Hospital resource intensity and cirrhosis mortality in United States

Table 1 Patient and hospital characteristics by hospital performance quintile in risk and reliability-adjusted cirrhosis mortality

	Q1 (highest performance)	Q2	Q3	Q4	Q5 (lowest performance)	Overall	P value
Patient characteristics
Patients	21524	11117	12427	12648	15017	72733	-
Demographics
Age
Mean age (yr)	56.8	57.5	57.6	57.3	57.4	57.2	< 0.00001
Sex
Female (%)	36.4	36.7	35.9	35.0	35.3	35.9	0.01381
Race
White (%)	59.9	55.6	54.8	51.7	52.6	55.4	< 0.00001
Black (%)	5.8	7.7	5.6	5.7	9.0	6.7
Hispanic (%)	15.2	20.2	21.5	17.4	20.3	18.5
Asian or Pacific Islander (%)	1.6	1.8	2.3	1.3	2.2	1.8
Native American (%)	1.6	0.5	0.8	1.1	0.9	1.1
Other (%)	1.6	2.0	2.6	3.3	3.1	2.4
Missing (%)	14.4	12.1	12.4	19.6	12.0	14.1
Insurance
Medicare (%)	36.1	37.2	38.0	36.9	37.3	37.0	< 0.00001
Medicaid (%)	22.9	24.5	24.8	23.8	26.5	24.4
Private Insurance (%)	27.4	26.5	25.2	25.3	22.5	25.5
Self-Pay (%)	7.5	7.4	7.3	8.4	7.8	7.7
No Charge (%)	1.0	0.4	0.6	0.5	1.5	0.9
Other (%)	5.0	4.0	4.0	5.0	4.3	4.6
Cause of cirrhosis1
Alcoholic liver disease (%)	61.0	62.5	61.0	60.8	60.3	61.1	0.00880
Alcoholic cirrhosis (%)	60.9	62.4	60.9	60.6	60.2	60.9	0.00589
Non-alcoholic cirrhosis (%)	38.0	36.9	38.0	38.6	39.0	38.1	0.00762
Biliary cirrhosis (%)	2.3	1.5	2.0	1.7	1.6	1.9	< 0.00001
HCV positive (%)	25.3	23.0	22.1	25.1	26.4	24.6	< 0.00001
Unspecified liver disease or cirrhosis (%)	2.7	2.0	2.0	2.0	1.8	2.2	< 0.00001
A1AT, Cu, Fe disease (%)	0.89	0.65	0.64	0.74	0.68	0.74	0.04067
Complications of Cirrhosis
Ascites (%)	31.8	27.5	30.2	30.3	26.9	29.6	< 0.00001
Variceal bleed (%)	9.6	10.3	9.6	9.3	9.4	9.6	0.05605
Hepatic Encephalopathy (%)	53.7	55.2	52.5	54.1	55.7	54.2	< 0.00001
Portal HTN (%)	44.3	41.1	44.9	42.7	41.5	43.0	< 0.00001
Hepatorenal syndrome (%)	9.3	7.8	8.2	8.3	8.9	8.6	0.00003
Hepatocellular carcinoma (%)	3.9	2.7	3.1	3.1	3.2	3.3	< 0.00001
Procedures
Liver transplant	2.7	0.6	1.0	1.1	2.4	1.7	< 0.00001
Esophagogastroduodenoscopy	18.1	19.0	20.4	19.3	18.3	18.9	< 0.00001
Paracentesis	32.9	29.7	30.0	29.7	29.2	30.6	< 0.00001
Mortality characteristics
APR-DRG Risk of Mortality
Minor risk of mortality (%)	5.9	7.8	6.8	6.5	9.1	7.1	< 0.00001
Moderate risk of mortality (%)	31.3	34.1	34.4	33.2	34.0	33.2
Major risk of mortality (%)	41.0	39.4	39.4	39.5	37.0	39.4
Extreme risk of mortality (%)	21.8	18.7	19.4	20.7	19.9	20.3
Mortality
Expired during admission (%)	5.1	6.0	7.5	9.8	12.3	7.9	< 0.00001
Hospital characteristic
Number of hospitals	161	161	161	161	161	805	-
Region
Northeast hospital region (%)	19.3	25.5	27.3	24.8	34.2	26.2	0.06961
Midwest hospital region (%)	18.6	13.7	17.4	13.0	9.3	14.4
South hospital region (%)	29.2	32.3	19.9	29.2	26.7	27.5
West hospital region (%)	32.9	28.6	35.4	32.9	29.8	31.9
Bed capacity
Small bedsize (%)	23.0	41.0	36.6	33.5	32.3	33.3	0.05554
Medium bedsize (%)	37.9	31.7	32.9	34.2	29.8	33.3
Large bedsize (%)	39.1	27.3	30.4	32.3	37.9	33.4
Hospital ICU beds (mean)	24.3	19.1	20.1	19.9	20.8	20.8	0.04608
Patient casemix
Hospital Cirrhosis Annual Volume (mean)	133.7	69.0	77.2	78.6	93.3	90.4	< 0.00001
Medicaid Days (mean)	18139	15339	18158	18699	22662	18599	0.18260
Admission characteristics
Length of stay (days) (mean)	5.9	5.7	5.9	6.2	6.4	6.0	0.00019
Total charges ($ mean)2	43391	36593	40500	43389	40340	40877	0.19458
Expired during admission (%)	4.0	5.3	7.3	10.1	13.2	8.0	< 0.00001
Staffing characteristics
Full-time LPN’s3 (mean)	1.65	2.18	2.18	1.94	2.34	2.06	0.03218
Full-time MD’s3 (mean)	2.74	2.02	2.55	1.88	1.8	2.2	0.27122
Teaching Status
Teaching hospital4 (%)	42.9	32.9	38.5	39.8	41.6	39.1	0.40386
Resident FTE’s (mean)	79.2	40.7	57.7	59.0	65.7	60.5	0.33158
Specialty Services
Liver transplant hospital (%)	15.5	5.0	5.0	5.6	4.3	7.1	0.00020

