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Ngu NL, Saxby E, Worland T, Anderson P, Stothers L, Hunter J, Elford AT, Ha P, Hartley I, Roberts A, Seah D, Tambakis G, Connoley D, Figredo A, Ratnam D, Liew D, Rogers B, Sievert W, Bell S, Le S. A Nonrandomized Pilot Study to Investigate the Acceptability and Feasibility of LivR Well: A Multifaceted 28-Day Home-Based Liver Optimization Program for Acute-on-Chronic Liver Failure. GASTRO HEP ADVANCES 2024; 4:100567. [PMID: 39877863 PMCID: PMC11773469 DOI: 10.1016/j.gastha.2024.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Accepted: 10/11/2024] [Indexed: 01/31/2025]
Abstract
Background and Aims Acute-on-chronic liver failure (ACLF) has a 22%-74% 28-day mortality rate and 30%-40% 30-day readmission rate. We investigated the acceptability and feasibility of a multimodal community intervention for ACLF. Methods A single-arm nonrandomized pilot study of consecutive participants with ACLF was conducted in a tertiary health service. Participants received weekly medical and nursing reviews, dietetics, physiotherapy, pharmacy, social work, addiction medicine, and neuropsychiatry, where indicated. A digital platform included remote weight monitoring and online surveys. The primary outcome was acceptability/feasibility. Secondary outcomes included safety, mortality, readmission, liver disease severity, and costs. Results Fifty-nine patients were enrolled with median age 51 years (interquartile range (IQR): 45-59); majority alcohol etiology (74%),and median Model for End-Stage Liver Disease Sodium score 16 (IQR: 12-21). LivR Well was acceptable with low attrition (8 of 59), adherence to the program including home visits (mean 8.4 ± 4.2) and consultations (mean 2.4 ± 1.5) per patient. This was supported by positive feedback and themes identified through a qualitative subanalysis. Feasibility was demonstrated by recruitment rate of 4.94 patients/month and 86% completion. Mortality was lower than expected at 3%, 30-day readmission rate was 15%, and median Model for End-Stage Liver Disease Sodium score reduced to 15 (P = .01). Median 6-month costs reduced from $30,454 (IQR: $21,953-$65,657) to $17,657 ($4249-$42,876) (P = .009). The total 6-month health-care cost was $1,868,859 (95% confidence interval 1,081,821-2,655,897) compared to $2,518,227 (95% confidence interval 1,959,610-3,076,844). Conclusion LivR Well was acceptable, feasible, and safe with low short-term mortality and readmission rates. Health-care costs were reduced by 26% driven by a 40% reduction in 30-day readmission. Further evaluation includes a randomized controlled trial of LivR Well compared to standard care.
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Affiliation(s)
- Natalie L.Y. Ngu
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Edward Saxby
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
- Monash Digital Therapeutics and Innovation Laboratory (MoTILa), Monash University, Monash Health Translation Precinct, Melbourne, Victoria, Australia
| | - Thomas Worland
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
| | - Patricia Anderson
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
| | - Lisa Stothers
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
| | - Jo Hunter
- Monash Digital Therapeutics and Innovation Laboratory (MoTILa), Monash University, Monash Health Translation Precinct, Melbourne, Victoria, Australia
- Pharmacy Department, Monash Health, Melbourne, Victoria, Australia
| | - Alexander T. Elford
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
- Faculty of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Phil Ha
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
| | - Imogen Hartley
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
| | - Andrew Roberts
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
| | - Dean Seah
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
| | - George Tambakis
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
| | - Declan Connoley
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
| | - Anita Figredo
- Hospital in the Home, Monash Health, Melbourne, Victoria, Australia
| | - Dilip Ratnam
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Danny Liew
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Benjamin Rogers
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Hospital in the Home, Monash Health, Melbourne, Victoria, Australia
| | - William Sievert
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Sally Bell
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Suong Le
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Monash Digital Therapeutics and Innovation Laboratory (MoTILa), Monash University, Monash Health Translation Precinct, Melbourne, Victoria, Australia
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Tillakeratne S, Pearson SA, Alavi M, Hajarizadeh B, Martinello M, Law M, George J, Amin J, Matthews G, Grebely J, Dore GJ, Valerio H. Trends in viral hepatitis liver-related morbidity and mortality in New South Wales, Australia. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 51:101185. [PMID: 39282135 PMCID: PMC11402402 DOI: 10.1016/j.lanwpc.2024.101185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 08/13/2024] [Accepted: 08/15/2024] [Indexed: 09/18/2024]
Abstract
Background Monitoring hepatitis B virus (HBV) and hepatitis C virus (HCV) liver-related morbidity and mortality is key to evaluate progress towards elimination targets. Methods HBV and HCV notifications in NSW, Australia (1995-2022) were linked to hospital and mortality records. Temporal trends in decompensated cirrhosis (DC), hepatocellular carcinoma (HCC), and mortality were evaluated among people notified for HBV and HCV. Segmented Poisson regression models were used to assess the impact of the viral hepatitis elimination era (1 January 2015-31 December 2022) on advanced liver disease and mortality. Findings During 1995-2022, there were 64,865 people with an HBV notification and 112,277 people with an HCV notification in NSW. Between 2002 and 2022, there were significant reductions in age-adjusted HBV- and HCV-related DC, HCC, and liver-related mortality. Among those with HBV, age-standardised incidence per 1000 person-years (py) in 2002, 2015, and 2022 was 3.08, 1.47, and 1.16 for DC (p < 0.001); 2.97, 1.45, and 0.75 for HCC (p < 0.001); and 2.84, 1.93, and 1.40 for liver-related mortality (p < 0.001). Among those with HCV, age-standardised incidence per 1000 py in 2002, 2015, and 2022, was 5.53, 4.57, and 2.31 for DC (p < 0.001); 2.22, 2.59, and 1.87 for HCC (p < 0.001); and 3.89, 4.73, and 3.16 for liver-related mortality (p < 0.001). In 2022, absolute liver-related mortality per 100,000 population was 0.95 for HBV and 3.56 for HCV. In adjusted analyses, older age, comorbidity, and a history of alcohol use disorder were associated with increased liver-related mortality among those with HBV and HCV. Interpretation This population-level study demonstrated declining risks of DC, HCC, and mortality, with HBV-related declines commencing well before elimination era while HCV-related declines were mostly during elimination era. Population liver mortality indicates elimination target achieved for combined viral hepatitis and HBV, but not HCV. Funding The Kirby Institute, UNSW Sydney, and New South Wales Ministry of Health, Australia.
