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Readmission Rates and Associated Outcomes for Alcoholic Hepatitis: A Nationwide Cohort Study

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Abstract

Background/Aims

Alcoholic hepatitis (AH) can lead to sudden and severe hepatic decompensation necessitating recurrent hospitalizations. We evaluated the trends, predictors, and healthcare cost burden of AH-related readmissions in the USA.

Methods

Utilizing the National Readmissions Database 2010–2014, we performed a retrospective longitudinal analysis to identify the index readmission with AH for up to 90 days after discharge. Annual trends of 30- and 90-day AH-related readmissions were calculated. Predictors of 30- and 90-day readmission were determined by multivariate logistic regression. Annual healthcare cost burden associated with AH-linked readmissions was estimated.

Results

Of the 21,572 (unweighted: 50,769) AH-related hospitalizations, 4917 (22.8%) and 7890 (36.6%) were readmitted in 30 and 90 day, respectively, with rates that were statistically unchanged from 2010 to 2014. Predictors of 30-day readmissions included female gender, hepatitis C virus infection, cirrhosis, ascites, acute kidney injury, urinary tract infection, history of bariatric surgery, chronic pancreatitis, and high medical comorbidity index. Acute pancreatitis and palliative care consultation were associated with a lower risk of 30-day readmission. Predictors of 90-day readmission were similar to risk factors for 30-day readmission. From 2010 to 2014, the annual cost (and total hospitalization days) burden increased in 2014 to $164 million (22,244 days) and $321 million (42,772 days) for 30- and 90-day AH-related readmissions, respectively.

Conclusion

Despite relatively stable trends in AH-related readmission, the total LOS and cost has been rising. A target-directed approach with a focus on high-risk subpopulations may help understand the unique challenges associated with the rising cost of AH-related readmissions.

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Abbreviations

AH:

Alcoholic hepatitis

AKI:

Acute kidney injury

ALD:

Alcoholic liver disease

AUD:

Alcohol use disorder

CDI:

Clostridium difficile infection

DNR:

Do not resuscitate status

ESLD:

End-stage liver disease

HBV:

Hepatitis B virus infection

HCUP:

Healthcare cost and utilization project

HCV:

Hepatitis C virus infection

ICD-9-CM:

International Classification of Diseases, Ninth Edition, Clinical Modification

LOS:

Length of stay

NRD:

National Readmissions Database

PC:

Palliative care consultation

US:

United States

References

  1. Ishak KG, Zimmerman HJ, Ray MB. Alcoholic liver disease: pathologic, pathogenetic and clinical aspects. Alcohol Clin Exp Res. 1991;15:45–66.

    Article  CAS  PubMed  Google Scholar 

  2. Szabo G. More than meets the eye: severe alcoholic hepatitis can present as acute-on-chronic liver failure. J Hepatol. 2018;69:269–271. https://doi.org/10.1016/j.jhep.2018.05.031.

    Article  PubMed  Google Scholar 

  3. Michelena J, Altamirano J, Abraldes JG, et al. Systemic inflammatory response and serum lipopolysaccharide levels predict multiple organ failure and death in alcoholic hepatitis. Hepatology. 2015;62:762–772. https://doi.org/10.1002/hep.27779.

    Article  CAS  PubMed  Google Scholar 

  4. Karakike E, Moreno C, Gustot T. Infections in severe alcoholic hepatitis. Ann Gastroenterol Q Publ Hell Soc Gastroenterol. 2017;30:152–160. https://doi.org/10.20524/aog.2016.0101.

    Article  Google Scholar 

  5. Singal AK, Kamath PS, Gores GJ, Shah VH. Alcoholic hepatitis: current challenges and future directions. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2014;12:555–564. https://doi.org/10.1016/j.cgh.2013.06.013.

    Article  Google Scholar 

  6. Hughes E, Hopkins LJ, Parker R. Survival from alcoholic hepatitis has not improved over time. PLOS ONE. 2018;13:e0192393. https://doi.org/10.1371/journal.pone.0192393.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Grant BF, Chou SP, Saha TD, et al. Prevalence of 12-month alcohol use, high-risk drinking, and DSM-IV alcohol use disorder in the united states, 2001–2002 to 2012–2013: results from the national epidemiologic survey on alcohol and related conditions. JAMA Psychiatry. 2017;74:911–923. https://doi.org/10.1001/jamapsychiatry.2017.2161.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 alcohol use disorder: results from the national epidemiologic survey on alcohol and related conditions III. JAMA Psychiatry. 2015;72:757–766. https://doi.org/10.1001/jamapsychiatry.2015.0584.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Singal AK, Anand BS. Recent trends in the epidemiology of alcoholic liver disease. Clin Liver Dis. 2013;2:53–56. https://doi.org/10.1002/cld.168.

