Retrospective Cohort Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Oct 27, 2019; 11(10): 701-709
Published online Oct 27, 2019. doi: 10.4254/wjh.v11.i10.701
Impact on 30-d readmissions for cirrhotic patients with ascites after an educational intervention: A pilot study
Nicholas Lim, Otto Sanchez, Andrew Olson
Nicholas Lim, Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN 55455, United States
Otto Sanchez, Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN 55455, United States
Andrew Olson, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN 55455, United States
Author contributions: Lim N and Olson A designed the study; Lim N gathered the data; Sanchez O compiled figures and tables, and performed statistical analysis; Lim N and Olson A wrote the initial and final drafts of the manuscript; All authors have read and approved the final manuscript.
Institutional review board statement: This study was conducted with the approval of the institutional review board at the University of Minnesota, No. 1601S83245.
Informed consent statement: Due to its retrospective nature, informed consent was not required for this study.
Conflict-of-interest statement: The authors have no financial disclosures or conflicts-of-interest to declare.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at nlim@umn.edu. Informed consent was not required due to the retrospective nature of this study but all presented data are anonymized and risk of identification is low.
STROBE statement: The guidelines of the STROBE Statement have been adopted.
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: Nicholas Lim, MD, Assistant Professor, Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, 420 Delaware St SE, MMC 36, Minneapolis, MN 55455, United States. nlim@umn.edu
Telephone: +1-6-126258999
Received: June 17, 2019
Peer-review started: June 18, 2019
First decision: July 17, 2019
Revised: September 23, 2019
Accepted: October 2, 2019
Article in press: October 2, 2019
Published online: October 27, 2019
ARTICLE HIGHLIGHTS
Research background

The prevalence of cirrhosis in the United States is increasing with an increasing burden placed on the health care system. In 2010, a set of quality indicators were developed to provide a framework for the delivery of quality care in patients with cirrhosis. Despite this, the proportion of patients with cirrhosis receiving quality care remains relatively modest. Timely diagnostic paracentesis has been shown to be a quality indicator that is repeatedly missed in patients with cirrhosis admitted to hospital. Previous studies have shown that mandatory gastroenterology consultation, the use of standardized order sets and utilization of the electronic health record can improve quality care in patients with cirrhosis. To date, no studies have looked at the use of medical education to improve the quality of care provided to patients with cirrhosis.

Research motivation

Medical education has traditionally focused on learner outcomes. We developed an educational intervention delivered to medical residents with the intention of demonstrating that medical education could improve clinical outcomes. If proven, medical education could be a cheap and easily reproducible tool to improve quality care and other clinical outcomes in patients with cirrhosis. This is particularly relevant at a time when health care costs are rising in the United States.

Research objectives

Our main objective was to determine if an educational intervention can improve quality of care in cirrhotic patients admitted to hospital with ascites. Achieving this objective would provide one tool in addressing the deficit in quality care provided to patients with cirrhosis and stimulate further study into the use of medical education to do so.

Research methods

We conducted a pilot prospective cohort study using time-based randomization. An educational intervention was delivered to medical residents caring for patients with cirrhosis in the hospital. The control group comprised medical residents on alternate months who did not receive the educational intervention. Quality care- defined as complete adherence to all evidence-based quality indicators- was compared between the two groups. Clinical outcomes including complications, transfer to the intensive care unit, length of hospital stay, 30-d readmission and inpatient mortality were also compared.

Research results

We found that there remains a deficit in the provision of quality care in patients admitted to the cirrhosis with ascites. We found no difference in quality care between the two groups. We did find a lower rate of 30-d readmission in the intervention group that persisted after adjustment for age, gender and MELD-Na score.

Research conclusions

In this pilot study, although provision of quality care was not different between the intervention and control group, there was a reduction in 30-d readmission seen in the intervention group. There remains a deficit in quality care provided to patients with cirrhosis but the use of medical education shows potential as a cheap, effective tool to improve clinical outcomes in this population.

Research perspectives

Medical education has the potential to improve clinical outcomes in patients admitted to hospital with cirrhosis and ascites. Further refinement of our educational intervention implemented over a longer period of time may demonstrate sustained improvements in clinical outcomes in this population. Future research should look at the use of medical education to improve clinical outcomes in other patient populations such as heart failure and chronic kidney disease.