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Affiliation(s)
| | | | | | | | | | | | | | - Janaki Amin
- The Kirby Institute, UNSW Sydney, Australia
- Department of Health Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
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Favre-Bulle T, Moradpour D, Marques-Vidal P, Vaucher J. Trends in the burden of hospitalised patients with cirrhosis in Switzerland: a cross-sectional study of cirrhosis-related hospitalisations between 1998 and 2020. BMJ Open 2024; 14:e081822. [PMID: 39181561 PMCID: PMC11344505 DOI: 10.1136/bmjopen-2023-081822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 08/05/2024] [Indexed: 08/27/2024] Open
Abstract
OBJECTIVE Liver cirrhosis is an increasing cause of morbidity and mortality worldwide with a heavy load on healthcare systems. We analysed the trends in hospitalisations for cirrhosis in Switzerland. DESIGN Cross-sectional study. SETTING Large nationwide inpatient database, years between 1998 and 2020. PARTICIPANTS Hospitalisations for cirrhosis of adult patients were selected. MAIN OUTCOMES AND MEASURES Hospitalisations with either a primary diagnosis of cirrhosis or a cirrhosis-related primary diagnosis with a mandatory presence of cirrhosis as a secondary diagnosis were considered following the 10th revision of the International Statistical Classification of Diseases and Related Health Problems codes. Trends in demographic and clinical characteristics, in-hospital mortality and length of stay were analysed. Causes and costs of cirrhosis-related hospitalisations were available from 2012 onwards. RESULTS Cirrhosis-related hospitalisations increased from 1631 in 1998 to 4052 in 2020. Of the patients, 68.7% were men. Alcohol-related liver disease was the leading cause, increasing from 44.1% (95% CI, 42.4% to 45.9%) in 2012 to 47.9% (95% CI, 46.4% to 49.5%) in 2020. Assessed by exclusion of other coded causes, non-alcoholic fatty liver disease was the second cause at 42.7% (95% CI, 41.2% to 44.3%) in 2020. Hepatitis C virus-related cirrhosis decreased from 12.3% (95% CI, 11.2% to 13.5%) in 2012 to 3.2% (95% CI, 2.7% to 3.8%) in 2020. Median length of stay decreased from 11 to 8 days. Hospitalisations with an intensive care unit stay increased from 9.8% (95% CI, 8.4% to 11.4%) to 15.6% (95% CI, 14.5% to 16.8%). In-hospital mortality decreased from 12.1% (95% CI, 10.5% to 13.8%) to 9.7% (95% CI, 8.8% to 10.7%). Total costs increased from 54.4 million US$ (51.4 million €) in 2012 to 92.6 million US$ (87.5 million €) in 2020. CONCLUSIONS Cirrhosis-related hospitalisations and related costs increased in Switzerland from 1998 to 2020 but in-hospital mortality decreased. Alcohol-related liver disease and non-alcoholic fatty liver disease were the most prevalent and preventable aetiologies of cirrhosis-related hospitalisations.
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Affiliation(s)
- Timothee Favre-Bulle
- Service of Internal Medicine, Etablissements Hospitaliers du Nord Vaudois, Yverdon-les-Bains, Switzerland
- Department of Medicine, University of Lausanne Faculty of Biology and Medicine, Lausanne, Switzerland
| | - Darius Moradpour
- Department of Medicine, Service of Gastroenterology and Hepatology, University of Lausanne, Lausanne, Switzerland
| | | | - Julien Vaucher
- Department of Medicine, University of Lausanne, Lausanne, Switzerland
- Department of Medicine and Specialties, University of Fribourg, Fribourg, Switzerland
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Attree C, Fennessy S, Jeffrey G, Kontorinis N, Naylor N, Hazeldine S. Prior hospital attendances in deceased Australian patients with alcohol-related liver disease: a multicentre project. Intern Med J 2024; 54:1003-1009. [PMID: 38314610 DOI: 10.1111/imj.16339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 01/14/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND AND AIMS To establish the hospital visit history of patients who die with alcohol-related liver disease (ArLD). To determine if patients with ArLD present to hospital early or in the terminal phase of their disease. METHODS Retrospective cohort study of patients with a history of ArLD who died as an inpatient at three tertiary Western Australian hospitals from February 2015 to February 2017. Hospital records were reviewed to identify the number and cause of emergency department (ED), inpatient and outpatient attendances in all Western Australian public hospitals in the 10 years prior to death. RESULTS One hundred fifty-nine patients (23% female) had a total of 753 ED, 3535 outpatient appointments, 1602 hospital admissions and 10 755 admission days. Twelve months prior to death, 82% of patients had a public hospital contact and 74% an admission. Patients who had their first hospital contact within 12 months prior to death were significantly more likely to have a liver-related cause of death (P < 0.01). Aboriginal and Torres Strait Islander patients (15% of cohort) died at a significantly younger age (M = 49.2, SD = 10.5 years) than non-Aboriginal and Torres Strait Islander patients (M = 59.9, SD = 10.2 years, P < 0.01). Despite having more ED attendances and hospital admissions, Aboriginal and Torres Strait Islander patients had significantly less (P = 0.04) outpatient appointments (Mdn = 5.5, interquartile range [IQR] = 1-18 vs Mdn = 11, IQR = 3-33). CONCLUSIONS Most patients with ArLD have multiple early attendances, which present an opportunity for early interventions. There are missed opportunities for Aboriginal and Torres Strait Islander patients for outpatient hospital engagement.