    Article  Google Scholar 

  10. Mellinger JL, Shedden K, Winder GS, et al. The high burden of alcoholic cirrhosis in privately insured persons in the United States. Hepatology. 2018;68:872–882. https://doi.org/10.1002/hep.29887.

    Article  PubMed  Google Scholar 

  11. Jinjuvadia R, Liangpunsakul S. Trends in alcoholic hepatitis related hospitalizations, financial burden, and mortality in the United States. J Clin Gastroenterol. 2015;49:506–511. https://doi.org/10.1097/MCG.0000000000000161.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Singal AK, Kuo Y-F, Anand BS. Hepatitis C virus infection in alcoholic hepatitis: prevalence patterns and impact on in-hospital mortality. Eur J Gastroenterol Hepatol. 2012;24:1178–1184. https://doi.org/10.1097/MEG.0b013e328355cce0.

    Article  PubMed  Google Scholar 

  13. Kim D, Li AA, Gadiparthi C, et al. Changing trends in etiology-based annual mortality from chronic liver disease, from 2007 through 2016. Gastroenterology. 2018;155:1154–1163.e3. https://doi.org/10.1053/j.gastro.2018.07.008.

    Article  PubMed  Google Scholar 

  14. Cholankeril G, Ahmed A. Alcoholic liver disease replaces hepatitis C virus infection as the leading indication for liver transplantation in the United States. Clin Gastroenterol Hepatol. 2018;16:1356–1358. https://doi.org/10.1016/j.cgh.2017.11.045.

    Article  PubMed  Google Scholar 

  15. Liangpunsakul S. Clinical characteristics and mortality of hospitalized alcoholic hepatitis patients in the United States. J Clin Gastroenterol. 2011;45:714–719. https://doi.org/10.1097/MCG.0b013e3181fdef1d.

    Article  PubMed  PubMed Central  Google Scholar 

  16. May FP, Rolston VS, Tapper EB, Lakshmanan A, Saab S, Sundaram V. The impact of race and ethnicity on mortality and healthcare utilization in alcoholic hepatitis: a cross-sectional study. BMC Gastroenterol. 2016;16:129. https://doi.org/10.1186/s12876-016-0544-y.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Heslin KC, Elixhauser A, Steiner CA. Identifying in-patient costs attributable to the clinical sequelae and comorbidities of alcoholic liver disease in a national hospital database. Addiction. 2017;112:782–791. https://doi.org/10.1111/add.13702.

    Article  PubMed  Google Scholar 

  18. Yedlapati SH, Stewart SH. Predictors of alcohol withdrawal readmissions. Alcohol Alcohol Oxf Oxfs. 2018;53:448–452. https://doi.org/10.1093/alcalc/agy024.

    Article  Google Scholar 

  19. Chavez LJ, Liu C-F, Tefft N, et al. Unhealthy alcohol use in older adults: association with readmissions and emergency department use in the 30 days after hospital discharge. Drug Alcohol Depend. 2016;158:94–101. https://doi.org/10.1016/j.drugalcdep.2015.11.008.

    Article  PubMed  Google Scholar 

  20. Hines AL, Barrett ML, Jiang HJ, Steiner CA. Conditions with the largest number of adult hospital readmissions by payer, 2011—statistical brief #172. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb172-Conditions-Readmissions-Payer.jsp; 2014. Accessed 16. 10.18.

  21. Chirapongsathorn S, Krittanawong C, Enders FT, et al. Incidence and cost analysis of hospital admission and 30-day readmission among patients with cirrhosis. Hepatol Commun. 2018;2:188–198. https://doi.org/10.1002/hep4.1137.

    Article  PubMed  PubMed Central  Google Scholar 

  22. NRD Database Documentation. https://www.hcup-us.ahrq.gov/db/nation/nrd/nrddbdocumentation.jsp. Accessed 8.10.8.

  23. SID: File Composition-Number of Hospitals by Year. https://www.hcup-us.ahrq.gov/db/state/siddist/siddist_hospital.jsp. Accessed 30.05.19.

  24. NRD Overview. https://www.hcup-us.ahrq.gov/nrdoverview.jsp. Accessed 8.10.8.

  25. Pang JX, Ross E, Borman MA, et al. Validation of coding algorithms for the identification of patients hospitalized for alcoholic hepatitis using administrative data. BMC Gastroenterol. 2015;. https://doi.org/10.1186/s12876-015-0348-5.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Sundaram V, May FP, Manne V, Saab S. Effects of clostridium difficile infection in patients with alcoholic hepatitis. Clin Gastroenterol Hepatol. 2014;12:1745–1752.e2. https://doi.org/10.1016/j.cgh.2014.02.041.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Acharya C, Betrapally NS, Gillevet PM, et al. Chronic opioid use is associated with altered gut microbiota and predicts readmissions in patients with cirrhosis. Aliment Pharmacol Ther. 2017;45:319–331. https://doi.org/10.1111/apt.13858.

