RESUMEN
AIMS: There are limited data on the management and outcomes of chronic liver disease (CLD) patients presenting with acute myocardial infarction (AMI), particularly according to the subtype of CLD. METHODS: Using the Nationwide Inpatient Sample (2004-2015), we examined outcomes of AMI patients stratified by severity and sub-types of CLD. Multivariable logistic regression was performed to assess the adjusted odds ratios (aOR) of receipt of invasive management and adverse outcomes in CLD groups compared with no-CLD. RESULTS: Of 7 024 723 AMI admissions, 54 283 (0.8%) had a CLD diagnosis. CLD patients were less likely to undergo coronary angiography (CA) and percutaneous coronary intervention (PCI) (aOR 0.62, 95%CI 0.60-0.63 and 0.59, 95%CI 0.58-0.60, respectively), and had increased odds of adverse outcomes including major adverse cardiovascular and cerebrovascular events (1.19, 95%CI 1.15-1.23), mortality (1.30, 95%CI 1.25-1.34) and major bleeding (1.74, 95%CI 1.67-1.81). In comparison to the non-severe CLD sub-groups, patients with all forms of severe CLD had the lower utilization of CA and PCI (P < .05). Among severe CLD patients, those with alcohol-related liver disease (ALD) had the lowest utilization of CA and PCI; patients with ALD and other CLD (OCLD) had more adverse outcomes than the viral hepatitis sub-group (P < .05). CONCLUSIONS: CLD patients presenting with AMI are less likely to receive invasive management and are associated with worse clinical outcomes. Further differences are observed depending on the type as well as severity of CLD, with the worst management and clinical outcomes observed in those with severe ALD and OCLD.
Asunto(s)
Hepatopatías , Infarto del Miocardio , Intervención Coronaria Percutánea , Angiografía Coronaria , Hemorragia , Mortalidad Hospitalaria , Humanos , Hepatopatías/complicaciones , Hepatopatías/epidemiología , Hepatopatías/terapia , Infarto del Miocardio/epidemiología , Infarto del Miocardio/terapia , Resultado del TratamientoRESUMEN
PURPOSE OF REVIEW: End-stage liver disease (ESLD) is associated with high symptom burden, poor quality of life, and significant healthcare costs. Palliative care, which is not synonymous with hospice or end-of-life care, is a multidisciplinary model of care that focuses on patient-centered goals with the intent of improving quality of life and reducing suffering. This review will summarize current literature supporting the benefits of early integration of palliative care in patients in this population. RECENT FINDINGS: Advance care planning (ACP) and goals of care discussions have been associated with improved quality of life, decreased anxiety, and improved satisfaction with care for both the patient and the caregiver. These discussions are beneficial to all patients with ESLD, including those listed for liver transplantation. SUMMARY: Despite the resounding benefits of palliative care for patients with other advanced diseases, palliative care remains underutilized in liver disease. There is an urgent need for education of hepatology/transplant providers as well as development of society guidelines to help dissemination and acceptability of palliative care for patients with ESLD.
Asunto(s)
Enfermedad Hepática en Estado Terminal/terapia , Cuidados Paliativos , Calidad de Vida , Planificación Anticipada de Atención , Costos de la Atención en Salud , Humanos , Trasplante de Hígado , Planificación de Atención al Paciente , Satisfacción del Paciente , Atención Dirigida al PacienteRESUMEN
OBJECTIVES: Access to subspecialty care may be difficult for patients with liver disease, but it is unknown whether access influences outcomes among this population. Our objectives were to determine rates and predictors of access to ambulatory gastrointestinal (GI) subspecialty care for patients with liver disease and to determine whether access to subspecialty GI care is associated with better survival. METHODS: We studied 28,861 patients within the Veterans Administration VISN 11 Liver Disease cohort who had an ICD-9-CM diagnosis code for liver disease from 1 January 2000 through 30 May 2011. Access was defined as a completed outpatient clinic visit with a gastroenterologist or hepatologist at any time after diagnosis. Multivariable logistic regression was used to determine predictors of access to a GI subspecialist. Survival curves were compared between those who did and those who did not see a specialist, with propensity score adjustment to account for other covariates that may affect access. RESULTS: Overall, 10,710 patients (37%) had a completed GI visit. On multivariable regression, older patients (odds ratio (OR) 0.98, P<0.001), those with more comorbidities (OR 0.98, P=0.01), and those living farther from a tertiary-care center (OR 0.998/mi, P<0.001) were less likely to be seen in clinic. Patients who were more likely to be seen included those who had hepatitis C (OR 1.5, P<0.001) or cirrhosis (OR 3.5, P<0.001) diagnoses prior to their initial visit. Patients with an ambulatory GI visit at any time after diagnosis were less likely to die at 5 years when compared with propensity-score-matched controls (hazard ratio 0.81, P<0.001). CONCLUSIONS: Access to ambulatory GI care was associated with improved 5-year survival for patients with liver disease. Innovative care coordination techniques may prove beneficial in extending access to care to liver disease patients.
