FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
An electronic quality improvement initiative for patients with cirrhosis has achieved significant reductions in 30-day readmission rates.
The program’s goals included universal use of rifaximin and goal-directed therapy in patients with hepatic encephalopathy, and timely administration of antibiotics and albumin for patients with spontaneous bacterial peritonitis.
Researchers enrolled 824 patients with decompensated cirrhosis or receiving liver transplants, who were admitted to an inpatient hepatology unit, according to a paper published online in Clinical Gastroenterology and Hepatology.
The initiative consisted of three phases; a year-long control period in which 626 admissions received usual care, then a nearly 1-year phase of the intervention involving a hand-held checklist, and a second 1.3-year long electronic phase in which the checklist was incorporated into the electronic provider order entry system.
The final electronic phase of the initiative was associated with a 40% lower odds of readmission within 30 days, compared with the control period, and 38% lower odds of readmission, compared with the hand-held checklist phase, with no significant impact on 90-day mortality rates.
Both the hand-held and electronic stages of the intervention were associated with significant increases in rifaximin use, compared with controls (78.1% for controls, 89.4% for hand-held, and 96.3% for electronic), and the use of rifaximin in patients with overt hepatic encephalopathy lowered the risk of 30-day readmission by 61%.
“Reduced readmissions were likely mediated in large part by the ability to obtain the medication as an outpatient; however, the role of rifaximin co-therapy during an admission for overt [hepatic encephalopathy] should be explored further,” wrote Dr. Elliot B. Tapper and coauthors from the Harvard Medical School.
Increased antibiotic prophylaxis for spontaneous bacterial peritonitis also showed an impact, with a 60% lower odds of 30-day readmission in those with a history of or index admission for peritonitis, even though the increase in secondary antibiotic prophylaxis was not significant for either phase.
The analysis also showed evidence that six or more cups lactulose on the day of admission for overt hepatic encephalopathy was associated with a significantly reduced risk of readmission within 30 days (Clin Gastroenterol Hepatol. 2015 Sep 22. doi: 10.1016/j.cgh.2015.08.041 ).
Researchers also noted that during the electronic phase of the intervention, the impact on readmission rates was greater among patients attending the liver service than it was among patients cared for by Beth Israel Deaconess Medical Center hospitalists or at a neighboring institution.
Readmissions were a major driver of the estimated $2 billion cost of hospital admissions for complications of chronic liver disease, the authors said.
“Our study advances the current literature on [quality improvement] for patients with cirrhosis by presenting an inexpensive, easy to implement, and generalizable approach.”
The study was supported by the Carl J. Shapiro Institute for Education and Research, Harvard Catalyst/The Harvard Clinical and Translational Science Center and Harvard University. No conflicts of interest were declared.
