Outcomes associated with a mandatory gastroenterology consultation to improve the quality of care of patients hospitalized with decompensated cirrhosis

Abstract

Background & Aims Patients with decompensated cirrhosis (DC) have significant morbidity, and resource utilization. In a cohort of patients with DC undergoing usual care (UC) in 2009, we demonstrated that quality indicators (QI) were met less than 50% of the time. We established a mandatory gastroenterology consultation (MC) to improve the care of patients with DC. We sought to evaluate the impact of the MC intervention on adherence to QI, and compared outcomes to UC. Methods Prospective cohort study with historic control examining all admissions in a year for DC at an academic medical center. All admissions were seen by a gastroenterologist encouraged to implement QI (MC). Scores were calculated for each group per admission as the proportion of QI met vs. QI for which the patient was eligible. QI scores were examined as a function of group assignment multivariable fractional logit regression. We evaluated the impact of the intervention on compliance with QIs, length of stay (LOS), 30-day readmission, and inpatient death. Results 303 patients were observed in 695 hospitalizations (149 patients in 379 admissions (UC); 154 patients in 316 admissions (MC)). The QI score was significantly higher in the MC group than the UC group (77.0% vs. 46.0%, p<0.001), reflecting a better management of ascites and documentation of transplant evaluation. The management of variceal bleeding improved also but did not reach statistical significance. Conclusion The MC intervention was associated with greater adherence to recommended care but was not powered to detect difference in LOS, readmission or mortality rates.

HEPACONTROL. A program that reduces early readmissions, mortality at 60 days, and healthcare costs in decompensated cirrhosis

“…Though more than 50 studies have evaluated different interventions designed to reduce early readmission related to various diseases, they have mostly involved advanced aged patients and/or patients with heart failure [18][19][20][21][22][23][24]. Very few studies have evaluated specific readmission reduction strategies (including transitional interventions) in decompensated cirrhosis patients [12,[25][26][27][28][29], and these few have reported contradictory results.…”

Exploring opportunities to prevent cirrhosis admissions in the emergency department: A multicenter multidisciplinary survey

“…Prior literature has shown the benefit of incorporating specialty consults in the management of hospitalized patients with cirrhosis during inpatient admissions . Our study results, however, highlight a new potential need for hepatology input on triage decisions in the ED.…”

Cost‐effectiveness of a chronic disease management model for cirrhosis: Analysis of a randomized controlled trial

“…7 The electronic checklist model described by Tapper et al 8 is not able to be implemented in many health-care settings without sophisticated electronic medical record systems and does not address many of the structural barriers identified following hospital discharge. Similarly, the mandatory consultation model described by Ghaoui et al 9 requires hospital administrators to fund relatively expensive inpatient specialist care without demonstration of improvement in critical clinical endpoints such as costs or patient survival.…”

“…3 A major problem associated with CLF management, identified by multiple investigators, has been suboptimal and poorly coordinated care resulting in poor implementation of the existing evidence base. 4,5 Despite the significance of this problem, to the best of our knowledge, only four studies to date have attempted broad-based interventions aimed at reducing CLF-related hospitalization and patient mortality [6][7][8][9] with only two of these studies applying interventions following discharge as outpatients. 6,7 In addition, only one of these studies employed a randomized controlled trial (RCT) methodology, 6 and only one attempted to characterize costs associated with the intervention.…”