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Affiliation(s)
- Chloe Attree
- Department of Gastroenterology and Hepatology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Sean Fennessy
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Gary Jeffrey
- Department of Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Nickolas Kontorinis
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Nola Naylor
- Department of Gastroenterology and Hepatology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Simon Hazeldine
- Department of Gastroenterology and Hepatology, Fiona Stanley Hospital, Perth, Western Australia, Australia
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Valery PC, Roche S, Brown C, O'Beirne J, Hartel G, Leggett B, Skoien R, Powell EE. High prevalence of diabetes among young First Nations Peoples with metabolic dysfunction-associated steatotic liver disease: a population-based study in Australia. Int J Equity Health 2024; 23:84. [PMID: 38689295 PMCID: PMC11061954 DOI: 10.1186/s12939-024-02153-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/18/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Liver disease is an important contributor to the mortality gap between First Nations Peoples and non-Indigenous Australian adults. Despite a high burden of metabolic comorbidities among First Nations Peoples, data about the epidemiology of metabolic dysfunction-associated steatotic liver disease (MASLD) in this population is scarce. METHODS A retrospective analysis of all adults hospitalized with MASLD or metabolic dysfunction-associated steatohepatitis (MASH) with/without cirrhosis during 2007-2019 in the state of Queensland was performed. Patients were followed from the first admission with MASLD/MASH (identified based on validated algorithms) to decompensated cirrhosis and overall mortality. We explored differences according to Indigenous status using Multivariable Cox regression. FINDINGS 439 First Nations Peoples and 7,547 non-Indigenous Australians were followed for a median of 4.6 years (interquartile range 2.7-7.2). Overall, women were overrepresented, but more so in the First Nations cohort (72.7% vs. 57.0%, p < 0.001). First Nations patients were younger, a higher proportion lived in remote and socioeconomic disadvantaged areas, and had higher comorbidity compared to non-Indigenous Australians (all p < 0.001). Diabetes, the most common comorbidity affecting both groups, was overrepresented in First Nations Peoples versus non-Indigenous Australians (43.5% vs. 30.8%, p < 0.001, respectively). Nineteen (4.3%) First Nations Peoples and 332 (4.4%) of non-Indigenous patients progressed to cirrhosis decompensation (9.0% [95%CI 4.5-17.7] vs. 7.7% [95%CI 6.6-8.9; p = 0.956] respectively within 10 years). In multivariable analysis, there was no association between Indigenous status and progression to decompensated cirrhosis (p = 0.759) and survival (p = 0.437). CONCLUSIONS This study provides the first population-based epidemiological data on MASLD in First Nations Australians. The high prevalence of diabetes (that is associated with advanced fibrosis and liver disease mortality) among young First Nations Peoples with MASLD raises concern about future risk of progressive liver disease in this patient population. These data highlight the importance of early identification of MASLD, and providing culturally appropriate intervention to reduce disease progression in parallel with the management of cardiometabolic comorbidities.
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Affiliation(s)
- Patricia C Valery
- Cancer & Chronic Disease Research Group, QIMR Berghofer Medical Research Institute, 300 Herston Road, 4006, Herston, QLD, Australia.
- The University of Queensland, St Lucia, QLD, Australia.
| | - Shruti Roche
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Catherine Brown
- Cancer & Chronic Disease Research Group, QIMR Berghofer Medical Research Institute, 300 Herston Road, 4006, Herston, QLD, Australia
| | - James O'Beirne
- Department of Gastroenterology and Hepatology, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia
| | - Gunter Hartel
- Cancer & Chronic Disease Research Group, QIMR Berghofer Medical Research Institute, 300 Herston Road, 4006, Herston, QLD, Australia
- The University of Queensland, St Lucia, QLD, Australia
- School of Nursing, Queensland University of Technology, Brisbane, QLD, Australia
| | - Barbara Leggett
- The University of Queensland, St Lucia, QLD, Australia
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Richard Skoien
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Elizabeth E Powell
- Cancer & Chronic Disease Research Group, QIMR Berghofer Medical Research Institute, 300 Herston Road, 4006, Herston, QLD, Australia
- The University of Queensland, St Lucia, QLD, Australia
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Centre for Liver Disease Research, Translational Research Institute, Faculty of Medicine, The University of Queensland, St Lucia, QLD, Australia
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Hayward KL, Weersink RA, Bernardes CM, McIvor C, Rahman T, Skoien R, Clark PJ, Stuart KA, Hartel G, Valery PC, Powell EE. Changing Prevalence of Medication Use in People with Cirrhosis: A Retrospective Cohort Study Using Pharmaceutical Benefits Scheme Data. Drugs Real World Outcomes 2023; 10:605-618. [PMID: 37828144 PMCID: PMC10730495 DOI: 10.1007/s40801-023-00390-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Safe and appropriate use of medicines is essential to improve health outcomes in cirrhosis. However, little is known about the number and type of medicines dispensed to people with cirrhosis in Australia, as this predominantly occurs in the community. We aimed to characterise the prescriptions dispensed to people with cirrhosis and explore changes in the use of medication groups over time. METHODS Pharmaceutical Benefits Scheme data between 1 January 2016 and 30 June 2020 was extracted for consenting CirCare participants (multi-site, prospective, observational study). Prescriptions dispensed from cirrhosis diagnosis until liver transplant or death were included. Safety classifications for dispensed medicines were defined using published evidence-based recommendations. The pattern of medication use was analysed in 6-monthly time intervals. Generalised estimating equations models were used to estimate the change in consumption of medicines over time. RESULTS Five hundred twenty-two patients (mean age 60 years, 70% male, 34% decompensated at recruitment) were dispensed 89,615 prescriptions during the follow-up period, representing a median of 136 [interquartile range (IQR) 62-237] prescriptions and a median of 16 (IQR 11-23) unique medicines per patient (total n = 9306 medicines). The most commonly used medicines were proton pump inhibitors (PPIs) (dispensed at least once to 73% of patients), opioids (68%) and antibiotics (89%). Polypharmacy was prevalent, with 59-69% of observed participants in each time period dispensed five or more unique medicines. Prescription medication use increased over time (p < 0.001) independently of age, comorbidity burden and liver disease aetiology. The likelihood of taking PPIs, opioids, antidepressants and inhaled medicines also increased with each successive time period. Use of angiotensin therapies, metformin and statins differed over time between patients with compensated versus decompensated cirrhosis. General practitioners prescribed 69% of dispensed medicines, including a higher proportion of 'unsafe' and 'safety unknown' medicines compared with consultants/specialists (p < 0.001). CONCLUSIONS Polypharmacy is common in people with cirrhosis and some medication groups may be overused. Pharmacovigilance is required and future medication safety efforts should target high-risk prescribing practices and promote medication rationalisation in the community.
