Randomized intervention and outpatient follow-up lowers 30-d readmissions for patients with hepatic encephalopathy, decompensated cirrhosis

Table 1 Characteristic features of index admission by readmission status, n (%)

	Total	Not readmitted (n = 159)	Readmitted (n = 81)	P value
Index admission characteristics
Reasons for admission1
Acute kidney injury	65, 27.08	41, 25.79	24, 29.63	0.54
Hyponatremia	16, 6.67	11, 6.92	5, 6.17	1.00
Hepatic encephalopathy	45, 18.75	26, 16.35	19, 23.46	0.22
Volume overload	111, 46.25	81, 50.94	30, 37.04	0.06
Variceal bleed	42, 17.50	31, 19.50	11, 13.58	0.29
Lower GI bleed	19, 7.92	11, 6.92	8, 9.88	0.45
SBP	21, 8.75	14, 8.81	7, 8.64	1.00
Complications of cirrhosis during admission1
Presence of AKI	80, 33.33	50, 31.45	30, 37.04	0.39
HE	49, 20.42	31, 19.50	18, 22.22	0.62
Ascites	139, 57.92	95, 59.75	44, 54.32	0.49
Variceal bleeding	37, 15.42	26, 16.35	11, 13.58	0.71
SBP	16, 6.67	12, 7.55	4, 4.94	0.59
HRS	14, 5.83	8, 5.03	6, 7.41	0.56
Coagulopathy	56, 23.33	36, 22.64	20, 24.69	0.75
Portal hypertension	46, 19.17	34, 21.38	12, 14.81	0.30
HPS	15, 6.25	8, 5.03	7, 8.64	0.27
HCC	11, 4.58	6, 3.77	5, 6.17	0.51
Procedures performed during admission1
EGD	136, 56.67	92, 57.86	44, 54.32	0.68
Paracentesis	115, 47.92	73, 45.91	42, 51.85	0.41
Emergent TIPS	10, 4.17	9, 5.66	1, 1.23	0.17
HD	15, 6.25	7, 4.40	8, 9.88	0.16
Colonoscopy/flex sig	24, 10.00	18, 11.32	6, 7.41	0.37
Disposition1
Home	159, 66.25	107, 67.30	52, 64.20	0.66
Home with Home Health Newly Arranged	39, 16.25	24, 15.09	15, 18.52
Home with Home Health Previously Arranged	3, 1.25	2, 1.26	1, 1.23
SNF newly Arranged	21, 8.75	16, 10.06	5, 6.17
SNF Previously Arranged	11, 4.58	5, 3.14	6, 7.41
Left Against Medical Advice	2, 0.83	1, 0.63	1, 1.23
Transfer (long term acute care hospital)	3, 1.25	2, 1.26	1, 1.23
Homeless	2, 0.83	2, 1.26	0, 0.00

¹Patient can have more than one of variable listed.

SBP: Spontaneous bacterial peritonitis; AKI: Acute kidney injury; HE: Hepatic encephalopathy; HRS: Hepatorenal syndrome; HPS: Hepato-pulmonary syndrome; HCC: Hepatocellular carcinoma; EGD: Esophago-gastro-duodenoscopy; GI: Gastrointestinal; TIPS: Transjugular intrahepatic portosystemic shunt; HD: Hemodialysis; SNF: Skilled Nursing Facility.

Table 2 Characteristics and reasons for readmission

Readmission status	n	%
No	159	66.25
Yes	81	33.75
Number of readmissions within 30 d
0	159	66.25
1	63	26.25
2	14	5.83
3	3	1.25
5	1	0.42
Location of 1st readmission
OSUWMC	59	72.84
Outside hospital	22	27.16
Reason for 1st readmission1
Hepatic encephalopathy	26	32.10
Volume overload	22	27.16
Acute kidney injury	16	19.75
Variceal bleed	12	14.82
Hyponatremia	10	12.35
Lower GI bleed	4	4.94
Spontaneous Bacterial Peritonitis	3	3.70
LOS of first readmission (n = 81, mean ± SD), median = 5, range = 1 to 69	8.11 ± 8.98
LOS of all readmissions (n = 105, mean ± SD), median = 4, range = 0 to 124	9.03 ± 14.42
Cost of first readmission (n = 45, mean ± SD), median= $31848.95, range $765-325656.38	$55548.29 ± 65164.91
Waiting time for first readmission (n = 81, mean ± SD), median = 12, range = 1-30	12.65 ± 7.55

¹Patient can have more than one of variable listed.

OSUWMC: The Ohio State University Wexner Medical Center; GI: Gastrointestinal; LOS: Length of stay.

