Hospital readmissions in decompensated cirrhotics: Factors pointing toward a prevention strategy

Table 1 ICD-9 codes used to identify patients

Bleeding from esophageal varices	456
Esophageal varices in diseases classified elsewhere	456.2
Spontaneous bacterial peritonitis	567.23
Alcoholic fatty liver	571
Alcoholic cirrhosis of liver	571.2
Laennec's cirrhosis	571.2
Cirrhosis of liver nos	571.5
Cirrhosis of liver without mention of alcohol	571.5
Macro nodular cirrhosis	571.5
Micro nodular cirrhosis	571.5
Portal cirrhosis NOS	571.5
Posthepatitic cirrhosis	571.5
Post necrotic cirrhosis	571.5
Cholangitic cirrhosis	571.6
Cholestatic cirrhosis	571.6
Hepatic encephalopathy	572.2
Portal hypertension	572.3
Hepatorenal syndrome	572.4
Other sequelae of chronic liver disease	572.8
Hepatopulmonary syndrome	573.5
Ascites	789.5

Table 2 Baseline characteristics of cohort (n = 222) n (%)

Demographics	Number of patients
Male	149 (67.2)
White	168 (76)
Married	82 (36.9)
Age	mean ± SD: 56.7 (11.7)
Insurance
Private insurance	81 (36.5)
Medicaid or mass health	74 (33.3)
Medicare	62 (27.9)
No Insurance (self-pay/free care)	5 (2.3)
Education
High school/equivalent or less	127 (57.2)
Some college and above	60 (27)
Not recorded	35 (15.8)
Clinical History
Alcohol use
Former heavy use	110 (49.5)
No significant history	65 (29.3)
Current heavy use	47 (21.2)
Smoking
Never smoked	82 (36.7)
Former smoker	77 (34.7)
Current smoker	63 (28.4)
Etiology of cirrhosis
Alcohol	83 (37.4)
HCV or HBV (HCV, n = 46)	49 (22.1)
Combination of etiologies (mainly HCV + alcohol)	40 (18)
NASH	29 (13)
Cryptogenic or other etiologies	21 (9.5)
Co-morbidities (Top 5)
Mental health (Depression or bipolar disorder)	68 (30.2)
Diabetes mellitus	65 (29.8)
Coronary artery disease	27 (12)
Chronic kidney disease	27 (12)
Hepatocellular carcinoma	24 (10.6)

HCV: Hepatitis C virus; HBV: Hepatitis B virus.

Table 3 Hospitalization characteristics n (%)

Index hospitalization
Complication of cirrhosis at index admission	Number of patients
Volume-related	64 (28.8)
Hepatic encephalopathy	61 (27.5)
Variceal bleeding	54 (24.3)
Spontaneous bacterial peritonitis	27 (12.2)
Other or > 1 complication	16 (7.2)
	mean ± SD
Length of stay	7.2 (7.8)
MELD at admission	13.3 (7.7)
MELD at discharge	12.2 (7.5)
Readmissions	Number of patients
Readmitted with the same complication	88 (49.4)
Readmitted in one month	46 (20.7)
Cause of readmission
Hepatic encephalopathy	49 (35.5)
Volume-related	38 (27.5)
Variceal bleeding	31 (22.5)
Other or > 1 complication	12 (8.7)
Spontaneous bacterial peritonitis	8 (5.8)

MELD: Model for end-stage liver disease.

Table 4 Post-discharge follow-up n (%)

	Number of patients	30-d readmissions	P value
Post-discharge status
Home	120 (54.3)	19 (15.9)	P < 0.12
VNA	60 (27.2)	14 (23.3)
SNF/rehab or LTAC	30 (13.5)	8 (26.7)
Eloped	5 (2.3)	0
Shelter	5 (2.3)	0
Mental Institute	1 (0.4)	1(100)
Follow-up outpatient visits
Gastroenterologist	83 (37.4)	10 (12.1)	P = 0.9
PCP	22 (9.9)	2 (9.1)
Both	31 (14)	4 (12.9)
Readmitted before visit	29 (13.1)	29 (100)
Total	165 (74.3)	45 (27.3)
First post-discharge outpatient follow-up (PCP and/or GI)
< 2 d	35 (21.2)	31 (60.0)	P = 0.1
2-14 d	66 (40.0)	13 (19.7)
> 14 d	64 (38.8)	3 (4.7)
Time to visit (d)	Mean ± SD
Time to first visit by GI	22.6 (43.7)
Time to first visit by PCP	31.9 (35)
Time to first visit by PCP or GI	24.7 (33.8)

PCP: Primary care physician; GI: Gastrointestinal.

Table 5 Predictors of time to readmission

Variable	Univariate analysis			Multivariate analysis
	HR	P value		HR	P value
	(95%CI)			(95%CI)
Education level (ref = Some college and above)1	1.00	0.02		1.00
Finished high school and less	1.64 (1.02-2.46)	0.02		1.56 (0.98-2.46)	0.05
MELD category (ref = MELD < 15 )	1.00	0.007		1.00
15 ≤ MELD < 25	1.45 (0.97-2.15)	0.06		1.52 (1.00-2.31)	0.04
MELD ≥ 25	2.51 (1.33-4.75)	0.004		2.51 (1.24-5.11)	0.01
Etiology of CLD (ref = Alcohol)	1.00	0.03		1.00
HCV	1.74 (1.10-2.76)	0.03		1.73 (1.06-2.82)	0.02
NASH/Cryptogenic	1.25 (0.76-2.05)	0.36		1.81 (1.02-3.18)	0.04
Other/Combination of etiologies	1.94 (1.20-3.11)	0.006		2.02 (1.24-3.29)	0.004
History of HCC	1.85 (1.10-3.08)	0.01		1.67 (0.95-2.93)	0.07
HE	1.51 (1.04-2.16)	0.01		1.61 (1.11-2.40)	0.01

¹Education variable was adjusted for unknown status. HCC: Hepatocellular carcinoma; MELD: Model for End-Stage Liver Disease; HCV: Hepatitis C virus.

Table 6 Predictors of 30-d readmission

Variable	Univariate analysis		Multivariate analysis
	OR	P value	OR	P value
	(95%CI)		(95%CI)
Insurance (ref =Medicaid/No insurance)	1		1
Medicare1	1.8 (1.00 -3.94)	0.05	3.42 (1.3-9.00)	0.01
Education (ref = Some college and above)	1.00		1
Finished high school and less2	3.56 (1.40-9.00)	0.002	2.62 (1.01-7.12)	0.05
ALT > ULN at discharge	2.52 (1.29-4.89)	0.006	2.29 (1.09-5.11)	0.03
Hepatic encephalopathy	2.17 (1.10-4.29)	0.01	2.34 (1.09-4.80)	0.03

¹Insurance variable was adjusted for patients with private insurance;

²Education variable was adjusted for unknown status. ULN: Upper limit of normal.