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Affiliation(s)
- Kelly L Hayward
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia
| | - Rianne A Weersink
- Department of Clinical Pharmacy, Deventer Hospital, Deventer, The Netherlands
| | | | - Carolyn McIvor
- Department of Gastroenterology and Hepatology, Logan Hospital, Meadowbrook, QLD, Australia
| | - Tony Rahman
- Gastroenterology and Hepatology Department, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Richard Skoien
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Paul J Clark
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia
- Department of Gastroenterology and Hepatology, Mater Hospital, South Brisbane, QLD, Australia
| | - Katherine A Stuart
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Gunter Hartel
- QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
- School of Nursing, Queensland University of Technology, Brisbane, QLD, Australia
| | | | - Elizabeth E Powell
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.
- Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia.
- QIMR Berghofer Medical Research Institute, Herston, QLD, Australia.
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Livingston M, Room R, Chikritzhs T, Taylor N, Yuen WS, Dietze P. Trends in alcohol-related liver disease mortality in Australia: An age-period-cohort perspective. Addiction 2023; 118:2156-2163. [PMID: 37349258 DOI: 10.1111/add.16275] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/13/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND AND AIMS There have been few systematic attempts to examine how alcohol-related mortality has changed in Australia, and no studies that have explored cohort effects in alcohol-related mortality. This study uses more than 50 years of data to measure age, period and cohort trends in alcohol-related liver disease (ALD) mortality. DESIGN, SETTING AND CASES This was a retrospective age-period-cohort analysis of total Australian ALD mortality data from 1968 to 2020 in Australia. There was a total of 35 822 deaths-27 208 men (76%) and 8614 women (24%). MEASUREMENTS Deaths from ALD were grouped into 5-year age groups and periods (e.g. deaths for 20-24-year-olds between 1968 and 1972 were combined). FINDINGS ALD mortality peaked in the late 1970s and early 1980s for both men and women. In age-period-cohort models, mortality was highest for cohorts born 1915-30. For example, men born between 1923 and 1927 had a relative risk of 1.58 [95% confidence interval (CI) = 1.52, 1.64] compared with men born between 1948 and 1952. For women, there was an increase in risk for cohorts born in the 1960s [e.g. the 1963-67 cohort had a relative risk (RR) of 1.16 (95% CI = 1.07, 1.25) compared with women born in 1948-52]. For men, there was a broad decline in mortality over time [e.g. in 2020, the RR was 0.87 (95% CI = 0.82, 0.92) compared with the reference year of 2000]. For women, mortality declined until 2000 and has been stable since. CONCLUSIONS Alcohol-related liver disease mortality has declined across the Australian population since the 1970s and 1980s partly due to cohort-specific shifts as the highest-risk birth cohorts age. For women, this decline had stalled by the year 2000, and cohorts of women born during the 1960s were at higher risk than earlier cohorts, suggesting the need for thoughtful interventions as this population enters its highest-risk years for ALD mortality.
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Affiliation(s)
- Michael Livingston
- National Drug Research Institute, Curtin University, Perth, Australia
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia
- Burnet Institute, Melbourne, Australia
| | - Robin Room
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia
- Centre for Social Research on Alcohol and Drugs, Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
| | - Tanya Chikritzhs
- National Drug Research Institute, Curtin University, Perth, Australia
| | - Nicholas Taylor
- National Drug Research Institute, Curtin University, Perth, Australia
- Burnet Institute, Melbourne, Australia
- School of Psychology, Deakin University, Geelong, Australia
| | - Wing See Yuen
- National Drug and Alcohol Research Centre, UNSW, Sydney, Australia
| | - Paul Dietze
- National Drug Research Institute, Curtin University, Perth, Australia
- Burnet Institute, Melbourne, Australia
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Ngu NLY, Flanagan E, Bell S, Le ST. Acute-on-chronic liver failure: Controversies and consensus. World J Gastroenterol 2023; 29:232-240. [PMID: 36687118 PMCID: PMC9846945 DOI: 10.3748/wjg.v29.i2.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/01/2022] [Accepted: 12/21/2022] [Indexed: 01/06/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) is a poorly defined syndrome characterised by rapid clinical deterioration in patients with chronic liver disease. Consequences include high short-term morbidity, mortality, and healthcare resource utilisation. ACLF encompasses a dysregulated, systemic inflammatory response, which can precipitate extra hepatic organ failures. Common precipitants include infection, alcoholic hepatitis, and reactivation of viral hepatitis although frequently no cause is identified. Heterogenous definitions, diagnostic criteria, and treatment guidelines, have been proposed by international hepatology societies. This can result in delayed or missed diagnoses of ACLF, significant variability in clinical management, and under-estimation of disease burden. Liver transplantation may be considered but the mainstay of treatment is organ support, often in the intensive care unit. This review will provide clarity around where are the controversies and consensus in ACLF including: Epidemiology and resource utilisation, key clinical and diagnostic features, strategies for management, and research gaps.
