Integration of Cirrhosis Best Practices Into Electronic Medical Record Documentation Associated With Reduction in 30-Day Mortality Following Hospitalization

Abstract

Background: Hospital admissions for patients with cirrhosis continue to increase. In New York City, 25% to 30% of hospitalized cirrhotics are readmitted within 30 days. Rehospitalization is associated with increased mortality, poor quality of life, and financial burden to patients, hospitals, and payers. Preventable readmissions are partially accounted for by a well-documented quality gap between evidencebased guidelines for cirrhosis management and real-world adherence to these recommendations. Methods:We performed a prospective cohort study that compared outcomes among cirrhotic patients admitted to 4 internal medicine teams over a 6-month period. An electronic medical record (EMR) note template that outlined best-practice measures for cirrhotics was developed. Inpatient providers on 2 teams were instructed to include it in daily progress notes and discharge summaries. The recommended practices included diagnostic paracentesis and diuretics for ascites, rifaximin, and lactulose for hepatic encephalopathy, beta blockers for esophageal varices, and antibiotic prophylaxis for spontaneous bacterial peritonitis. The remaining 2 teams continued the standard of care for cirrhotic patients. The primary outcome was 30-day readmissions. Secondary outcomes included in-hospital mortality, 30-day mortality, length of stay, and adherence to best-practice guidelines.Results: Over a 6-month period, 108 cirrhotic patients were admitted, 83 in the interventional group and 25 in the control group. MELD-Na scores on admission did not differ between the groups (20.1 vs. 21.1, P = 0.56). Thirty-day readmissions were not significantly different between the interventional and control groups (19.3% vs. 24%, P = 0.61). However, 30-day mortality was significantly lower in the interventional group (8.4% vs. 28%, P = 0.01). There was no difference between the 2 groups in in-hospital mortality (4.8% vs. 0%, P = 0.27), 90-day mortality (15.7% vs. 28.0%, P = 0.17) or length of stay (10.2 vs. 12.6 d, P = 0.34). Adherence to best-practice metrics was similar between the groups, except for rates of diagnostic paracentesis, which were higher in the interventional group (98% vs. 80%, P = 0.01). Conclusion:Implementation of an EMR note template with cirrhosis best practices was associated with lower 30-day mortality and higher rates of diagnostic paracentesis among admitted patients with cirrhosis. These findings suggest that the integration of best-practice measures into the EMR may improve outcomes in hospitalized cirrhotic patients. Larger studies are required to validate these findings.

Hospitalized patients with cirrhosis: Addressing gaps in care

“…Various QI interventions in cirrhosis targeted higher compliance to recommended process measures with the goal of achieving superior clinical outcomes (survival, decreased rate of complications) and avoiding unwarranted hospital service utilization (preventable admissions/readmissions, unjustified length of hospital stay). To overcome the knowledge gap due to time restrains and difficulty for hospital practitioners to keep up to date with the latest guidelines, many QI trials have used easy-to-access and time-efficient tools to reduce variation in clinical practice: handheld checklists, 16 templated notes, 17 best practice alerts/decision support, 16 and clinical pathways/order sets 18,19 . More resource-intensive solutions have addressed institutional logistics and culture changes but require high commitment across all shareholders: “best practice” in emergency room focusing on timely interventions, 20 dedicated teams to perform emergency room or inpatient paracentesis, 21 bundled interventions to ensure timely performance of diagnostic paracentesis (education + workflow support/ultrasound/premade kits + alert + orderset) 22 or postdischarge care management programs 23,24 …”

The Current Status of the Liver Liquid Biopsy in MASH Related HCC: Overview and Future Directions

“…This concept in a liver process has been validated for liver fibrosis, by correlating the grade of liver fibrosis with plasma liver enzymes in multiple clinical trials, i.e., Fib-4 [ 21 , 22 , 23 , 24 , 25 , 26 , 27 ]. The MELD score (modeling for end-stage liver disease) predicts mortality at 90 days in patients listed for liver transplantation, and it is the standard for liver graft allocation in the US and abroad [ 28 , 29 , 30 ]. Nevertheless, a reliable LLBx that predicts the development of HCC prior to its detection by imaging, remains to be determined and validated.…”