Outpatient telephonic transitional care after hospital discharge improves survival in cirrhotic patients

Table 1 Comparison of baseline demographic and disease related characteristics between the groups

Factor	Total, n = 169	Intervention, n = 76	Control, n = 93	P value
Male	86 (50.9)	41 (53.9)	45 (48.4)	0.54
Age	58.2 ± 12.0	58.6 ± 11.4	57.9 ± 12.6	0.75
Etiology of cirrhosis
Alcohol	55 (32.5)	27 (35.5)	28 (30.1)
NAFLD	40 (23.7)	18 (23.7)	22 (23.7)
HCV	27 (16.0)	11 (14.5)	16 (17.2)
HBV	2 (1.2)	0	2 (2.2)	0.49
Combination of above	5 (3.0)	1 (1.3)	4 (4.3)
Others	40 (24.9)	19 (25.0)	21 (22.6)
MELD score during index admission	17.7 ± 7.9	17.8 ± 8.6	17.5 ± 7.3	0.88
Problems during initial hospitalization
HE	64 (37.9)	34 (44.7)	30 (32.3)	0.11
Infection	51 (30.2)	23 (30.3)	28 (30.1)	1
AKI	64 (37.9)	30 (39.5)	34 (36.6)	0.75
GIB	57 (33.7)	28 (36.8)	29 (31.2)	0.51
Index admission LOS, d	5 (3.0, 9.0)	6 (3.0, 10.5)	5 (4.0, 9.0)	0.95
Discharge destination				0.43
Home	100 (59.2)	41 (53.9)	59 (63.4)
Home with care	35 (20.7)	17 (22.4)	18 (19.4)
Skilled nursing facility	34 (20.1)	18 (23.7)	16 (17.2)
Follow up appointment provided prior to discharge	138 (82.9)	63 (82.9)	75 (80.6)	0.53
Came for appointment
Yes	59 (34.9)	27 (35.5)	32 (34.4)	0.98
No	63 (37.3)	29 (38.2)	34 (36.6)
No appointment provided	30 (17.8)	13 (17.1)	17 (18.3)
Admitted before appointment	16 (9.5)	7 (9.2)	9 (9.7)
Died before appointment	1 (0.6)	0	1 (1.1)
Duration between discharge and appointment	14 (7, 28)	14 (7, 28)	13 (9, 23)	0.79
Readmissions within
1 mo	63 (37.3)	28 (36.8)	35 (37.6)	1
3 mo	93 (55.0)	43 (56.6)	51 (54.8)	0.76
6 mo	107 (63.3)	49 (64.5)	58 (62.4)	0.87
Problems during initial readmission
HE	36 (21.3)	21 (42.9)	15 (26.0)	0.11
Infection	28 (16.6)	14 (28.6)	14 (24.1)	1
AKI	47 (27.8)	22 (44.9)	25 (43.1)	1
GIB	17 (10.1)	6 (12.2)	11 (19.0)	0.3
Time between discharge and readmit, d	24 (11, 66)	22 (11, 59)	23.5 (12, 57)	0.63
Readmission LOS, d	6 (3, 10)	5 (3, 8)	6 (4, 12)	0.06
Alive at
1 mo	156 (92.3)	72 (94.7)	84 (90.3)	0.39
3 mo	137 (81.1)	66 (86.8)	71 (76.3)	0.11
6 mo	128 (75.7)	64 (84.2)	64 (68.8)	0.031

Statistics presented as median (P25, P75) or n (column %).

¹P < 0.05 considered significant. HCV: Hepatitis C virus; HBV: Hepatitis B virus; NAFLD: Non-alcoholic fatty liver disease; MELD: Model for end-stage liver disease; HE: Hepatic encephalopathy; AKI: Acute kidney injury; GIB: Gastrointestinal bleeding; LOS: Length of stay.

Table 2 Multivariate analysis of factors associated with mortality

	Multivariate analysis
Factor	HR (95%CI)	P value
Intervention vs controls	0.4 (0.2-0.82)	0.012
Age	1.01 (0.99-1.04)	0.503
Female gender	1.2 (0.6-2.4)	0.605
Etiology of cirrhosis
EtOH vs HCV	0.72 (0.29-1.8)	0.48
NAFLD vs HCV	0.41 (0.24-2.1)	0.088
MELD score (for every 1 unit increment)	1.05 (1.01-1.1)	0.024
Index hospitalization length of stay (for every 1 d increment)	0.99 (0.95-1.02)	0.47
Discharge to home with home care vs home	1.65 (0.75-3.64)	0.212
Discharge to SNF vs home	1.4 (0.56-3.48)	0.47

HR: Hazard ratio; CI: Confidence interval; EtOH: Alcohol; HCV: Hepatitis C virus; NAFLD: Non-alcoholic fatty liver disease; MELD: Model for end-stage liver disease; SNF: Skilled nursing facility.

Table 3 Multivariate fine and gray competing risk analysis of factors associated with readmission

	Multivariate analysis
Factor	HR (95%CI)	P value
Intervention vs controls	0.99 (0.66-1.48)	0.95
Age	0.99 (0.97-1.01)	0.39
Female gender	1.36 (0.87-2.1)	0.18
Etiology of cirrhosis
EtOH vs HCV	0.99 (0.13-7.77)	0.99
NAFLD vs HCV	1.03 (0.51-2.54)	0.93
MELD score (for every 1 unit increment)	1.03 (0.99-1.05)	0.09
Index hospitalization length of stay (for every 1 d increment)	0.99 (0.97-1.02)	0.59
Discharge to home with home care vs home	1.12 (0.69-2.01)	0.55
Discharge to SNF vs home	0.96 (0.51-1.83)	0.91

HR: Hazard ratio; CI: Confidence interval; EtOH: Alcohol; HCV: Hepatitis C virus; NAFLD: Non-alcoholic fatty liver disease; MELD: Model for end-stage liver disease; SNF: Skilled nursing facility.

Table 4 Comparison of studies describing various interventions targeted to improve outcomes after hospital discharge in cirrhotic patients

Ref.	Intervention type	Number of patients	Timing of intervention	Unplanned readmission rate				Mortality
				1 mo	3 mo	6 mo		1 mo	3 mo	6 mo
Wigg et al[8], 2013	Chronic disease management program	C:20 T:40	12 mo after discharge	C: 0.4/person/yr T: 1/person/yr				1C: 15% 1T: 10%
Morando et al[10], 2013	Care management checkup model	C: 60 T: 40	12 mo after discharge	C: 42% T: 15%	NA		NA	1C: 46% 1T: 23%
Tapper et al[9], 2016	Handheld (1st phase) and electronic (2nd phase) checklists	C: 626 T: 1st: 470 2nd: 624	Inpatient stay	C: 38% T: 1st: 35% 2nd: 27%	NA		NA	NA	C: 20% T: 1st: 15% 2nd: 21%	NA
Kanwal et al[7], 2016	Early follow up in clinic	C: 17094 T: 8123	At discharge	C: 14% T: 15%	NA		NA	C: 5% T: 3%	NA	NA
Current study	Outpatient telephonic transitional care	C: 93 T: 76	30 d after discharge	C: 38% T: 37%	C: 55% T: 57%		C: 62% T: 65%	C: 10% T: 5%	C: 24% T: 13%	C: 31% T: 16%

¹Only data on 12 mo mortality rates are available. C: Control arm; T: Intervention arm; NA: Not available.