Table 3 Comparison of patient demographics and clinical characteristics by randomization arm, n (%)

	Intervention (n = 120)	Standard of care (n = 120)	P value
Patient demographics
Age (mean ± SD)	56.54 ± 11.21	56.14 ± 11.21	0.78
Age group
65+	32, 26.67	28, 23.33	0.79
40-64	75, 62.50	80, 66.67
18-39	13, 10.83	12, 10.00
Gender
Male	60, 50.00	75, 62.50	0.03
Female	60, 50.00	45, 32.50
Race
White	105, 87.50	97, 80.83	0.22
Other	15, 12.50	23, 19.17
Ethnicity
Not Hispanic or latino	113, 94.17	114, 95.00	0.81
Hispanic or latino	3, 2.50	1, 0.83
Unknown / Not reported	4, 3.33	5, 4.17
Zip code income (mean ± SD)	$68045 ± $21370	$68455 ± $21651	0.88
Employment status
Unemployed	33, 27.50	30, 25.00	0.78
Disabled	24, 20.00	24, 20.00
Retired	26, 21.67	30, 20.00
Employed, part time	5, 4.17	3, 2.50
Employed, full time	23, 19.17	28, 23.33
Other / Unknown	9, 7.50	14, 11.67
Insurance type
Self-pay	4, 3.33	3, 2.50	0.54
No Charge / Other / Unknown	7, 5.83	7, 5.83
Private insurance	38, 31.67	35, 29.17
Medicare	32, 26.67	44, 36.67
Medicaid	39, 32.50	31, 25.83
Number of admissions at OSU for DC in last 1 year (mean ± SD)	1.99 ± 1.61	1.84 ± 1.48	0.45
MELD-Na score admit (mean ± SD)	21.32 ± 8.19	22.47 ± 7.85	0.27
MELD-Na score discharge (mean ± SD, n = 117+118)	20.07 ± 7.74	20.25 ± 6.93	0.84
CTP score admit (mean ± SD)	9.31 ± 2.02	9.41 ± 1.89	0.69
CTP score discharge (mean ± SD)	8.44 ± 1.86	8.73 ± 1.89	0.24
Etiology of cirrhosis (Index admission1)
Alcoholic	61, 50.83	60, 50.00	1.00
Non-alcoholic fatty liver	42, 35.00	37, 30.83	0.58
Viral	21, 17.50	22, 18.33	1.00
Hep B	1, 4.76	3, 13.64	0.80
Hep C	19, 90.48	18, 81.82
Hep B and C	1, 4.76	1, 4.55
Cryptogenic	6, 5.00	7, 5.83	1.00
Autoimmune	1, 0.83	1, 0.83	1.00
Primary sclerosing cholangitis	2, 1.67	2, 1.67	1.00
Hemochromatosis	0, 0.0	3, 2.5	0.25
Alpha 1 anti-trypsin deficiency	3, 2.5	0, 0.0	0.25
Under evaluation for liver transplant
No	45, 37.50	61, 50.83	0.08
Yes	63, 52.50	53, 44.17
Unknown	12, 10.00	6, 5.00

¹Patient can have more than one of variable listed.

OSUWMC: The Ohio State University Wexner Medical Center; DC: Decompensated cirrhosis; MELD-Na: Model of End Stage Liver Disease Score; CTP: Child Pugh Score.

Table 4 Characteristic features during index admission in two randomization arms, n (%)

Index admission characteristics	Intervention (n = 120)	Standard of care (n = 120)	P value
Reasons for admission1
Acute kidney injury	30, 25.00	35, 29.17	0.56
Hyponatremia	10, 8.33	6, 5.00	0.44
Hepatic encephalopathy	22, 18.33	23, 19.17	1
Volume overload	59, 49.17	52, 43.33	0.44
Variceal bleed	21, 17.50	21, 17.50	1
Lower GI bleed	8, 6.67	11, 9.17	0.63
SBP	9, 7.50	12, 10.00	0.65
Complications of cirrhosis during admission1
Presence of AKI	39, 32.50	41, 34.17	0.89
HE	25, 20.83	24, 20.00	1
Ascites	70, 58.33	69, 57.50	1
Variceal bleeding	21, 17.50	16, 13.33	0.48
SBP	10, 8.33	6, 5.00	0.44
HRS	7, 5.83	7, 5.83	1
Coagulopathy	32, 26.67	24, 20.00	0.29
Portal hypertension	19, 15.83	27, 22.50	0.25
HPS	10, 8.33	5, 4.17	0.29
HCC	6, 5.00	5, 4.17	1
Procedures performed during admission1
EGD	68, 56.67	68, 56.67	1
Paracentesis	60, 50.00	55, 45.83	0.61
TIPS	7, 5.83	3, 2.50	0.33
HD	5, 4.17	10, 8.33	0.29
Colonoscopy/flex sig	13, 10.83	11, 9.17	0.83
Disposition
Home	83, 69.17	76, 63.33	0.44
Home with home health newly arranged	17, 14.17	22, 18.33
Home with home health previously arranged	2, 1.67	1, 0.83
SNF newly arranged	7, 5.83	14, 11.67
SNF previously arranged	6, 5.00	5, 4.17
Left against medical advice	1, 0.83	1, 0.83
Transfer (Long term acute care hospital)	3, 2.50	0, 0.00
Homeless	1, 0.83	1, 0.83

¹Patient can have more than one of variable listed.

