Skip to main content

Advertisement

SpringerLink
Log in

Strategies to Reduce 30-Day Readmissions in Patients with Cirrhosis

  • Liver (S Cotler and E Kallwitz, Section Editors)
  • Published:
Current Gastroenterology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Approximately, one quarter of patients discharged after a hospitalization for decompensated cirrhosis will be readmitted within 30 days. These readmissions have been associated with increased morbidity and mortality, can be financially harmful to the health system, and may be partially preventable. This review summarizes the literature on readmissions, providing clinicians with tools for risk prediction and a taxonomy for preventative interventions.

Recent Findings

Readmission strategies can be categorized according to complexity (simple versus complex) and specificity (focused versus broad). The literature thus far provides the following generalizable inferences: 1) Interventions should be integrated in the clinical workflow, 2) default options are more powerful than voluntary actions, 3) knowledge improvement should focus on the front line clinicians, 4) process improvements do not always translate into better outcomes, and 5) any successful intervention must include viable alternatives to hospitalization.

Summary

A growing body of literature provides concrete and actionable guidance for interventions to reduce readmissions in patients with cirrhosis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. • Tapper EB. Building effective quality improvement programs in liver disease: a systematic review of quality improvement initiatives. Clin Gastroenterol Hepatol. 2016. A systematic review of quality improvement initiatives for patients with cirrhosis highlights the common features of successful and unsuccessful programs.

  2. Volk ML, Tocco RS, Bazick J, Rakoski MO, Lok AS. Hospital readmissions among patients with decompensated cirrhosis. Am J Gastroenterol. 2012;107(2):247–52.

    Article  PubMed  Google Scholar 

  3. •• 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. The first population-based cohort study on readmsisions. It established that readmission risk is proportional to the number of hepatic decompensations, most linked to hepatic encephalopathy overall and substance abuse-related admissions among non-decompensated patients with alcoholic cirrhosis.

  4. Bajaj JS, O’Leary JG, Reddy KR, Wong F, Olson JC, Subramanian RM, et al. Second infections independently increase mortality in hospitalized patients with cirrhosis: the North American consortium for the study of end‐stage liver disease (NACSELD) experience. Hepatology. 2012;56(6):2328–35.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Tapper EB, Risech-Neyman Y, Sengupta N. Psychoactive medications increase the risk of falls and fall-related injuries in hospitalized patients with cirrhosis. Clin Gastroenterol Hepatol. 2015;13(9):1670–5.

    Article  PubMed  Google Scholar 

  6. Tapper EB. Challenge accepted: confronting readmissions for our patients with cirrhosis. Hepatology. 2016.

  7. •• Bajaj JS, Reddy KR, Tandon P, Wong F, Kamath PS, Garcia-Tsao G, et al. The three-month readmission rate remains unacceptably high in a large north american cohort of cirrhotic patients. Hepatology. 2015. The first multicenter evaluation of readmissions. This cohort of complex patients with decompensated cirrhosis have a >50% 90-day readmission rate. Independent associations with readmission risk include hepatic encephalopathy and proton-pump inhibitor use.

  8. Singal AG, Rahimi RS, Clark C, Ma Y, Cuthbert JA, Rockey DC, et al. An automated model using electronic medical record data identifies patients with cirrhosis at high risk for readmission. Clin Gastroenterol Hepatol. 2013;11(10):1335–41.e1.

    Article  PubMed  Google Scholar 

  9. Tapper EB, Finkelstein D, Mittleman MA, Piatkowski G, Lai M. Standard assessments of frailty are validated predictors of mortality in hospitalized patients with cirrhosis. Hepatology. 2015.

  10. Li R, Tierney A, Carr R. The impact of Peri-discharge interventions on 30-day readmission and 90-day mortality rates for patients admitted with hepatic encephalopathy. Am J Gastroenterol. 2014;109:S131.

    Article  Google Scholar 

  11. •• Morando F, Maresio G, Piano S, Fasolato S, Cavallin M, Romano A, 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(2):257–64. The most significant publication on care redesign for patients with cirrhosis. This Italian group enrolled a small cohort of post-discharge patients to receive as-needed multidisciplinary management at day-hospitals equipped to perform testing and procedures. They significantly reduced readmissions and overall costs.

  12. •• Tapper EB, Finkelstein D, Mittleman MA, Piatkowski G, Chang M, Lai M. A quality improvement initiative reduces 30-day rate of readmission for patients with cirrhosis. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2015. An online decision aid built into the electronic ordering system used default options to standardize care for patients with decompensated cirrhosis, particularly those with hepatic encephalopathy and reduced readmissions by 40%. A prior checklist intervention failed to reduce readmissions.

  13. •• 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(7):850–8.e4. An intervention consisting of case management and nursing home-visits failed to reduce readmissions for patients with decompensated cirrhosis. This is likely because the identification of early decompensations does not itself prevent the need for hospitalization.

  14. •• Russo MW, Levi DM, Pierce R, Casingal V, Eskind L, deLemos A, et al. A Prospective study of a protocol that reduces readmission after liver transplantation. Liver Transpl. 2016. A classic example of quality improvement processes was employed to determine and address the root causes for post-transplant readmissions. The authors were successful in reducing 30-day readmissions.