    Article  CAS  PubMed  Google Scholar 

  28. Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43:1130–1139.

    Article  PubMed  Google Scholar 

  29. Consumer Price Index Data from 1913 to 2017. US Inflation Calculator. http://www.usinflationcalculator.com/inflation/consumer-price-index-and-annual-percent-changes-from-1913-to-2008/; Published July 19, 2008. Accessed 21.02.17.

  30. Tapper EB, Halbert B, Mellinger J. Rates of and reasons for hospital readmissions in patients with cirrhosis: a multistate population-based Cohort study. Clin Gastroenterol Hepatol. 2016;14:1181–1188.e2. https://doi.org/10.1016/j.cgh.2016.04.009.

    Article  PubMed  Google Scholar 

  31. Bajaj JS, Reddy KR, Tandon P, et al. The 3-month readmission rate remains unacceptably high in a large North American cohort of patients with cirrhosis. Hepatology. 2016;64:200–208. https://doi.org/10.1002/hep.28414.

    Article  PubMed  Google Scholar 

  32. Graupera I, Solà E, Fabrellas N, et al. Urine monocyte chemoattractant protein-1 is an independent predictive factor of hospital readmission and survival in cirrhosis. PLOS ONE. 2016;11:e0157371. https://doi.org/10.1371/journal.pone.0157371.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Basra S, Anand BS. Definition, epidemiology and magnitude of alcoholic hepatitis. World J Hepatol. 2011;3:108–113. https://doi.org/10.4254/wjh.v3.i5.108.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Alcohol and Hepatitis C. https://pubs.niaaa.nih.gov/publications/arh25-4/245-254.htm. Accessed 18.10.18.

  35. Veena AB, Rajesh G, Varghese J, Sundaram KR, Balakrishnan V. Alcoholic chronic pancreatitis and alcoholic liver cirrhosis: differences in alcohol use habits and patterns in Indian subjects. Pancreas. 2012;41:703–706. https://doi.org/10.1097/MPA.0b013e31823b62ca.

    Article  PubMed  Google Scholar 

  36. Dutta SK, Mobrahan S, Iber FL. Associated liver disease in alcoholic pancreatitis. Am J Dig Dis. 1978;23:618–622.

    Article  CAS  PubMed  Google Scholar 

  37. Gullo L, Casadei R, Campione O, Grigioni W, Marrano D. Alcoholic liver disease in alcoholic chronic pancreatitis: a prospective study. Ital J Gastroenterol. 1995;27:69–72.

    CAS  PubMed  Google Scholar 

  38. Pace A, de Weerth A, Berna M, et al. Pancreas and liver injury are associated in individuals with increased alcohol consumption. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc.. 2009;7:1241–1246. https://doi.org/10.1016/j.cgh.2009.06.010.

    Article  Google Scholar 

  39. Ong JP, Elariny H, Collantes R, et al. Predictors of nonalcoholic steatohepatitis and advanced fibrosis in morbidly obese patients. Obes Surg. 2005;15:310–315. https://doi.org/10.1381/0960892053576820.

    Article  PubMed  Google Scholar 

  40. Lee Y, Doumouras AG, Yu J, et al. Complete resolution of nonalcoholic fatty liver disease after bariatric surgery: a systematic review and meta-analysis. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2018;. https://doi.org/10.1016/j.cgh.2018.10.017.

    Article  Google Scholar 

  41. Ekstedt M, Franzén LE, Holmqvist M, et al. Alcohol consumption is associated with progression of hepatic fibrosis in nonalcoholic fatty liver disease. Scand J Gastroenterol. 2009;44:366–374. https://doi.org/10.1080/00365520802555991.

    Article  CAS  PubMed  Google Scholar 

  42. Ruhl CE, Everhart JE. Joint effects of body weight and alcohol on elevated serum alanine aminotransferase in the United States population. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2005;3:1260–1268.

    CAS  Google Scholar 

  43. Seitz HK, Mueller S, Hellerbrand C, Liangpunsakul S. Effect of chronic alcohol consumption on the development and progression of nonalcoholic fatty liver disease (NAFLD). Hepatobiliary Surg Nutr. 2015;4:147–151. https://doi.org/10.3978/j.issn.2304-3881.2014.12.01.

    Article  PubMed  PubMed Central  Google Scholar 

  44. McIlvennan CK, Eapen ZJ, Allen LA. Hospital readmissions reduction program. Circulation. 2015;131:1796–1803. https://doi.org/10.1161/CIRCULATIONAHA.114.010270.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Mathurin P, O’Grady J, Carithers RL, et al. Corticosteroids improve short-term survival in patients with severe alcoholic hepatitis: meta-analysis of individual patient data. Gut. 2011;60:255–260. https://doi.org/10.1136/gut.2010.224097.

