultations and assessments (74.5% versus 40.1%; P < 0.001) compared with the retrospective group regardless of comparisons between the VAMC and university cohorts. Both groups had a similar number of days npo, but the prospective group had fewer days of inadequate nutrition. The 90‐day readmission rate was significantly lower in the prospective group versus the retrospective group (39.4% versus 28.4%; P = 0.04), which was associated with greater nutrition outpatient follow‐up. In conclusion, nutritional consultation rates in inpatients with cirrhosis can be significantly improved after educational intervention and is associated with lower 90‐day readmission rates.

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A Quality Improvement Initiative Reduces 30-Day Rate of Readmission for Patients With Cirrhosis

Cited by 135 publications

References 28 publications

The Quality and Outcomes of Care Provided to Patients with Cirrhosis by Advanced Practice Providers

The Quality and Outcomes of Care Provided to Patients with Cirrhosis by Advanced Practice Providers

Clinical Interventions to Reduce Preventable Hospital Readmission After Percutaneous Coronary Intervention

Nutritional Assessment in Inpatients With Cirrhosis Can Be Improved After Training and Is Associated With Lower Readmissions

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