Advertisement

Attendance at a Transitional Liver Clinic May Be Associated with Reduced Readmissions for Patients with Liver Disease

Published:October 13, 2021DOI:https://doi.org/10.1016/j.amjmed.2021.09.016

      Abstract

      Introduction

      Patients with liver disease have high rates of early hospital readmission, but there are no studies of effective, scalable interventions to reduce this risk. In this study, we examined the impact of a Physician Assistant (PA)-led post-discharge Transitional Liver Clinic (TLC) on hospital readmissions.

      Methods

      We performed a cohort study of all adults seen by a hepatologist during admission to a tertiary care center in 2019 (excluding transplant patients). We compared those who attended the TLC with those who did not, with respect to 30-day readmission and mortality. Propensity score-adjusted modeling was used to control for confounding.

      Results

      Of 498 patients, 98 were seen in the TLC; 35% had alcoholic liver disease and 58% had cirrhosis. Attendees were similar to non-attendees with respect to demographics, liver disease characteristics and severity, comorbidities, and discharge disposition. Thirty-day cumulative incidence of readmissions was 12% in TLC attendees, compared with 22% in non-attendees (P = .02), while 30-day mortality was similar (2.0% vs 4.3%; P = .29). In a model using propensity score adjustment, TLC attendance remained associated with reduced readmissions (subhazard ratio 0.52; 95% confidence interval, 0.27-0.997; P = .049). The effect of TLC was greater in women compared with men (P = .07) and in those without chronic kidney disease (P = .02), but there were no differences across other subgroups.

      Conclusions

      Patients with liver disease seen in a PA-led TLC may have a significant reduction in the 30-day readmission rate. Randomized trials are needed to establish the efficacy of PA-led post-discharge transitional care for this population.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Orman ES
        • Ghabril M
        • Emmett TW
        • Chalasani N
        Hospital readmissions in patients with cirrhosis: a systematic review.
        J Hosp Med. 2018; 13: 490-495
        • Shaheen AA
        • Nguyen HH
        • Congly SE
        • Kaplan GG
        • Swain MG
        Nationwide estimates and risk factors of hospital readmission in patients with cirrhosis in the United States.
        Liver Int. 2019; 39: 878-884
        • Adejumo AC
        • Cholankeril G
        • Iqbal U
        • et al.
        Readmission rates and associated outcomes for alcoholic hepatitis: a nationwide cohort study.
        Dig Dis Sci. 2020; 65: 990-1002
        • Garg SK
        • Sarvepalli S
        • Singh D
        • et al.
        Incidence and risk factors associated with 30-day readmission for alcoholic hepatitis.
        J Clin Gastroenterol. 2019; 53: 759-764
        • Peeraphatdit TB
        • Kamath PS
        • Karpyak VM
        • et al.
        Alcohol rehabilitation within 30 days of hospital discharge is associated with reduced readmission, relapse, and death in patients with alcoholic hepatitis.
        Clin Gastroenterol Hepatol. 2020; 18: 477-485.e5
        • Agrawal K
        • Kumar P
        • Markert R
        • Agrawal S
        Risk factors for 30-day readmissions of individuals with decompensated cirrhosis.
        South Med J. 2015; 108: 682-687
        • Volk ML
        • Tocco RS
        • Bazick J
        • Rakoski MO
        • Lok AS
        Hospital readmissions among patients with decompensated cirrhosis.
        Am J Gastroenterol. 2012; 107: 247-252
        • Wigg AJ
        • McCormick R
        • Wundke R
        • Woodman RJ
        Efficacy of a chronic disease management model for patients with chronic liver failure.
        Clin Gastroenterol Hepatol. 2013; 11: 850-858.e4
        • Rao BB
        • Sobotka A
        • Lopez R
        • Romero-Marrero C
        • Carey W
        Outpatient telephonic transitional care after hospital discharge improves survival in cirrhotic patients.
        World J Hepatol. 2019; 11: 646-655
        • Morando F
        • Maresio G
        • Piano S
        • et al.
        How to improve care in outpatients with cirrhosis and ascites: a new model of care coordination by consultant hepatologists.
        J Hepatol. 2013; 59: 257-264
        • Morales BP
        • Planas R
        • Bartoli R
        • et al.
        HEPACONTROL. A program that reduces early readmissions, mortality at 60 days, and healthcare costs in decompensated cirrhosis.
        Dig Liver Dis. 2018; 50: 76-83
      1. Centers for Medicare & Medicaid Services. Evaluation & management visits. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Evaluation-and-Management-Visits. Accessed June 10, 2021.

        • McDonald CJ
        • Overhage JM
        • Barnes M
        • et al.
        The Indiana Network for Patient Care: a working local health information infrastructure.
        Health Aff (Millwood). 2005; 24: 1214-1220
        • Mitchell SG
        • Schwartz RP
        • Alvanzo AAH
        • et al.
        The use of technology in participant tracking and study retention: lessons learnedfrom a clinical trials network study.
        Subst Abus. 2015; 36: 420-426
      2. Organ Procurement and Transplantation Network. MELD calculator. Available at: https://optn.transplant.hrsa.gov/resources/allocation-calculators/meld-calculator/. Accessed January 18, 2021.

        • Fine JP
        • Gray RJ
        A proportional hazards model for the subdistribution of a competing risk.
        J Am Stat Assoc. 1999; 94: 496-509
        • Ufere NN
        • Donlan J
        • Indriolo T
        • et al.
        Burdensome transitions of care for patients with end-stage liver disease and their caregivers.
        Dig Dis Sci. 2021; 66: 2942-2955
        • Hansen LO
        • Young RS
        • Hinami K
        • Leung A
        • Williams MV
        Interventions to reduce 30-day rehospitalization: a systematic review.
        Ann Intern Med. 2011; 155: 520-528
        • Leppin AL
        • Gionfriddo MR
        • Kessler M
        • et al.
        Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials.
        JAMA Intern Med. 2014; 174: 1095-1107
        • Tapper EB
        • Hao S
        • Lin M
        • et al.
        The quality and outcomes of care provided to patients with cirrhosis by advanced practice providers.
        Hepatology. 2020; 71: 225-234
        • Kanwal F
        • Asch SM
        • Kramer JR
        • Cao Y
        • Asrani S
        • El-Serag HB
        Early outpatient follow-up and 30-day outcomes in patients hospitalized with cirrhosis.
        Hepatology. 2016; 64: 569-581
        • Bindman AB
        • Blum JD
        • Kronick R
        Medicare's transitional care payment—a step toward the medical home.
        N Engl J Med. 2013; 368: 692-694
        • Roper KL
        • Ballard J
        • Rankin W
        • Cardarelli R
        Systematic review of ambulatory transitional care management (TCM) visits on hospital 30-day readmission rates.
        Am J Med Qual. 2017; 32: 19-26
        • Hu C
        • Anjur V
        • Saboo K
        • et al.
        Low predictability of readmissions and death using machine learning in cirrhosis.
        Am J Gastroenterol. 2021; 116: 336-346