SBP: Spontaneous Bacterial Peritonitis; AKI: Acute kidney injury; HE: Hepatic encephalopathy; HRS: Hepatorenal syndrome; HPS: Hepato-pulmonary syndrome; HCC: Hepatocellular carcinoma; EGD: Esophago-gastro-duodenoscopy; TIPS: Transjugular intrahepatic portosystemic shunt; HD: Hemodialysis; SNF: Skilled Nursing Facility; GI: Gastrointestinal.

Table 5 Clinical and laboratory features during index admission and discharge in two randomization arms, n (%)

	Intervention (n = 120)	Standard of care (n = 120)	P value
Index admission labs (mean ± SD)
Sodium	132.59 ± 5.58	132.28 ± 6.28	0.68
Serum creatinine (mg/dL)	1.42 ± 1.11	1.64 ± 1.47	0.19
Total bilirubin (mg/dL)	5.90 ± 9.10	6.19 ± 7.80	0.79
Albumin (g/dL)	2.83 ± 0.59	2.85 ± 0.55	0.72
INR	1.68 ± 0.52	1.70 ± 0.59	0.80
Hemoglobin (g/dL)	10.22 ± 2.34	10.02 ± 2.04	0.48
Ascites
Absent	35, 29.17	35, 29.17	0.44
Slight	26, 21.67	34, 28.33
Moderate	59, 49.17	51, 42.50
Encephalopathy
None	91, 75.83	96, 80.00	0.78
Grade 1-2	22, 18.33	18, 15.00
Grade 3-4	7, 5.83	6, 5.00
Dialysis at least twice in last week
No	117, 97.50	115, 95.83	0.72
Yes	3, 2.50	5, 4.17
Index admission discharge labs (mean ± SD)
Sodium (mmol/L)	134.72 ± 4.14	134.95 ± 3.57	0.64
Serum creatinine (mg/dL)	1.31 ± 1.06	1.37 ± 1.18	0.69
Total bilirubin (mg/dL, n = 237)	5.50 ± 8.80	5.39 ± 6.96	0.92
Albumin (g/dL, n = 237)	2.98 ± 0.64	2.94 ± 0.61	0.65
INR (n = 238)	1.71 ± 0.49	1.69 ± 0.45	0.65
Hemoglobin (g/dL)	9.30 ± 1.69	9.21 ± 1.68	0.68
Ascites
Absent	42, 35.00	39, 32.50	0.35
Slight	56, 46.67	66, 55.00
Moderate	22, 18.33	15, 12.50
Encephalopathy
None	117, 97.50	112. 93.33	0.10
Grade 1-2	2, 1.67	8, 6.67
Grade 3-4	1, 0.83	0, 0.00
Dialysis at least twice in last week
No	114, 95.00	110, 91.67	0.44
Yes	6, 5.00	10, 8.33

Table 6 Outcomes and reasons of readmission characteristics by randomization arms, n (%)

	Intervention (n = 120)	Standard of care (n = 120)	P value
Readmission
No	77, 64.17	82, 68.33	0.59
Yes	43, 35.83	38, 31.67
Number of readmissions within 30 d
0	77, 64.17	82, 68.33	0.65
1	31, 25.83	32, 26.67
2	9, 7.50	5, 4.17
3	2, 1.67	1, 0.83
5	1, 0.83	0, 0.00
Location of 1st readmission
Our institution	36, 83.72	23, 60.53	0.03
Outside hospital	7, 16.28	15, 39.47
Reason for 1st readmission1
Acute kidney injury	10, 23.26	6, 15.79	0.58
Hyponatremia	4, 9.30	6, 15.79	0.50
Hepatic encephalopathy	9, 20.93	17, 44.74	0.03
Volume overload	13, 30.23	9, 23.68	0.62
Variceal bleed	6, 13.95	6, 15.79	1.00
Lower GI bleed	1, 2.33	3, 7.89	0.34
Spontaneous bacterial peritonitis	2, 4.65	1, 2.63	1.00
Other	20, 46.51	22, 57.89	0.37
Index admission cost (mean ± SD, n = 116 + 109)	61581 ± 47825	59547 ± 46669	0.46
Index admission LOS (mean ± SD)	8.17 ± 5.56	8.08 ± 6.11	0.63
First readmission LOS (n = 43 + 38, mean ± SD)	7.58 ± 7.57	8.71 ± 10.41	0.58
All readmissions LOS (n = 60 + 45, mean ± SD)	9.28 ± 16.88	8.69 ± 10.44	0.82
Waiting time for first readmission (n = 43 + 38, mean ± SD)	11.16 ± 7.10	14.34 ± 7.77	0.06

¹Patient can have more than one of variable listed.

GI: Gastrointestinal; LOS: Length of stay.