Some cirrhosis deaths have moved out of the hospital

Last Updated: 2017-06-26

By Scott Baltic

NEW YORK (Reuters Health) - Although in-hospital mortality for patients with cirrhosis has been on a downward trend, at least part of that decrease appears to have been paid for by an increased risk of death in the 30 days immediately following hospital discharge, according to a U.S. study.

"Our results suggest the improvement in overall outcomes of patients hospitalized with cirrhosis is considerably less than might be suggested by reduction in in-hospital mortality alone," the researchers concluded.

The study, based on 10 years of data from the Veterans Administration healthcare system, is the first to examine temporal trends in the overall outcomes for U.S. cirrhosis patients requiring hospitalization, its authors say.

Among 109,358 patients hospitalized in the VA system for cirrhosis between 2004 and 2013, in-hospital mortality declined by one-third, from 11.4% to 7.6%, and one-year mortality fell from 34.5% to 33.2%. Over that same period, the average hospital stay decreased from 13.6 to 9.3 days.

But 30-day mortality increased from 9.3% to 10.1%, and after 2006, the risk of death within 30 days after discharge was higher than the risk of dying in the hospital.

Better medical care for patients with cirrhosis was paralleled by changes in healthcare delivery, such as quality-improvement initiatives and financing reforms, that promoted shorter inpatient stays, the authors noted.

"It is plausible that these efforts have shifted the burden of mortality (and morbidity) to the period early after discharge without having a true impact on overall outcomes of cirrhosis patients," they wrote June 13 online in the American Journal of Gastroenterology.

They suggest that transitional and long-term care programs specifically for patients with cirrhosis might help "improve the observed modest decreases in overall mortality in hospitalized cirrhosis patients."

Transitional care programs might include follow-up visits with clinicians within the first week after discharge and a care team that's responsible for patient monitoring between clinic visits, with or without a home care component, coauthor Dr. Fasiha Kanwal of Baylor College of Medicine, Houston, and Michael E. DeBakey VA Medical Center, Houston, told Reuters Health by email.

Clinicians can use the study's findings "to inform patients and their caregivers about the timing of heightened vulnerability after hospital discharge," added Dr. Kanwal.

Dr. Andrew J. Muir of Duke University School of Medicine in Durham, North Carolina, who is vice-chair of the hepatitis C special interest group at the American Association for the Study of Liver Diseases, told Reuters Health by email, "This study rings true for me. During my career, lengths of stay for admissions have decreased and much more care is provided in the days and weeks after admission."

"This study highlights the need for effective transitions in care at the time of discharge and close monitoring of patients in that period of time soon after discharge, in the event things are not going well," said Dr. Muir, who was not connected with the new research.

Dr. Raymond T. Chung, director of the Hepatology and Liver Center at Massachusetts General Hospital in Boston, who was also not connected with the study, told Reuters Health by email, "We should be encouraged by the overall message that in-hospital mortality attributable to complications of cirrhosis, together with length of stay, have improved over time."

"However," he added, "the fact that some of this mortality risk was shifted to the first 30 days after discharge heightens concern that these patients are still unstable and are in need of more intensive transitional care. Much as efforts to intensify outpatient care for other chronic conditions such as congestive heart failure and diabetes have improved overall outcomes, these findings strongly suggest that cirrhosis care could benefit from a similar systematic approach."

The study was supported, in part, by the Veterans Administration Center for Innovations in Quality, Effectiveness and Safety at the Michael E. DeBakey VA Medical Center, Houston.

SOURCE: http://go.nature.com/2rV4wCO

Am J Gastroenterol 2017.