Opportunities for Improvement: 30‐Day Readmission Rates in Patients with Chronic Liver Disease

Background:

Early or 30‐day hospital readmission rates are used to measure quality of inpatient hospital care. Consequences of early readmission often include duplication for much of the assessment, diagnosis, and treatment from the previous admission. This repetition of services results in an economic burden to hospitals and healthcare systems which is often disproportionately allocated to deteriorating chronic disease states, including chronic liver disease (CLD). In patients with advanced liver disease one in five patients hospitalized will be readmitted within 30 days and this number nearly doubles for patients with decompensated cirrhosis. Previous risk factors for readmission are MELD scores, gender, and number of medications. The primary aim of this study is to quantify annual hospital admissions and 30‐day readmissions at a county teaching hospital without a hepatology service or clinic. The secondary aim is to identify the frequency of specific CLD related discharge medications.

Methods:

This is a retrospective study of adult patients discharged from a single institution between January 1, 2010 to December 31, 2010, and followed for one year. Subjects were identified by discharge ICD‐9 codes for chronic liver disease. The first admission within the calendar year was the labeled as the index visit for each subject. Subsequent hospital admissions were identified with the use of the computerized medical record which include inpatient and outpatient medical records.

Results:

242 patients with CLD were discharged from our institution and followed for 1 year. The group consisted of 179 (73.9%) male patients, 87.2% had alcohol‐induced liver disease and 39.3% were positive for Hepatitis C virus. These patients totaled 442 hospital admissions, of which 20.8% were within 30 days of their previous hospital discharge. Of the 104 (42.9%) patients who were readmitted after the index visit, 55 experienced at least one 30‐day readmission, resulting in a 30‐day readmission rate of 22.7%. The most common discharge medications from the index visit were loop diuretics (n=118, 48.8%), aldosterone antagonists (n=98, 40.5%), non‐selective beta‐blockers (n=78, 32.2%), and lactulose (n=53, 21.9%). Medications more recently proven to prevent CLD morbidity and mortality were less likely to be prescribed at discharge: prednisone (n=13, 5.4%), pentoxifylline (n=4, 1.7%), prednisolone (n=3, 1.2%), pegylated interferon and or ribavirin (n=1, 0.4%), and rifaxamin (n=0).

Conclusions:

These results highlight the practice of reactively treating symptoms resulting from CLD without incorporation of additional medications capable of preventing CLD complications. Increasing the utilization of these medications could decrease the readmission burden on hospitals and healthcare systems.