    Article  CAS  PubMed  Google Scholar 

  46. Thursz MR, Richardson P, Allison M, et al. Prednisolone or pentoxifylline for alcoholic hepatitis. N Engl J Med. 2015;372:1619–1628. https://doi.org/10.1056/NEJMoa1412278.

    Article  CAS  PubMed  Google Scholar 

  47. Philips CA, Pande A, Shasthry SM, et al. Healthy donor fecal microbiota transplantation in steroid-ineligible severe alcoholic hepatitis: a pilot study. Clin Gastroenterol Hepatol. 2017;15:600–602. https://doi.org/10.1016/j.cgh.2016.10.029.

    Article  PubMed  Google Scholar 

  48. Mathurin P, Moreno C, Samuel D, et al. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med. 2011;365:1790–1800. https://doi.org/10.1056/NEJMoa1105703.

    Article  CAS  PubMed  Google Scholar 

  49. Lee BP, Mehta N, Platt L, et al. Outcomes of early liver transplantation for patients with severe alcoholic hepatitis. Gastroenterology. 2018;155:422–430.e1. https://doi.org/10.1053/j.gastro.2018.04.009.

    Article  PubMed  Google Scholar 

  50. Lee BP, Vittinghoff E, Hsu C, et al. Predicting low-risk for sustained alcohol use after early liver transplant for acute alcoholic hepatitis: the SALT Score. Hepatol Baltim Md. 2018;. https://doi.org/10.1002/hep.30478.

    Article  Google Scholar 

  51. Orman ES, Ghabril M, Emmett TW, Chalasani N. Hospital readmissions in patients with cirrhosis: a systematic review. J Hosp Med. 2018;. https://doi.org/10.12788/jhm.2967.

    Article  PubMed  Google Scholar 

  52. Bini EJ, Weinshel EH, Generoso R, et al. Impact of gastroenterology consultation on the outcomes of patients admitted to the hospital with decompensated cirrhosis. Hepatol Baltim Md. 2001;34:1089–1095. https://doi.org/10.1053/jhep.2001.29204.

    Article  CAS  Google Scholar 

  53. 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. https://doi.org/10.1002/hep.28558.

    Article  PubMed  Google Scholar 

  54. Bajaj JS, Acharya C, Fagan A, et al. Proton pump inhibitor initiation and withdrawal affects gut microbiota and readmission risk in cirrhosis. Am J Gastroenterol. 2018;113:1177–1186. https://doi.org/10.1038/s41395-018-0085-9.

    Article  CAS  PubMed  Google Scholar 

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Funding

George Cholankeril is supported by NIH Training Grant T32DK007056. None of the authors received financial or material support for the research and work in this manuscript.

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Authors and Affiliations

  1. Department of Medicine, North Shore Medical Center, 81 Highland Ave., Salem, MA, 01970, USA

    Adeyinka C. Adejumo

  2. Department of Medicine, Tufts University School of Medicine, Boston, MA, USA

    Adeyinka C. Adejumo

  3. Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA

    George Cholankeril, Brian C. Boursiquot, Donghee Kim & Aijaz Ahmed

  4. Department of Medicine, Geisinger Medical Center, Danville, PA, USA

    Umair Iqbal

  5. Department of Internal Medicine, Santa Clara Valley Medical Center, San Jose, CA, USA

    Eric R. Yoo

  6. Department of Surgery, Abdominal Transplantation, Stanford University School of Medicine, Stanford, CA, USA

    Waldo C. Concepcion

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  1. Adeyinka C. Adejumo
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Contributions

ACA was responsible for study concept and design, acquisition of data, statistical analysis, interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content, and approval of final draft manuscript. GC, UI, ERY, BCB, WCC and DK were responsible for study concept, interpretation of data, and critical revision of the manuscript for important intellectual content, and approval of final draft manuscript. AA was responsible for study concept and design, interpretation of data, critical revision of the manuscript for important intellectual content, approval of final draft manuscript and supervision of research project.

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Correspondence to Adeyinka C. Adejumo.

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All authors were involved in the final approval of the version of the manuscript submitted and have agreed to be accountable for all aspects of the work. There is no relevant conflict of interest or disclosures, including financial and material support for the research and work in this manuscript.

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Adejumo, A.C., Cholankeril, G., Iqbal, U. et al. Readmission Rates and Associated Outcomes for Alcoholic Hepatitis: A Nationwide Cohort Study. Dig Dis Sci 65, 990–1002 (2020). https://doi.org/10.1007/s10620-019-05759-4

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