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Affiliation(s)
- Natalie L Y Ngu
- Department of Gastroenterology and Hepatology, Monash Health, Clayton 3168, Victoria, Australia
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton 3800, Victoria, Australia
- Department of Gastroenterology and Hepatology, Alfred Health, Melbourne 3004, Victoria, Australia
| | - Eliza Flanagan
- Department of Gastroenterology and Hepatology, Monash Health, Clayton 3168, Victoria, Australia
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton 3800, Victoria, Australia
- Monash digital Therapeutics and Innovation Laboratory (MoTILa), Monash University, Clayton 3168, Victoria, Australia
| | - Sally Bell
- Department of Gastroenterology and Hepatology, Monash Health, Clayton 3168, Victoria, Australia
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton 3800, Victoria, Australia
| | - Suong T Le
- Department of Gastroenterology and Hepatology, Monash Health, Clayton 3168, Victoria, Australia
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton 3800, Victoria, Australia
- Monash digital Therapeutics and Innovation Laboratory (MoTILa), Monash University, Clayton 3168, Victoria, Australia
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9
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Ngu NL, Saxby E, Worland T, Anderson P, Stothers L, Figredo A, Hunter J, Elford A, Ha P, Hartley I, Roberts A, Seah D, Tambakis G, Liew D, Rogers B, Sievert W, Bell S, Le S. A home-based, multidisciplinary liver optimisation programme for the first 28 days after an admission for acute-on-chronic liver failure (LivR well): a study protocol for a randomised controlled trial. Trials 2022; 23:744. [PMID: 36064596 PMCID: PMC9444080 DOI: 10.1186/s13063-022-06679-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 08/20/2022] [Indexed: 11/22/2022] Open
Abstract
Background Acute-on-chronic liver failure (ACLF) represents a rising global healthcare burden, characterised by increasing prevalence among patients with decompensated cirrhosis who have a 28-day transplantation-free mortality of 33.9%. Due to disease complexity and a high prevalence of socio-economic disadvantage, there are deficits in quality of care and adherence to guideline-based treatment in this cohort. Compared to other chronic conditions such as heart failure, those with liver disease have reduced access to integrated ambulatory care services. The LivR Well programme is a multidisciplinary intervention aimed at improving 28-day mortality and reducing 30-day readmission through a home-based, liver optimisation programme implemented in the first 28 days after an admission with either ACLF or hepatic decompensation. Outcomes from our feasibility study suggest that the intervention is safe and acceptable to patients and carers. Methods We will recruit adult patients with chronic liver disease from the emergency departments, in-patient admissions, and an ambulatory liver clinic of a multi-site quaternary health service in Melbourne, Australia. A total of 120 patients meeting EF-Clif criteria will be recruited to the ACLF arm, and 320 patients to the hepatic decompensation arm. Participants in each cohort will be randomised to the intervention arm, a 28-day multidisciplinary programme or to standard ambulatory care in a 1:1 ratio. The intervention arm includes access to nursing, pharmacy, physiotherapy, dietetics, social work, and neuropsychiatry clinicians. For the ACLF cohort, the primary outcome is 28-day mortality. For the hepatic decompensation cohort, the primary outcome is 30-day re-admission. Secondary outcomes assess changes in liver disease severity and quality of life. An interim analysis will be performed at 50% recruitment to consider early cessation of the trial if the intervention is superior to the control, as suggested in our feasibility study. A cost-effectiveness analysis will be performed. Patients will be followed up for 12 weeks from randomisation. Three exploratory subgroup analyses will be conducted by (a) source of referral, (b) unplanned hospitalisation, and (c) concurrent COVID-19. The trial has been registered with the Australian New Zealand Clinical Trials Registry. Discussion This study implements a multidisciplinary intervention for ACLF patients with proven benefits in other chronic diseases with the addition of novel digital health tools to enable remote patient monitoring during the COVID-19 pandemic. Our feasibility study demonstrates safety and acceptability and suggests clinical improvement in a small sample size. An RCT is required to generate robust outcomes in this frail, high healthcare resource utilisation cohort with high readmission and mortality risk. Interventions such as LivR Well are urgently required but also need to be evaluated to ensure feasibility, replicability, and scalability across different healthcare systems. The implications of this trial include the generalisability of the programme for implementation across regional and urban centres. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621001703897. Registered on 13 December 2021. WHO Trial Registration Data Set. See Appendix 1 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06679-x.
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Affiliation(s)
- Natalie Ly Ngu
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia. .,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia.
| | - Edward Saxby
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Thomas Worland
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Patricia Anderson
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Lisa Stothers
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Anita Figredo
- Hospital in the Home, Level 4, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Jo Hunter
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Alexander Elford
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Phil Ha
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Imogen Hartley
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Andrew Roberts
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Dean Seah
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - George Tambakis
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Danny Liew
- Adelaide Medical School, The University of Adelaide, Corner of North Terrace & George St, Adelaide, South Australia, 5000, Australia
| | - Benjamin Rogers
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia.,Hospital in the Home, Level 4, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - William Sievert
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia
| | - Sally Bell
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia
| | - Suong Le
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia
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10
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Trends in decompensated cirrhosis and hepatocellular carcinoma among people with a hepatitis B notification in New South Wales. JHEP Rep 2022; 4:100552. [PMID: 36119722 PMCID: PMC9478454 DOI: 10.1016/j.jhepr.2022.100552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 07/01/2022] [Accepted: 07/19/2022] [Indexed: 01/27/2023] Open
Abstract
Background & Aims Population-level trends and factors associated with HBV-related decompensated cirrhosis (DC), hepatocellular carcinoma (HCC), and liver-related mortality are crucial to evaluate the impacts of therapeutic interventions. Methods Trends in HBV-DC and -HCC diagnoses and liver-related mortality in New South Wales, Australia, were determined through linkage of HBV notifications (1993-2017) to hospital admissions (2001-2018), mortality (1993-2018), and cancer registry (1994-2014) databases. Late HBV notification was defined as notification at or within 2 years of a DC or HCC diagnosis. Cox proportional-hazards regression and multivariable logistic regression analyses were performed to evaluate associated factors. Results Among 60,660 people with a HBV notification, 1,276 (2.0%) DC and 1,087 (1.8%) HCC diagnoses, and 1,219 (2.0%) liver-related deaths were documented. Since the early 2000s, the number of DC and HCC diagnoses increased; however, age-standardised incidence decreased from 2.64 and 1.95 in 2003 to 1.14 and 1.09 per 1,000 person-years in 2017, respectively. Similarly, age-standardised liver mortality decreased from 2.60 in 2003 to 1.14 per 1,000 person-years in 2017. Among people with DC and HCC diagnoses, late HBV notification declined from 41% and 40% between 2001-2009 to 29% and 25% in 2010-2018, respectively. Predictors of DC diagnosis included older age (birth <1944, adjusted hazard ratio [aHR] 2.06, 95% CI 1.57–2.69), alcohol use disorder (aHR 4.82, 95% CI 3.96–5.87) and HCV co-infection (aHR 1.88, 95% CI 1.53–2.31). Predictors of HCC diagnosis included older age (birth <1944, aHR 3.94, 95% CI 2.91–5.32) and male sex (aHR 3.79, 95% CI 3.05–4.71). Conclusion In an era of improved antiviral therapies, the risk of HBV-related liver morbidity and mortality has declined. HCV co-infection and alcohol use disorder are key modifiable risk factors associated with the burden of HBV. Lay summary Rising hepatitis B-related morbidity and mortality is a major public health concern. However, the development of highly effective medicines against hepatitis B virus (HBV) has brought renewed optimism for its elimination by 2030. This study shows a steady decline in HBV-related liver morbidity and mortality in New South Wales, Australia. Moreover, late hepatitis notification has also declined, allowing individuals with HBV to have access to timely antiviral treatment. Despite this, hepatitis C co-infection and alcohol use disorder are key modifiable risk factors associated with HBV disease burden. To attain the desired benefits from highly effective antiviral treatment, managing comorbidities, including hepatitis C and high alcohol use, must improve among individuals with hepatitis B.
