Background: Cirrhosis was the fifteenth leading cause of death in the United States in 2019, with ascites being the most common major complication leading to hospital admission. Patients with ascites have recurrent hospital admissions with disproportionate use of hospital resources. Large volume abdominal paracentesis can be done safely by trained providers and is associated with a low risk of complications even in the presence of thrombocytopenia and coagulopathy. A dedicated paracentesis clinic has been shown to reduce Emergency Department (ED) admissions for ascites, and paracentesis procedures. The purpose of this study is to describe the effect of a dedicated paracentesis clinic, on healthcare utilization by patients with ascites; and compare the cost to an emergency room admission.
Methods: The study design is a retrospective review of ultrasound-guided paracentesis procedures performed in the Palliative Paracentesis clinic from a period of March 2020 to November 2021. The Cook County Health Institutional Review Board (IRB) Review approved this study. We reviewed the medical charts, collected data on patient demographics, etiology of ascites, standard laboratory data and encounter history. We obtained hospital costs for clinic visits and ED observation admission from the Billing department. We imputed costs the 2019 Medicare “Outpatient prospective payment system”, for abdominal paracentesis procedure with imaging guidance (CPT code 49083), was $762. The inpatient paracentesis reimbursement is tied to the Medicare prospective payment system for hospital inpatients known as “Diagnosis Related Groups” or DRGs. MS-DRGs for cirrhosis and alcoholic hepatitis with CC is $6,157.
Results: Forty patients enrolled in the clinic had 491 clinic encounters. 75% of patients were men. The most common diagnosis (62.5%) was alcoholic liver cirrhosis. Five patients had weekly visits. A mean of 7.6 liters was removed per visit. There was one complication (0.2%) of ascitic leakage. Four patients were discharged, four patients were lost to follow up and two patients went into hospice. Five patients died from liver failure, septic shock, Spontaneous Bacterial peritonitis and COVID-19. The total cost of outpatient paracentesis procedures ranges from $408,941 to $441,307. For the study period, we assumed that, without the clinic, these patients would need emergency room observation admission. DRGs for cirrhosis and alcoholic hepatitis with CC (ascites) is $6,157. Thus, multiple ED visits with inpatient observation admission and reimbursement ties to the cirrhosis DRG, total costs could range from $3,121,778 with inpatient admission of less than 6 hours and 30 minutes; $3,319,651 for an inpatient observation between 6 hours and 30 minutes and 12 hours and 30 minutes; and $3,614,742 for an inpatient observation admission of more than 12 hours.
Conclusions: This study shows that patients with cirrhosis with ascites may represent a small population who account for multiple ED visits and hospital admissions. The potential inpatient cost for institution is far greater than the cost of a procedure done in the dedicated clinic despite these patients having almost no post-procedural complications. Alternative models of care should be considered to reduce healthcare utilization costs and pressure on ED services. The study is limited as cost estimates were imputed based on hospital accounting data that is likely to vary between institutions.