Reducing variation in hospital mortality for alcohol‐related liver disease in North West England

Abstract

Summary Background Variations in emergency care quality for alcohol‐related liver disease (ARLD) have been highlighted. Aim To determine whether introduction of a regional quality improvement (QI) programme was associated with a reduction in potentially avoidable inpatient mortality. Method Retrospective observational cohort study using hospital administrative data spanning a 1‐year period before (2014/2015) and 3 years after a QI initiative at seven acute hospitals in North West England. The intervention included serial audit of a bundle of process metrics. An algorithm was developed to identify index (“first”) emergency admissions for ARLD (n = 3887). We created a standardised mortality ratio (SMR) to compare relative mortality and regression models to examine risk‐adjusted odds of death. Results In 2014/2015, three of seven hospitals had an SMR above the upper control limit (“outliers”). Adjusted odds of death for patients admitted to outlier hospitals was higher than non‐outliers (OR 2.13, 95% CI 1.32‐3.44, P = 0.002). Following the QI programme there was a step‐wise reduction in outliers (none in 2017/2018). Odds of death was 67% lower in 2017/2018 compared to 2014/2015 at original outlier hospitals, but unchanged at other hospitals. Process audit performance of outliers was worse than non‐outliers at baseline, but improved after intervention. Conclusions There was a reduction in unexplained variation in hospital mortality following the QI intervention. This challenges the pessimism that is prevalent for achieving better outcomes for patients with ARLD. Notwithstanding the limitations of an uncontrolled observational study, these data provide hope that co‐ordinated efforts to drive adoption of evidence‐based practice can save lives.

The Liverpool alcohol‐related liver disease algorithm identifies twice as many emergency admissions compared to standard methods when applied to Hospital Episode Statistics for England

“…Full methods of the algorithm have been published elsewhere. 7 In brief, ICD‐10 codes must conform to one of four patterns (Table 1 and Table S4 ): (1) ArLD‐specific codes as a primary diagnosis (standard approach); (2) ArLD‐specific code as a secondary diagnosis with all higher order diagnoses either a symptom, sign or complication of liver disease or another alcohol‐specific diagnosis; (3) nonspecific liver disease recorded as a primary diagnosis with all lower order diagnoses either a symptom, sign or complication of liver disease or an alcohol‐specific diagnosis; (4) nonspecific liver disease recorded as a secondary diagnosis with all higher order diagnoses either a symptom, sign or complication of liver disease or alcohol‐specific diagnosis. Each care episode contains up to 23 diagnostic codes assigned by clinical coders after discharge using the International Classification of Disease 10th Revision.…”

“…The algorithm was quality assured by two independent analysts by comparison to previously published admission data from seven acute NHS hospitals in the North West of England. 7 The LAA was applied to HES data between the financial years 2014/15 to 2017/18…”

“…Furthermore, alcohol may not be specified as the cause of liver disease but can be inferred from the presence of other alcohol‐specific codes. The Liverpool ArLD Algorithm 7 (LAA) accounts for this diversity of coding patterns using combinations of primary and secondary diagnoses compatible with ArLD. The application of this method to a regional administrative dataset in the North West of England uplifted the apparent case volume by 94.2%.…”

New dimensions for hospital services and early detection of disease: a Review from the Lancet Commission into liver disease in the UK

“…Regionally, standardised care bundles, as advocated for in previous Lancet Commission Reviews, have been shown to reduce variation between hospitals in mortality rates for patients admitted with alcohol-related liver disease. 34 Medical directors should work alongside specialist commissioners to identify appropriate locations. Public Health England's Atlas of Variation in liver outcomes provides a framework to identify areas with the highest need.…”

Editorial: the burden of alcohol‐related liver disease emergency admissions in England may be twice as high as previously thought

“…It also includes ‘secondary diagnoses’, or in other words, diagnoses that were coded but not in the first data field of a record of an admission episode. In addition it includes a wider set of ICD‐10 codes that encompass complications of ALD, non‐specific liver disease and other alcohol‐specific diseases 6 …”