Observational Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Aug 27, 2019; 11(8): 646-655
Published online Aug 27, 2019. doi: 10.4254/wjh.v11.i8.646
Outpatient telephonic transitional care after hospital discharge improves survival in cirrhotic patients
Bhavana Bhagya Rao, Anastasia Sobotka, Rocio Lopez, Carlos Romero-Marrero, William Carey
Bhavana Bhagya Rao, Anastasia Sobotka, Rocio Lopez, Carlos Romero-Marrero, William Carey, Department of Gastroenterology Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
Author contributions: Rao BB contributed to study concept and design, acquisition of data, analysis and interpretation of data, statistical analysis, and drafting of the manuscript; Sobotka A contributed to implementation of intervention, acquisition of data, and critical revision of the manuscript for important intellectual content; Lopez R contributed to statistical analysis; Romero-Marrero C contributed to critical revision of the manuscript for important intellectual content and study supervision; Carey W contributed to study concept and design, critical revision of the manuscript for important intellectual content, and study supervision.
Institutional review board statement: The study was reviewed and approved by the Cleveland Clinic Foundation Institutional Review Board.
Informed consent statement: After review of the study characteristics, a waiver of informed consent was approved by the Cleveland Clinic Foundation Institutional Review Board.
Conflict-of-interest statement: No potential conflicts of interest relevant to this article were reported.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: William Carey, MD, Doctor, Department of Gastroenterology Hepatology and Nutrition, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States. careyw@ccf.org
Telephone: +1-216-4446521 Fax: +1-216-4455477
Received: January 29, 2019
Peer-review started: January 29, 2019
First decision: March 3, 2019
Revised: June 12, 2019
Accepted: July 4, 2019
Article in press: July 5, 2019
Published online: August 27, 2019
Abstract
BACKGROUND

Intervention to improve outcomes in cirrhotic patients (CP) after hospital discharge often focus on 30 d readmission rate (RR). However, recent studies suggest dissociation between RR and survival. At our center, CP are now offered outpatient telephonic transitional care (OTTC) by a care coordinator for 30 d after hospital discharge.

AIM

To determine the effect of OTTC on survival in CP.

METHODS

In this cohort study from a tertiary center, CP who received OTTC formed the intervention group. They were compared with a control group discharged during the same period. Mortality and RR were compared between the groups.

RESULTS

After OTTC introduction, 194 CP were discharged. After applying exclusion criteria, 169 CP (51% male, mean age 58 years ± 12 years) were included. OTTC group comprised 76 patients and was compared with 93 controls. Baseline disease and index admission related characteristics were not significantly different between the groups. The intervention group showed significantly higher 6 mo survival compared to controls (84.2% vs 68.8%; P = 0.03), while RR at 1, 3, and 6 mo were comparable. On multivariable analysis, the intervention group showed lower odds for mortality compared to the controls (hazard ratio: 0.4; 95% confidence interval: 0.2-0.82; P = 0.012), while higher model for end-stage liver disease scores were associated with higher mortality (hazard ratio: 1.05; 95% confidence interval: 1.01-1.1; P = 0.024).

CONCLUSION

CP provided OTTC had higher 6 mo survival compared to controls without a difference in RR. Use of RR to gauge quality of care provided during hospitalization or subsequent transitional care programs should be revisited.

Keywords: Quality improvement, Transitional care, Outpatient monitoring, Outcomes assessment

Core tip: We share results of a novel intervention that provides transitional care via telephone to cirrhotic patients after hospital discharge. Over a 6 mo follow-up, the intervention group experienced 60% lower odds for mortality compared to controls with similar readmission rates. Our manuscript not only describes an effective transitional care program to improve post-discharge outcomes in cirrhotic patients but also highlights the need to acknowledge the dissociation between readmissions and survival in this population.