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
Research background

Given the increasing concern about the high rates of readmission in cirrhotic patients (CP) after hospital discharge (HD), focus is now being laid on transitional care interventions to try to mediate a reduction. However, prior studies have also demonstrated a possible adverse impact on patient survival with reduced readmissions. Hence additional studies to comprehensively assess post discharge outcomes in CP and to try to improve them are necessary.

Research motivation

It is alarming but true that nearly 53% of CP get readmitted at least once within 3 mo of HD. This implies a tremendous financial and psychosocial burden to our current healthcare system and measures to improve the prognosis of patients after HD warrant attention.

Research objectives

We developed and evaluated a novel strategy for the care of CP at our center called the outpatient telephonic transitional care program (OTTC). The objectives of this study were to determine the effect of OTTC on survival and readmission rates (RR) at different intervals up to 6 mo after HD in CP and thus further explore the relationship of RR to survival.

Research methods

In this observational study, CP who were treated in our inpatient hepatology service between March 1 and December 31, 2016 were retrospectively assessed. Those who had received the OTTC program formed the intervention arm, and the rest formed concomitant controls. Survival and RR at 1, 3, and 6 mo after HD were compared between the two groups.

Research results

In our study, an overall RR of 55% was noted within 3 mo of HD, which correlates with the national average. Interestingly the RR at 1, 3, and 6 mo were comparable between the intervention and control groups. However, the patients who received the OTTC intervention showed markedly better 6 mo survival compared to the controls with a hazard ratio of 0.4 (95% confidence interval: 0.2-0.82; P = 0.012).

Research conclusions

In this study, we demonstrated the beneficial impact of a novel transitional care intervention program that provided a survival benefit to CP after HD. In addition, we highlighted an important dissociation between RR and survival, thus shedding further light on the importance of focusing on survival rather than RR as an outcome while assessing post discharge outcomes in CP. Given the high burden on hospitalizations for CP, our novel and easy to implement intervention may now be adopted at multiple centers to further assess its impact and provide improved care for CP.

Research perspectives

Our results reaffirm that CP remain at significant risk for readmission and mortality after HD. A focus on providing appropriate transitional care is essential to improve post discharge outcomes. The OTTC program we describe is minimally resource intensive and can afford a survival benefit to CP. The tenets of the OTTC program should be further explored and assessed in other institutions and settings. Continued emphasis on survival rather than RR is warranted because CP demonstrated a dissociation between these parameters.