Background: One in three heavy drinkers experience acute alcohol-associated hepatitis (AAH). AAH is defined as acute liver injury with elevated bilirubin and AST/ALT ratio >1.5 in the setting of heavy alcohol use. AAH has a high mortality rate and is associated with development of chronic liver disease; thus, it is crucial to correctly identify patients with true AAH. Professional guidelines recommend using Maddrey’s discriminant function (MDF) to stratify disease severity and treating with prednisolone when disease is severe (MDF>32). Unfortunately, the diagnosis of AAH is often inconsistent in the hospital setting. We aimed to understand current practices regarding AAH at a large tertiary care center to identify barriers to a standardized management approach.
Methods: The electronic health record was queried for records containing a diagnosis of AAH with an admission between 1/1/2021 – 6/30/2021. Records without AAH as an active problem during index admission were excluded. Relevant laboratory and management data were collected. Control prothrombin time (PT) was calculated using a derivation of the MDF equation. Comparisons were made using Chi squared analysis for categorical variables or student’s t tests for continuous variables. Statistical significance was evaluated at p=0.05.
Results: One hundred and fifteen records were identified. Only 54.7% of records included a calculated MDF score in the treatment plan. The median control PT used to calculate the MDF was 12.0 seconds, but there was a wide range of values used (9.9 – 16.0 seconds). Approximately 25% of control PT values were greater than the upper limit of the institutions reference range. Twenty-five records were classified as severe AAH by the care teams, but 30 records would qualify for the diagnosis using a control PT of 11 seconds. About 50% of records listed alcohol withdrawal requiring medication during the index admission. Individuals who were diagnosed with AAH by their care teams but did not meet true diagnostic criteria were 14.5x as likely in alcohol withdrawal (82% vs. 24.1%; 95% CI: 6.0, 34.4). Further, alcohol withdrawal was associated with not having an MDF score documented (38.3% in withdrawal vs. 72.7% without withdrawal, p = 0.004). One in five individuals with alcohol withdrawal and no MDF calculation had moderate AAH (MDF> 15). There was no difference in the control PT for those with alcohol withdrawal versus those without (11.7 +/- 0.9 vs. 12.0 +/- 1.3, p =0.23).
Conclusions: These results suggest inconsistent diagnosis and management approach for AAH across the institution. The approach to those admitted for alcohol withdrawal versus those without alcohol withdrawal is different suggesting a potential bias in care. Furthermore, calculation and documentation of the MDF is inconsistent. As a result, there are potentially missed opportunities to treat AAH which may contribute to worsening health status and increased hospitalization. Future steps of this qualitative improvement project include evaluating for appropriate inpatient consultation and designing a documentation smart phrase and admission checklist for AAH.