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Atención Ambulatoria , Accesibilidad a los Servicios de Salud , Hepatopatías/terapia , Comorbilidad , Femenino , Humanos , Pruebas de Función Hepática , Masculino , Persona de Mediana Edad , Puntaje de Propensión , Especialización , Tasa de Supervivencia , Estados Unidos , VeteranosAsunto(s)
Embolización Terapéutica , Várices Esofágicas y Gástricas/terapia , Hemorragia Gastrointestinal/terapia , Esponja de Gelatina Absorbible/administración & dosificación , Vena Porta , Trombosis de la Vena/terapia , Oclusión con Balón , Várices Esofágicas y Gástricas/diagnóstico por imagen , Várices Esofágicas y Gástricas/etiología , Várices Esofágicas y Gástricas/fisiopatología , Hemorragia Gastrointestinal/diagnóstico por imagen , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/fisiopatología , Hepatitis C/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Vena Porta/diagnóstico por imagen , Vena Porta/fisiopatología , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/etiología , Trombosis de la Vena/fisiopatologíaRESUMEN
UNLABELLED: Prevalence of cirrhosis among older adults is expected to increase; therefore, we studied the health status, functional disability, and need for supportive care in a large national sample of individuals with cirrhosis. A prospective cohort of individuals with cirrhosis was identified within the longitudinal, nationally representative Health and Retirement Study. Cirrhosis cases were identified in linked Medicare data via ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes and compared to an age-matched cohort without cirrhosis. Two primary outcome domains were assessed: (1) patients' health status (perceived health status, comorbidities, health care utilization, and functional disability as determined by activities of daily living and instrumental activities of daily living), and (2) informal caregiving (hours of caregiving provided by a primary informal caregiver and associated cost). Adjusted negative binomial regression was used to assess the association between cirrhosis and functional disability. A total of 317 individuals with cirrhosis and 951 age-matched comparators were identified. Relative to the comparison group, individuals with cirrhosis had worse self-reported health status, more comorbidities, and used significantly more health care services (hospitalizations, nursing home stays, physician visits; P < 0.001 for all bivariable comparisons). They also had greater functional disability (P < 0.001 for activities of daily living and instrumental activities of daily living), despite adjustment for covariates such as comorbidities and health care utilization. Individuals with cirrhosis received more than twice the number of informal caregiving hours per week (P < 0.001), at an annual cost of US $4700 per person. CONCLUSION: Older Americans with cirrhosis have high rates of disability, health care utilization, and need for informal caregiving. Improved care coordination and caregiver support is necessary to optimize management of this frail population.
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Cuidadores/estadística & datos numéricos , Costo de Enfermedad , Cirrosis Hepática/epidemiología , Medicare/estadística & datos numéricos , Jubilación/estadística & datos numéricos , Anciano , Población Negra/estadística & datos numéricos , Comorbilidad , Bases de Datos Factuales/estadística & datos numéricos , Evaluación de la Discapacidad , Femenino , Costos de la Atención en Salud , Estado de Salud , Hispánicos o Latinos/estadística & datos numéricos , Humanos , Incidencia , Cirrosis Hepática/economía , Masculino , Medicaid/estadística & datos numéricos , Prevalencia , Estudios Prospectivos , Estados Unidos/epidemiología , Población Blanca/estadística & datos numéricosRESUMEN
BACKGROUND: Expedited liver transplant evaluations of critically ill patients can be challenging due to limited time for data gathering and psychosocial evaluation. AIMS: To compare clinical outcomes between expedited and traditional transplant evaluation patients and assess for differences in outpatient resource utilization and staff burden between groups. DESIGN: Adult liver transplant recipients who underwent transplant from 2015 to 2019 were included. Expedited evaluation was defined as time from initiating transplant evaluation to transplant listing <2 weeks. Primary outcomes included rates of graft rejection, graft failure, and death within 1-year posttransplant. Secondary outcomes included number of acute care visits, office visits, and medical record documentation made by transplant staff within 1-year posttransplant. Outcomes were compared using Cox regression models. RESULTS: Of the 335 patients included, 92 (27.5%) were expedited and 243 (72.5%) were traditional. Expedited patients were significantly younger, had greater MELD scores, and required more inpatient care and life support at time of transplant. There was no significant difference in risk of graft rejection (HR 1.3, P = .4), graft failure (HR 1.3, P = .6), or mortality (HR 1.0, P = .9) between groups. Expedited transplant was not associated with increased healthcare or staff utilization: acute care visits (rate ratio 0.9, P = .7), office visits (ß = -1.05, P = .2), and medical record documentation (ß = 3.4, P = 0.4). CONCLUSIONS: Despite being more critically ill, patients requiring expedited transplant evaluation have favorable outcomes after transplant and do not require more intensive staff time and resources compared to traditional candidates.
