Dos and Don'ts in the Management of Cirrhosis: A View from the 21st Century

Thomson, Mary; Tapper, Elliot B.; Lok, Anna S.

doi:10.1038/s41395-018-0028-5

Cited by 14 publications

(16 citation statements)

References 16 publications

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“…In addition, our study suggests that referral rates to specialty palliative care in ESLD may be lower than those for veterans with advanced cancer, highlighting potential room for improvement [25]. Supportive care QIs were more frequently met, likely owing to the fact that avoidance of high doses of acetaminophen and provision of paracentesis for ascites are wellestablished practices in the management of all patients with ESLD [26]. The avoidance of NSAIDs, however, was not followed 39% of the time, which may reflect the tension that providers face when only limited options are present to alleviate pain in patients with ESLD, who are at higher risk of adverse events from available pain relief strategies, such as narcotics [27].…”

Section: Discussionmentioning

confidence: 83%

Measuring the Quality of Palliative Care for Patients with End-Stage Liver Disease

et al. 2020

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Background/Aims We examined the quality of palliative care received by patients with decompensated cirrhosis using an explicit set of palliative care quality indicators (QIs) for patients with end-stage liver disease (PC-ESLD). Methods We identified patients newly diagnosed with decompensated cirrhosis at a single veterans health center and followed up them for 2 years or until death. We piloted measurement of PC-ESLD QIs in all patients confirmed to have ESLD using a chart abstraction tool. Results Out of 167 patients identified using at least one sampling strategy, 62 were confirmed to meet ESLD criteria with chart abstraction. Ninety-eight percent of veterans in the cohort were male, mean age at diagnosis was 61 years, and 74% were White. The overall QI pass rate was 68% (64% for information care planning QIs and 76% for supportive care QIs). Patients receiving specialty palliative care consultation were more likely to receive information care planning QIs (67% vs. 37%, p = 0.02). The best performing sampling strategy had a sensitivity of 62% and specificity of 60%. Conclusion Measuring the quality of palliative care for patients with ESLD is feasible in the veteran population. Our singlecenter data suggest that the quality of palliative care is inadequate in the veteran population with ESLD, though patients offered specialty palliative care consultation and those affected by homelessness, drug, and alcohol abuse may receive better care. Our combination of ICD-9 codes can be used to identify a cohort of patients with ESLD, though better sensitivity and specificity may be needed.

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Section: Discussionmentioning

confidence: 83%

Measuring the Quality of Palliative Care for Patients with End-Stage Liver Disease

et al. 2020

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“…Hepatic encephalopathy represents a major burden on the healthcare system and quality improvement is needed to potentially improve the outcomes of affected patients . In our large cohort, we determined that there was a potential for improvement in controlling medication‐related precipitating factors, preventing aspiration pneumonia and preventing readmissions by resuming and continuing appropriate HE medications on discharge.…”

Section: Discussionmentioning

confidence: 99%

“…This indicates that this subgroup was not adhering to previously prescribed HE medications. The data ultimately indicate that HE therapy monitoring is a continuous process that should not stop once the patient is discharged …”

Section: Discussionmentioning

confidence: 99%

“…These medications are frequently prescribed by practitioners other than hepatologists for chronic pain, anxiety and insomnia that are prevalent in patients with cirrhosis . Therefore, careful and repeated reassessment of their risk/benefit ratio in the out‐patient and in‐patient setting accompanying by communication with the prescribing team could provide alternatives to avoid potential HE precipitation …”

Section: Discussionmentioning

confidence: 99%

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Targets to improve quality of care for patients with hepatic encephalopathy: data from a multi‐centre cohort

Bajaj

O’Leary²,

Tandon³

et al. 2019

Aliment Pharmacol Ther

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Background: Hepatic encephalopathy (HE) can adversely affect outcomes in bothin-patients and out-patients with cirrhosis.Aim: To define targets for improving quality of care in HE management in the multicentre North American Consortium for End-Stage Liver Disease (NACSELD) cohort.Method: NACSELD in-patient cohort was analysed for (a) medication-associated precipitants, (b) aspiration pneumonia development, (c) HE medication changes, and (d) 90-day HE recurrence/readmissions. Comparisons were made between patients on no-therapy, lactulose only, rifaximin only or both. Ninety-day HE-readmission analysis was adjusted for MELD score.Results: Two thousand eight hundred and ten patients (1102 no-therapy, 659 lactulose, 154 rifaximin, 859 both) were included. HE on admission, and HE rates during hospitalisation were highest in those on lactulose only or dual therapy compared to no-therapy or rifaximin only (P < 0.001). Medications were the most prevalent precipitants (32%; 21% lactulose over/underuse, 5% benzodiazepines, 4% opioids, 1% rifaximin underuse, 1% hypnotics). Patients with medication-associated precipitants had a better prognosis compared to other precipitants. A total of 23% (n = 217) reached grade 3/4 HE, of which 16% developed HE-related aspiration pneumonia. Two thousand four hundred and twenty patients were discharged alive without liver transplant (790 no-therapy, 639 lactulose, 136 rifaximin, 855 both); 12.5% (n = 99) of no-therapy patients did not receive a discharge HE therapy renewal. Ninety-day HE-related readmissions were seen in 16% of patients (9% no-therapy, 9% rifaximin only, lactulose only 18%, dual 21%, <0.001), which persisted despite MELD adjustment (P = 0.009).Conclusion: Several targets to improve HE management were identified in a large cohort of hospitalised cirrhotic patients. Interventions to decrease medication-precipitated HE, prevention of aspiration pneumonia, and optimisation of HE medications are warranted. | 1519BAJAJ et Al. SUPPORTING INFORMATIONAdditional supporting information will be found online in the Supporting Information section at the end of the article.How to cite this article: Bajaj JS, O'Leary JG, Tandon P, et al.Targets to improve quality of care for patients with hepatic encephalopathy: data from a multi-centre cohort. Aliment

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“…Very few quality improvement projects have focused on nutritional assessment and improving nutrition in patients with cirrhosis. Recent guidelines by ISHEN and the European Association for the Study of the Liver along with recent reviews have highlighted the importance of optimum nutrition in patients with cirrhosis, which starts with a dedicated nutritional assessment . The nutritional risk stratification of these fragile patients can form the first step for subsequent interventions aimed at improving nutrition and sarcopenia.…”

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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Dos and Don'ts in the Management of Cirrhosis: A View from the 21st Century

Cited by 14 publications

References 16 publications

Measuring the Quality of Palliative Care for Patients with End-Stage Liver Disease

Measuring the Quality of Palliative Care for Patients with End-Stage Liver Disease

Targets to improve quality of care for patients with hepatic encephalopathy: data from a multi‐centre cohort

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

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