  15. Volk ML, Kanwal F. Quality of care in the cirrhotic patient. Clin Transl Gastroenterol. 2016;7(4):e166.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Tapper EB. Early readmissions after liver transplantation and the power of quality improvement. Liver Transpl. 2016;22(6):717–9.

    Article  PubMed  Google Scholar 

  17. Johnson EA, Spier BJ, Leff JA, Lucey MR, Said A. Optimising the care of patients with cirrhosis and gastrointestinal haemorrhage: a quality improvement study. Aliment Pharmacol Ther. 2011;34(1):76–82.

    Article  CAS  PubMed  Google Scholar 

  18. Wundke R, Altus R, Sandford J, Wigg A. Improving management of oesophageal varices in patients with cirrhosis. Qual Saf Health Care. 2010;19(6):536–41.

    PubMed  Google Scholar 

  19. • 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. This is an important paper that demonstrates how early clinical follow-up after discharge improves mortality and increases readmission rates, highlighting that there is both a hierarchy of outcomes (readmissions are secondary) and the need for care-coordination of alternatives to rehospitalization.

  20. • Ghaoui R, Friderici J, Desilets DJ, Lagu T, Visintainer P, Belo A, et al. Outcomes associated with a mandatory gastroenterology consultation to improve the quality of care of patients hospitalized with decompensated cirrhosis. J Hosp Med. 2015;10(4):236–41. In the absence of a standardized care protocol, mandatory gastroenterology consults did not improve outcomes and only slightly improved adherence to quality indicators.

    Article  PubMed  Google Scholar 

  21. Desai AP, Satoskar R, Appannagari A, Reddy KG, Te HS, Reau N, et al. Co-management between hospitalist and hepatologist improves the quality of care of inpatients with chronic liver disease. J Clin Gastroenterol. 2014;48(4):e30–6.

    Article  PubMed  Google Scholar 

  22. Tapper EB, Lai M. Factors affecting adherence to a quality improvement checklist on an inpatient hepatology service. Proc (Baylor Univ Med Cent). 2014;27(2):100.

    Google Scholar 

  23. Bradley EH, Curry L, Horwitz LI, Sipsma H, Wang Y, Walsh MN, et al. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ Cardiovasc Qual Outcomes. 2013;6(4):444–50.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Burke RE, Coleman EA. Interventions to decrease hospital readmissions: keys for cost-effectiveness. JAMA Intern Med. 2013;173(8):695–8.

    Article  PubMed  Google Scholar 

  25. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520–8.

    Article  PubMed  Google Scholar 

  26. Halpern SD, Ubel PA, Asch DA. Harnessing the power of default options to improve health care. N Engl J Med. 2007;357(13):1340–4.

    Article  CAS  PubMed  Google Scholar 

  27. Mellinger JL, Volk ML. Multidisciplinary management of patients with cirrhosis: a need for care coordination. Clin Gastroenterol Hepatol. 2013;11(3):217–23.

    Article  PubMed  Google Scholar 

  28. • Mellinger JL, Moser S, Welsh DE, Yosef MT, Van T, McCurdy H, et al. Access to subspecialty care and survival among patients with liver disease. Am J Gastroenterol. 2016. Highlighting the benefits of multisciplinary care coordination, these authors demonstrate that access to gastroenterology care improves all-cause mortality in patients with liver disease.

  29. Bini EJ, Weinshel EH, Generoso R, Salman L, Dahr G, Pena‐Sing I, et al. Impact of gastroenterology consultation on the outcomes of patients admitted to the hospital with decompensated cirrhosis. Hepatology. 2001;34(6):1089–95.

    Article  CAS  PubMed  Google Scholar 

  30. • Mayorga CA, Rockey DC. Clinical utility of a standardized electronic order set for the management of acute upper gastrointestinal hemorrhage in patients with cirrhosis. Clin Gastroenterol Hepatol. 2013;11(10):1342–8. The authors create an online decision aid to facilitate guideline-based care for variceal bleeding. Uptake was 50% among clinicians caring for bleeding patients.

  31. Bass NM, Mullen KD, Sanyal A, Poordad F, Neff G, Leevy CB, et al. Rifaximin treatment in hepatic encephalopathy. N Engl J Med. 2010;362(12):1071–81.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Gastroenterology/Hepatology, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA

    Elliot B. Tapper

  2. Division of Gastroenterology/Hepatology and Transplantation Institute, Loma Linda University Health, Loma Linda, CA, USA

    Michael Volk

Authors
  1. Elliot B. Tapper
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael Volk
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michael Volk.

Ethics declarations

Conflict of Interest

Elliot Tapper and Michael Volk declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Liver

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Tapper, E.B., Volk, M. Strategies to Reduce 30-Day Readmissions in Patients with Cirrhosis. Curr Gastroenterol Rep 19, 1 (2017). https://doi.org/10.1007/s11894-017-0543-3

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11894-017-0543-3

Keywords

Search

Navigation