The World Health Organization has set a 65% HBV mortality reduction target by 2030. Since the early 2000s, diagnoses of decompensated cirrhosis and HCC increased, but age-standardised incidence rates decreased. Age-standardised liver mortality rates decreased from 2.64 in 2003 to 0.97 per 1,000 person-years in 2017. Late HBV notification declined from 41% and 40% during 2001-2009 to 28% and 26% in 2010-2018, respectively. Hepatitis C co-infection and alcohol-use disorder are key modifiable risk factors associated with HBV disease burden.
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11
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The Hidden Epidemic: The Prevalence and Impact of Concurrent Liver Diseases in Patients Undergoing Liver Transplantation in Australia and New Zealand. Transplant Direct 2022; 8:e1345. [PMID: 37077731 PMCID: PMC10109460 DOI: 10.1097/txd.0000000000001345] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/31/2022] [Accepted: 04/18/2022] [Indexed: 11/26/2022] Open
Abstract
Prevalence of concurrent liver diseases among liver transplant recipients and impact on posttransplant outcomes are unknown. Methods This retrospective study included adult liver transplants between January 1' 1985' and December 31' 2019' from the Australian and New Zealand Liver and Intestinal Transplant Registry. Up to 4 liver disease causes were recorded for each transplant; concurrent liver diseases were defined as >1 liver disease indication for transplantation, excluding hepatocellular carcinoma. Impact on posttransplant survival was determined using Cox regression. Results A total of 840 (15%) of 5101 adult liver transplant recipients had concurrent liver diseases. Recipients with concurrent liver diseases were more likely male (78% versus 64%) and older (mean age 52 versus 50 y). A higher proportion of liver transplants for hepatitis B (12% versus 6%), hepatitis C (33% versus 20%), alcohol liver disease (23% versus 13%), and metabolic-associated fatty liver disease (11% versus 8%, all P < 0.001) were identified when all indications were included than with primary diagnosis only. The number and proportion of liver transplants performed for concurrent liver diseases have increased from 8 (6%) during Era 1 (1985-1989) to 302 (20%) during Era 7 (2015-2019; P < 0.001). Concurrent liver diseases were not associated with increased posttransplant mortality (adjusted hazard ratio, 0.98, 95% confidence interval, 0.84-1.14). Conclusions Concurrent liver diseases are increasing among adult liver transplant recipients in Australia and New Zealand; however, they do not appear to impact posttransplant survival. Reporting all liver disease causes in the transplant registry reports provides more accurate estimates of liver disease burden.
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12
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Valery PC, Bernardes CM, Hayward KL, Hartel G, Haynes K, Gordon LG, Stuart KA, Wright PL, Johnson A, Powell EE. Poor disease knowledge is associated with higher healthcare service use and costs among patients with cirrhosis: an exploratory study. BMC Gastroenterol 2022; 22:340. [PMID: 35836105 PMCID: PMC9284723 DOI: 10.1186/s12876-022-02407-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/29/2022] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Optimal management of cirrhosis is complex, and patients often lack knowledge and skills, which can affect self-management. We assessed patient knowledge about cirrhosis and examined whether knowledge was associated with clinical outcomes, healthcare service use, and healthcare costs. A cross-sectional 'knowledge survey' was conducted during 2018-2020. We assessed patient knowledge about cirrhosis and explore whether knowledge was associated with clinical outcomes, healthcare service use, and costs. METHODS Patients with cirrhosis (n = 123) completed a 'knowledge survey'. We calculated the proportion of correct answers to eight questions deemed to be "key knowledge" about cirrhosis by an expert panel, and dichotomized patients as 'good knowledge'/'poor knowledge'. Clinical data, healthcare costs, and health-related quality of life (SF-36) were available. RESULTS 58.5% of patients had 'good knowledge' about cirrhosis. Higher education level was associated with higher odds of having 'good knowledge' about cirrhosis (adjusted-OR = 5.55, 95%CI 2.40-12.84). Compared to patients with 'poor knowledge', those with 'good knowledge' had a higher health status in the SF-36 physical functioning domain (p = 0.011), fewer cirrhosis-related admissions (adjusted incidence rate ratio [IRR] = 0.59, 95%CI 0.35-0.99) and emergency presentations (adj-IRR = 0.34, 95%CI 0.16-0.72), and more planned 1-day cirrhosis admissions (adj-IRR = 3.96, 95%CI 1.46-10.74). The total cost of cirrhosis admissions was lower for patients with 'good knowledge' (adj-IRR = 0.30, 95%CI 0.29-0.30). CONCLUSION Poor disease knowledge is associated with increased use and total cost of healthcare services. Targeted educational interventions to improve patient knowledge may be an effective strategy to promote a more cost-effective use of healthcare services.
