Abstract
BACKGROUND: Patients with decompensated cirrhosis have increased healthcare needs and consequentially greater healthcare utilization. Whether specific types of decompensating events including ascites, spontaneous bacterial peritonitis (SBP), hepatic encephalopathy (HE), variceal bleeding (VB), and hepatorenal syndrome (HRS) are associated with greater risk of hospital readmission is unclear. AIMS: We aim to describe an inpatient cohort admitted with decompensated cirrhosis at a single tertiary care center and evaluate important clinical endpoints including length of stay (LOS), inpatient mortality and 30-day readmission rates (R-30) by presence and type of liver decompensation events. METHODS: Patients with decompensated cirrhosis admitted to a medical service at TOH between July 2014–2016 were identified using ICD codes. Cirrhosis and decompensating events were confirmed by chart review. RESULTS: Of the 302 patient admissions reviewed to date, 190 were first presentation to TOH with decompensated cirrhosis. Among those, 40.5% consumed alcohol in the prior week, and 62.6% of patients had one or more pre-existing complications of cirrhosis (ascites 53.7%, HE 25.8%, SBP 6.8%, VB 12.6%, HRS 1.1%). The average MELD-Na on admission was 19.2 (SD 6.8) for all unique patients. Admissions were complicated by ascites in 70.5%, HE in 25.5%, VB in 20.5%, SBP in 9.5%, and HRS in 5.8%. Patients with ascites, HE and HRS had significantly longer LOS compared to those without: ascites median LOS 6.9 days (IQR 4.0–17.5, p = 0.025), HE 8.7 (4.5–22.0, p = 0.046), HRS 20.7 (11.7–26.9, p = 0.0022). VB trended towards prolonging LOS but not significantly (median 5.29, IQR 3.28–6.89, p=0.051). SBP did not significantly impact LOS (median 12.1, IQR 4.9–24.0, p = 0.13). R-30 was significantly greater in those with HE (37.5%, p=0.008) compared to those without, while other in-hospital decompensating events did not significantly impact R-30 (ascites 23.9%, p=0.72; SBP 27.8%, p=0.63; HRS 9.1%, p=0.26; VB 18.0%, p=0.65). Pre-existing HE was also a significant predictor of R-30 (34.7%, p=0.026). Overall inpatient mortality rate was 19.0%. Inpatient mortality was greatest in those with an in-hospital diagnosis of HRS (72.7%, p<0.0001), followed by SBP (55.6%, p<0.0001) and ascites (19.0%, p=0.002). Mortality rates were not significantly different in patients with HE and VB compared to those without (18.8%, p=0.89; and 20.5%, p=0.94, respectively). CONCLUSIONS: In our cohort, patients admitted with decompensated cirrhosis have high in-hospital mortality, prolonged LOS and increased risk of 30-day readmission. Decompensating events, notably HE, negatively impact hospital outcomes such as LOS and R-30, while HRS, SBP and ascites are associated with increased mortality. Future work will target strategies to improve the care for these patients. FUNDING AGENCIES: None