The Future of Quality Improvement for Cirrhosis

Tapper, Elliot B.; Parikh, Neehar D.

doi:10.1002/lt.26079

Cited by 19 publications

(17 citation statements)

References 56 publications

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“…Prior estimates from Medicaid data are validated in many cohorts when adjusting for lab data, and ndings of disparities have been unlikely to be reversed with statistical adjustment using labs. 11,12 Further, we do not have access to information concerning a provider or patient's decision-making, such as implicit bias, or patient refusal of treatment. In our study, more men were prescribed rifaximin, but further studies are needed to uncover the reasons why.…”

Section: Discussionmentioning

confidence: 99%

Linkage to Hospital Pharmacy for Rifaximin Receipt Prior to Discharge from Hospitalization with Hepatic Encephalopathy Reduces Early Readmissions in Patients with Liver Cirrhosis: A Quality Improvement Project

Nwankwo

Annakie

Deshmukh

et al. 2023

Preprint

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Background and Aims Hepatic Encephalopathy (HE) leads to multiple hospitalizations in liver cirrhosis. This imposes a significant burden on patients caregivers, and the healthcare system. Rifaximin reduces HE recurrence and hospitalizations, but many patients are not able to receive Rifaximin promptly after hospitalizations due to gaps in the prior authorization process and insurance coverage. This study shows the results of the Quality Improvement (QI) project aimed at improving access to Rifaximin by utilization of hospital pharmacy to provide Rifaximin at bedside or soon after hospital discharge with HE. Methods A retrospective analysis of 124 patients admitted to our hospital with recurrent HE was performed. All selected patients had Rifaximin prescribed for the first time during a hospitalization (index hospitalization). Both 30-day and 60-day liver-related hospitalizations were recorded for these patients. 80 patients were included in the intervention group when the hospital pharmacy was notified of the Rifaximin prescription prior to discharge as part of a QI project (Group A). Control (Group-B) group included 44 patients who had admission and were prescribed Rifaximin at discharge, prior to initiation of our QI project. Results The number of patients who had a re-admission after index hospitalization with HE was lower in Group A compared to Group B (48% vs 73%, p=0.002 for re-admission within 30 days; 56% vs 73%, p=0.007 for re-admission within 60 days respectively). Total hospitalizations decreased in Group A (reduced by 32%, and 59% for the 30-day and 60-day time frame, respectively) compared to Group B. The median days to readmission in Group A was 32, compared to 10 in Group B after the index hospitalization. Conclusion Providing Rifaximin to patients with recurrent HE before or soon after discharge from HE-related hospitalization reduced readmission rates for liver-related admissions at our hospital. A significantly higher number of patients did not require early readmission when Rifaximin was provided by the hospital pharmacy. This intervention could lead to lower costs, fewer complications related to frequent hospitalization, and thus reduced healthcare burden.

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Section: Discussionmentioning

confidence: 99%

Linkage to Hospital Pharmacy for Rifaximin Receipt Prior to Discharge from Hospitalization with Hepatic Encephalopathy Reduces Early Readmissions in Patients with Liver Cirrhosis: A Quality Improvement Project

Nwankwo

Annakie

Deshmukh

et al. 2023

Preprint

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“…Attention to human factors, making an action easy to accomplish within the clinician's workflow, improves the success of prescribing interventions (9). Some interventions can alert clinicians regarding best practice using posters, placards, or checklists.…”

Section: Discussionmentioning

confidence: 99%

An Electronic Decision Support Intervention Reduces Readmissions for Patients With Cirrhosis

et al. 2022

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INTRODUCTION: Rifaximin use in combination with lactulose is associated with a decreased risk of overt hepatic encephalopathy (HE). METHODS:We prospectively evaluated the impact of an interruptive electronic medical record alert to indicate rifaximin for patients with cirrhosis and HE on lactulose. RESULTS:The intervention was associated increased rifaximin utilization, particularly for nongastroenterology and hospitalist services odds ratio 1.20 95% confidence interval (1.09-1.31). For patients with HE, the intervention was associated with a lower readmission risk-adjusted subdistribution hazard ratio 0.63 95% confidence interval (0.48-0.82).

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“…Furthermore, these data show that utilization of the dashboard is directly linked to the outcome for which it was intended. The effect of dashboard use, however, is clear evidence of the dividends paid from VHA investment in centralized QI efforts (11,21). The VHA has a coordinated population-based approach across 127 VA facilities with established HIT led by teams of experts in system redesign, facilitators, and expert clinicians.…”

Section: Discussionmentioning

confidence: 99%

Patterns of Care Utilization and Hepatocellular Carcinoma Surveillance: Tracking Care Across the Pandemic

et al. 2022

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INTRODUCTION:We studied longitudinal trends in mortality, outpatient, and inpatient care for cirrhosis in a national cohort in the first 2 years of the coronavirus disease-2019 pandemic. We evaluated trends in hepatocellular carcinoma (HCC) surveillance and factors associated with completion.METHODS:Within the national cirrhosis cohort in the Veterans Administration from 2020 to 2021, we captured mortality, outpatient primary care provider, gastroenterology/hepatology (GI/HEP) visits, and hospitalizations. HCC surveillance was computed as percentage of time up to date with surveillance every 6 months (PTUDS). Multivariable models for PTUDS were adjusted for patient demographics, clinical factors, and facility-level variables.RESULTS:The total cohort was 68,073; 28,678 were eligible for HCC surveillance. Outpatient primary care provider and GI/HEP appointment rates initially dropped from 30% to 7% with a rebound 1 year into the pandemic and steady subsequent use. Telemedicine monthly visit rates rose from less than 10% to a peak of 20% with a steady gradual decline. Nearly 70% of Veterans were up to date with HCC surveillance before the pandemic with an early pandemic nadir of approximately 50% and 60% PTUDS 2 years into the pandemic. In adjusted models, use of a population-based cirrhosis dashboard (β 8.5, 95% CI 6.9–10.2) and GI/HEP visits both in-person (β 3.2, 95% CI 2.9–3.6) and telemedicine (β 2.1, 95% CI 1.9–2.4) were associated with a higher PTUDS.DISCUSSION:Outpatient utilization and HCC surveillance rates have rebounded but remain below at baseline. Population-based approaches and specialty care for cirrhosis were associated with a higher completion of HCC surveillance.

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The Future of Quality Improvement for Cirrhosis

Cited by 19 publications

References 56 publications

Linkage to Hospital Pharmacy for Rifaximin Receipt Prior to Discharge from Hospitalization with Hepatic Encephalopathy Reduces Early Readmissions in Patients with Liver Cirrhosis: A Quality Improvement Project

Linkage to Hospital Pharmacy for Rifaximin Receipt Prior to Discharge from Hospitalization with Hepatic Encephalopathy Reduces Early Readmissions in Patients with Liver Cirrhosis: A Quality Improvement Project

An Electronic Decision Support Intervention Reduces Readmissions for Patients With Cirrhosis

Patterns of Care Utilization and Hepatocellular Carcinoma Surveillance: Tracking Care Across the Pandemic

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