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Affiliation(s)
- Patricia C Valery
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, QLD, 4006, Australia. .,Centre for Liver Disease Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.
| | - Christina M Bernardes
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, QLD, 4006, Australia
| | - Kelly L Hayward
- Centre for Liver Disease Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Gunter Hartel
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, QLD, 4006, Australia
| | | | - Louisa G Gordon
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, QLD, 4006, Australia
| | - Katherine A Stuart
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Penny L Wright
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Amy Johnson
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Elizabeth E Powell
- Centre for Liver Disease Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
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13
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Amarasena S, Clark PJ, Gordon LG, Toombs M, Pratt G, Hartel G, Bernardes CM, Powell EE, Valery PC. Differences in the pattern and cost of hospital care between Indigenous and non-Indigenous Australians with cirrhosis: an exploratory study. Intern Med J 2022. [PMID: 35717648 DOI: 10.1111/imj.15854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 06/09/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Liver diseases are important contributors to the mortality gap between Indigenous and non-Indigenous Australians. AIMS This cohort study examined factors associated with hospital admissions and healthcare outcomes among Indigenous Australians with cirrhosis. METHODS Patient-reported outcomes were obtained by face-to-face interview (Chronic Liver Disease Questionnaire and Short Form 36 (SF-36)). Clinical data were extracted from medical records and through data linkage for 534 patients (25 indigenous). Cumulative overall survival (Kaplan-Meier), rates of hospital admissions and emergency presentations, and costs were assessed by indigenous status. Incidence rate ratios (IRR; Poisson regression) were reported. RESULTS Indigenous Australians admitted to hospital with cirrhosis had lower educational status compared with non-indigenous patients (79.2% vs 43.4%; P < 0.001). The two groups had, in general, similar clinical characteristics including disease severity (P = 0.78), presence of cirrhosis complications (P = 0.67), comorbidities (P = 0.62), rates of cirrhosis-related admissions (P = 0.86) and 5-year survival (P = 0.30). However, indigenous patients had a lower score in the SF-36 domain related to bodily pain (P = 0.037), more cirrhosis admissions via the emergency department (IRR = 1.42, 95% confidence interval (CI) 1.10-1.83) and fewer planned cirrhosis admissions (IRR = 0.32, 95% CI 0.14-0.72). The total cost for cirrhosis-related hospital admissions for 534 patients over 6 years (July 2012 to June 2018) was A$13.7 million. The cost of cirrhosis-related hospital admissions was double for indigenous patients (cost ratio = 2.04, 95% CI 2.04-2.05). CONCLUSIONS Our data highlight the disparities in health service use and patient-reported outcomes, despite having similar clinical profiles. Integration between primary care, Aboriginal Community Controlled Health Organisations and liver specialists is critical for appropriate health service delivery and effective use of resources. Chronic liver disease costs the community dearly.
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Affiliation(s)
- Samath Amarasena
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Paul J Clark
- Department of Gastroenterology and Hepatology, Mater Hospitals, Brisbane, Queensland, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Louisa G Gordon
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Maree Toombs
- Rural Clinical School, Faculty of Medicine, University of Queensland, Toowoomba, Queensland, Australia
| | - Greg Pratt
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Gunter Hartel
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Christina M Bernardes
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Elizabeth E Powell
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Centre for Liver Disease Research, Translational Research Institute, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Patricia C Valery
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
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14
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Zhuang YP, Wang SQ, Pan ZY, Zhong HJ, He XX. Differences in complications between hepatitis B-related cirrhosis and alcohol-related cirrhosis. Open Med (Wars) 2022; 17:46-52. [PMID: 34950772 PMCID: PMC8651059 DOI: 10.1515/med-2021-0401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/22/2021] [Accepted: 11/02/2021] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES This study aimed to investigate the differences in complications between hepatitis B virus (HBV)-related and alcohol-related cirrhoses. METHODS Medical records of patients with HBV-related and alcohol-related cirrhoses treated from January 2014 to January 2021 were, retrospectively, reviewed. The unadjusted rate and adjusted risk of cirrhotic complications between the two groups were assessed. RESULTS The rates of hepatocellular carcinoma (HCC) and hypersplenism were higher in HBV-related cirrhosis (both P < 0.05), whereas the rates of hepatic encephalopathy (HE) and acute-on-chronic liver failure (ACLF) were higher in alcohol-related cirrhosis (both P < 0.05). After adjusting for potential confounders, HBV-related cirrhotic patients had higher risks of HCC (odds ratio [OR] = 34.06, 95% confidence interval [CI]: 4.61-251.77, P = 0.001) and hypersplenism (OR = 2.29, 95% CI: 1.18-4.42, P = 0.014), whereas alcohol-related cirrhotic patients had higher risks of HE (OR = 0.22, 95% CI: 0.06-0.73, P = 0.013) and ACLF (OR = 0.30, 95% CI: 0.14-0.73, P = 0.020). CONCLUSION Cirrhotic patients with different etiologies had different types of complications: HBV-related cirrhotic patients exhibited increased risks of HCC and hypersplenism and alcohol-related cirrhotic patients more readily developing HE and ACLF.
