In the Journals

Improving cirrhosis outcomes requires increasing care coordination

Increasing care concentration for patients with cirrhosis, which was found to be less than optimal, increased mortality and health care use, according to data published in Clinical Gastroenterology and Liver Disease.

“Optimal management of cirrhosis is a multidisciplinary effort that demands vigilance,” Shirley Cohen-Mekelburg, MD, MS, from the University of Michigan, and colleagues wrote. “We show that increasing concentration of care among providers is associated with an increase in mortality and hospitalization.”

The study comprised 26,006 patients with cirrhosis on Medicare. During the study period, 4,482 patients either died or underwent liver transplantation. Among 10,906 patients with eligible hospital discharges, 3,213 had at least one readmission within 30 days. Specifically, 1,879 patients had one readmission during follow-up and 1,124 had two or more.

“While many different continuity of care measures exist, we focused on two of the most commonly used measures, the usual provider of care (UPC) index and the Bice-Boxerman continuity of care (COC) index,” the researchers wrote.

The median COC was 0.4 (interquartile range, 0.26-0.6) and the median UPC was 0.6 (IQR, 0.5-0.8), which correlated with one another (r = 0.93; P < .001). Higher COC also correlated with a higher likelihood of death or liver transplantation, 30-day readmission, and length of stay. UPC correlated with a higher likelihood of death or liver transplantation and length of stay, but not readmission.

Multivariate analysis for COC showed that death or liver transplantation positively correlated with older age in the range of 65 years to 74 years (HR = 1.41; 95% CI, 1.29-1.56) and with patients older than 75 years (HR = 2.24; 95% CI, 2.06-2.53), end-stage renal disease (HR = 1.69; 95% CI, 1.52-1.89), a higher Charlson comorbidity index (HR = 1.1; 95% CI, 1.09-1.11) alcohol-related cirrhosis (HR = 1.35; 95% CI, 1.25-1.46), non-viral nonalcohol-related cirrhosis (HR = 1.18; 95% CI, 1.05-1.33), hepatic encephalopathy (HR 1.11; 95% CI, 1.01-1.23), and hepatocellular carcinoma (HR = 1.88; 95% CI, 1.64-2.15).

In contrast, COC inversely correlated with female sex (HR = 0.75; 95% CI, 0.71-0.8), Hispanic race (HR = 0.67; 95% CI, 0.57-0.78), hepatitis C infection (HR = 0.86; 95% CI, 0.75-0.98), and varices (HR = 0.74; 95% CI, 0.64-0.86).

Cohen-Mekelburg and colleagues wrote that they found a 19% increase in 30-day readmissions for patients in the highest COC quartile, which “contrasts sharply with findings in other disease states. For every 10% increase in COC, there was a reduction in preventable hospitalizations for 2%.

“These data suggest that cirrhosis is a uniquely complex condition,” they wrote. “Compared to receiving from a single provider with whom they have a strong continuity of care, patients with cirrhosis may benefit from the active collaboration of multiple clinicians.”

For “next steps,” the researchers suggested further in-depth qualitative analysis to better understand the correlation between coordination measures and day-to-day clinical practice to optimize organization of care teams for improved cirrhosis management. – by Talitha Bennett

Disclosures: Cohen-Mekelburg reports no relevant financial disclosures. Please see the full study for all other authors relevant financial disclosures.

Increasing care concentration for patients with cirrhosis, which was found to be less than optimal, increased mortality and health care use, according to data published in Clinical Gastroenterology and Liver Disease.

“Optimal management of cirrhosis is a multidisciplinary effort that demands vigilance,” Shirley Cohen-Mekelburg, MD, MS, from the University of Michigan, and colleagues wrote. “We show that increasing concentration of care among providers is associated with an increase in mortality and hospitalization.”

The study comprised 26,006 patients with cirrhosis on Medicare. During the study period, 4,482 patients either died or underwent liver transplantation. Among 10,906 patients with eligible hospital discharges, 3,213 had at least one readmission within 30 days. Specifically, 1,879 patients had one readmission during follow-up and 1,124 had two or more.

“While many different continuity of care measures exist, we focused on two of the most commonly used measures, the usual provider of care (UPC) index and the Bice-Boxerman continuity of care (COC) index,” the researchers wrote.

The median COC was 0.4 (interquartile range, 0.26-0.6) and the median UPC was 0.6 (IQR, 0.5-0.8), which correlated with one another (r = 0.93; P < .001). Higher COC also correlated with a higher likelihood of death or liver transplantation, 30-day readmission, and length of stay. UPC correlated with a higher likelihood of death or liver transplantation and length of stay, but not readmission.

Multivariate analysis for COC showed that death or liver transplantation positively correlated with older age in the range of 65 years to 74 years (HR = 1.41; 95% CI, 1.29-1.56) and with patients older than 75 years (HR = 2.24; 95% CI, 2.06-2.53), end-stage renal disease (HR = 1.69; 95% CI, 1.52-1.89), a higher Charlson comorbidity index (HR = 1.1; 95% CI, 1.09-1.11) alcohol-related cirrhosis (HR = 1.35; 95% CI, 1.25-1.46), non-viral nonalcohol-related cirrhosis (HR = 1.18; 95% CI, 1.05-1.33), hepatic encephalopathy (HR 1.11; 95% CI, 1.01-1.23), and hepatocellular carcinoma (HR = 1.88; 95% CI, 1.64-2.15).

In contrast, COC inversely correlated with female sex (HR = 0.75; 95% CI, 0.71-0.8), Hispanic race (HR = 0.67; 95% CI, 0.57-0.78), hepatitis C infection (HR = 0.86; 95% CI, 0.75-0.98), and varices (HR = 0.74; 95% CI, 0.64-0.86).

Cohen-Mekelburg and colleagues wrote that they found a 19% increase in 30-day readmissions for patients in the highest COC quartile, which “contrasts sharply with findings in other disease states. For every 10% increase in COC, there was a reduction in preventable hospitalizations for 2%.

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“These data suggest that cirrhosis is a uniquely complex condition,” they wrote. “Compared to receiving from a single provider with whom they have a strong continuity of care, patients with cirrhosis may benefit from the active collaboration of multiple clinicians.”

For “next steps,” the researchers suggested further in-depth qualitative analysis to better understand the correlation between coordination measures and day-to-day clinical practice to optimize organization of care teams for improved cirrhosis management. – by Talitha Bennett

Disclosures: Cohen-Mekelburg reports no relevant financial disclosures. Please see the full study for all other authors relevant financial disclosures.