¹Patients have multiple diagnoses;

²19 hospitals missing total charge data on 1751 patients;

³per 10000 Adjusted Patient days;

⁴43 hospitals that changed teaching status during the study period were considered teaching if 50% or more of patients were admitted while a teaching hospital.

Table 2 Risk-adjusted effects of patient factors, era, and hospital resources on in-patient cirrhosis mortality

Characteristic	OR	95%CI	P value
Patient covariates
Age	1.00	0.97-1.01	0.592
Female	1.05	0.93-1.06	0.753
Ascites	1.79	0.96-1.15	0.262
Variceal hemorrhage	1.26	1.64-1.95	< 0.001
Hepatic encephalopathy	0.63	1.18-1.34	< 0.001
Portal hypertension	1.16	0.59-0.68	< 0.001
Hepatorenal syndrome	0.20	1.07-1.25	< 0.001
Received liver transplant	0.83	0.15-0.26	< 0.001
HCV positive	1.43	1.33-1.54	< 0.001
Alcoholic liver disease	1.23	1.33-1.54	< 0.001
Paracentesis during admission	0.76	0.71-0.82	0.006
EGD during admission	0.81	0.75-0.88	< 0.001
Co-morbidity burden (APR DRG risk of mortality)
Minor	Reference
Moderate	1.54	1.14-2.07	0.005
Major	6.02	4.55-7.96	< 0.001
Extreme	58.8	44.5-77.8	< 0.001
Era (year of admission)
2005	Reference
2006	0.89	0.79-1.00	0.053
2007	0.79	0.70-0.89	< 0.001
2008	0.75	0.66-0.85	< 0.001
2009	0.68	0.60-0.78	< 0.001
2010	0.51	0.56-0.59	< 0.001
2011	0.49	0.42-0.56	< 0.001
Hospital resources (hospital structural factors)
Hospital cirrhosis volume	1.01	1.00-1.01	0.025
Hospital medicaid days	1.01	1.00-1.01	0.029
Hospital liver transplant program	0.83	0.71-0.98	0.026
Full-time LPN’s	1.02	1.00-1.04	0.015
Full-time MD’s	0.99	0.98-1.00	0.140
Resident FTE’s	1.00	1.00-1.00	0.115
ICU beds	1.00	1.00-1.00	0.446