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Affiliation(s)
- Yu-Pei Zhuang
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, No. 19 Nonglinxialu, Guangzhou 510000, Guangdong Province, China
| | - Si-Qi Wang
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, No. 19 Nonglinxialu, Guangzhou 510000, Guangdong Province, China
| | - Zhao-Yu Pan
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, No. 19 Nonglinxialu, Guangzhou 510000, Guangdong Province, China
| | - Hao-Jie Zhong
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, No. 19 Nonglinxialu, Guangzhou 510000, Guangdong Province, China
| | - Xing-Xiang He
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, No. 19 Nonglinxialu, Guangzhou 510000, Guangdong Province, China
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15
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Johnson AL, Ratnasekera IU, Irvine KM, Henderson A, Powell EE, Valery PC. Bacteraemia, sepsis and antibiotic resistance in Australian patients with cirrhosis: a population-based study. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000695. [PMID: 34876410 PMCID: PMC8655566 DOI: 10.1136/bmjgast-2021-000695] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 11/07/2021] [Indexed: 12/14/2022] Open
Abstract
Objective Multiple factors predispose patients with cirrhosis to sepsis and/or bacteraemia and this has a high mortality rate. Within different geographical regions there are marked differences in the prevalence of infection with multidrug-resistant organisms (MDR). This study examined risk factors for and outcomes of sepsis/bacteraemia in public hospital admissions with cirrhosis in the state of Queensland, Australia, over the last decade, along with the bacterial pathogens responsible and their antibiotic susceptibility profiles. Design A population-based retrospective cohort study of public hospital admissions was conducted from 1 January 2008 to 31 December 2017. Hospital admissions for patients with a diagnosis of cirrhosis were categorised by the presence or absence of sepsis/bacteraemia. Clinical and sociodemographic information including cirrhosis aetiology, complications and comorbidities, and in-hospital mortality were examined using bivariate and multivariate analyses. In patients with bacteraemia, the type and prevalence of bacteria and antibiotic resistance was assessed. Results Sepsis/bacteraemia was present in 3951 of 103 165 hospital admissions with a diagnosis of cirrhosis. Factors associated with sepsis/bacteraemia included disease aetiology, particularly primary sclerosing cholangitis (adj-OR 15.09, 95% CI 12.24 to 18.60), alcohol (adj-OR 2.90, 95% CI 2.71 to 3.09), Charlson Comorbidity Index ≥3 (adj-OR 3.54, 95% CI 3.19 to 3.93) and diabetes (adj-OR 1.87, 95% CI 1.74 to 2.01). Overall case-fatality rate among admissions with sepsis/bacteraemia was 27.7% (95% CI 26.3% to 29.1%) vs 3.7% (95% CI 3.6% to 3.8%) without sepsis/bacteraemia. In-hospital death was significantly associated with sepsis/bacteraemia (adj-OR 6.50, 95% CI 5.95 to 7.11). The most common organisms identified were Escherichia coli and Staphylococcus aureus, present in 22.9% and 18.1%, respectively, of the 2265 admissions with a positive blood culture. The prevalence of MDR bacteria was low (5.6%) Conclusion Morbidity and mortality related to sepsis/bacteraemia in patients with cirrhosis remains a critical clinical problem.
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Affiliation(s)
- Amy L Johnson
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Centre for Liver Disease Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | | | | | - Andrew Henderson
- Infection Management Services, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- University of Queensland Centre for Clinical Research, Herston, Queensland, Australia
| | - Elizabeth E Powell
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Centre for Liver Disease Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Patricia C Valery
- QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
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16
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Howell J, Ward JS, Davies J, Clark PJ, Davis JS. Hepatocellular carcinoma in Indigenous Australians: a call to action. Med J Aust 2021; 214:201-202.e1. [PMID: 33608890 DOI: 10.5694/mja2.50961] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/27/2020] [Accepted: 10/13/2020] [Indexed: 11/28/2024]
Affiliation(s)
| | - James S Ward
- University of Queensland, Brisbane, QLD
- Poche Centre for Indigenous Health, University of Queensland, Brisbane, QLD
| | - Jane Davies
- Menzies School of Health Research, Darwin, NT
| | | | - Joshua S Davis
- Menzies School of Health Research, Darwin, NT
- John Hunter Hospital, Newcastle, NSW
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17
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Hayward KL, Johnson AL, Horsfall LU, Moser C, Valery PC, Powell EE. Detecting non-alcoholic fatty liver disease and risk factors in health databases: accuracy and limitations of the ICD-10-AM. BMJ Open Gastroenterol 2021; 8:bmjgast-2020-000572. [PMID: 33568418 PMCID: PMC7878135 DOI: 10.1136/bmjgast-2020-000572] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/22/2020] [Accepted: 01/06/2021] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE The prevalence of non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) cirrhosis is often underestimated in healthcare and administrative databases that define disease burden using International Classification of Diseases (ICD) codes. This retrospective audit was conducted to explore the accuracy and limitations of the ICD, Tenth Revision, Australian Modification (ICD-10-AM) to detect NAFLD, metabolic risk factors (obesity and diabetes) and other aetiologies of chronic liver disease. DESIGN/METHOD ICD-10-AM codes in 308 admitted patient encounters at two major Australian tertiary hospitals were compared with data abstracted from patients' electronic medical records. Accuracy of individual codes and grouped combinations was determined by calculating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and Cohen's kappa coefficient (κ). RESULTS The presence of an ICD-10-AM code accurately predicted the presence of NAFLD/NASH (PPV 91.2%) and obesity (PPV 91.6%) in most instances. However, codes underestimated the prevalence of NAFLD/NASH and obesity by 42.9% and 45.3%, respectively. Overall concordance between clinical documentation and 'grouped alcohol' codes (κ 0.75) and hepatitis C codes (κ 0.88) was high. Hepatitis B codes detected false-positive cases in patients with previous exposure (PPV 55.6%). Accuracy of codes to detect diabetes was excellent (sensitivity 95.8%; specificity 97.6%; PPV 94.9%; NPV 98.1%) with almost perfect concordance between codes and documentation in medical records (κ 0.93). CONCLUSION Recognition of the utility and limitations of ICD-10-AM codes to study the burden of NAFLD/NASH cirrhosis is imperative to inform public health strategies and appropriate investment of resources to manage this burgeoning chronic disease.
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Affiliation(s)
- Kelly Lee Hayward
- Centre for Liver Disease Research, The University of Queensland, Woolloongabba, Queensland, Australia.,Princess Alexandra Hospital, Metro South Hospital and Health Service, Woolloongabba, Queensland, Australia
| | - Amy L Johnson
- Centre for Liver Disease Research, The University of Queensland, Woolloongabba, Queensland, Australia.,Princess Alexandra Hospital, Metro South Hospital and Health Service, Woolloongabba, Queensland, Australia
| | - Leigh U Horsfall
- Centre for Liver Disease Research, The University of Queensland, Woolloongabba, Queensland, Australia.,Princess Alexandra Hospital, Metro South Hospital and Health Service, Woolloongabba, Queensland, Australia
| | - Chris Moser
- Statistical Services Branch, Queensland Government Department of Health and Ageing, Brisbane, Queensland, Australia
| | - Patricia C Valery
- Centre for Liver Disease Research, The University of Queensland, Woolloongabba, Queensland, Australia.,QIMR Berghofer Medical Research Institute, Population Health, Herston, Queensland, Australia
| | - Elizabeth E Powell
- Centre for Liver Disease Research, The University of Queensland, Woolloongabba, Queensland, Australia .,Princess Alexandra Hospital, Metro South Hospital and Health Service, Woolloongabba, Queensland, Australia
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