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Trasplante de Hígado , Trasplantes , Adulto , Humanos , Enfermedad Crítica , Modelos de Riesgos Proporcionales , Rechazo de Injerto/prevención & control , Receptores de Trasplantes , Supervivencia de Injerto , Estudios Retrospectivos , Factores de RiesgoRESUMEN
OBJECTIVES: Early rehospitalizations have been well characterized in many disease states, but not among patients with cirrhosis. The aims of this study were to identify the frequency, costs, predictors, and preventable causes of hospital readmissions among patients with decompensated cirrhosis. METHODS: Rates of readmission were calculated for 402 patients discharged after one of the following complications of cirrhosis: ascites, spontaneous bacterial peritonitis, renal failure, hepatic encephalopathy, or variceal hemorrhage. Costs of readmissions were calculated using the hospital accounting system. Predictors of time to first readmission were determined using Cox regression, and predictors of hospitalization rate/person-years were determined using negative binomial regression. The independent association between readmission rate and mortality was determined using Cox regression. Admissions within 30 days of discharge were assessed by two reviewers to determine if preventable. RESULTS: Overall, 276 (69%) subjects had at least one nonelective readmission, with a median time to first readmission of 67 days. By 1 week after discharge, 14% of subjects had been readmitted, and 37% were readmitted within 1 month. The mean costs for readmissions within 1 week and between weeks 1 and 4 were $28,898 and $20,581, respectively. During a median follow-up of 203 days, the median number of readmissions was 2 (range 0-40), with an overall rate of 3 hospitalizations/person-years. Patients with more frequent readmissions had higher risk of subsequent mortality, despite adjustment for confounders including the Model for End-stage Liver Disease (MELD) score. Predictors of time to first readmission included MELD score, serum sodium, and number of medications on discharge; predictors of hospitalization rate included these variables as well as the number of cirrhosis complications and being on the transplant list at discharge. Among 165 readmissions within 30 days, 22% were possibly preventable. CONCLUSIONS: Hospital readmissions among patients with decompensated cirrhosis are common, costly, moderately predictable, in some cases, possibly preventable, and independently associated with mortality. These findings support the development of disease management interventions to prevent rehospitalization.
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Hospitalización/estadística & datos numéricos , Cirrosis Hepática/economía , Readmisión del Paciente/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Ascitis/economía , Ascitis/etiología , Femenino , Estudios de Seguimiento , Hemorragia/economía , Hemorragia/etiología , Hospitalización/economía , Humanos , Tiempo de Internación , Cirrosis Hepática/complicaciones , Masculino , Persona de Mediana Edad , Alta del Paciente , Readmisión del Paciente/economía , Insuficiencia Renal/economía , Insuficiencia Renal/etiología , Estudios Retrospectivos , Factores de Riesgo , Factores de TiempoRESUMEN
BACKGROUND & AIMS: Mallory-Denk bodies (MDBs) are inclusions found in hepatocytes of patients with chronic liver diseases. Their clinical significance and prognostic value are not understood. METHODS: We performed cross-sectional and longitudinal analyses of patients with chronic hepatitis C (CHC) enrolled in the Hepatitis C Antiviral Long-Term Treatment against Cirrhosis (HALT-C) trial to identify clinical features associated with MDBs and changes in MDBs over time. Biopsy specimens were obtained at baseline and 1.5 and 3.5 years after patients were assigned to groups for the HALT-C trial; and patients were followed up to assess clinical and histologic outcomes. RESULTS: Of biopsy samples collected from 1050 patients, MDBs were present in 15%. They were associated with insulin resistance and laboratory and histologic markers of advanced liver disease (higher levels of periportal fibrosis, pericellular fibrosis, steatosis, and inflammation). After adjusting for disease severity (the ratio of aspartate aminotransferase to alanine aminotransferase, albumin, platelets, fibrosis, steatosis), the presence of MDBs was associated with histologic progression (odds ratio, 1.97; P = .04). Of the 844 patients from whom serial biopsy samples were collected, 61 (7.2%) developed MDBs (MDB gain) and 101 (12.0%) lost MDBs (MDB loss). The presence or absence of diabetes mellitus was associated with MDB gain (P = .006) or loss (P = .024), respectively. Development of MDBs was associated with decompensation (adjusted hazard ratio, 2.81; P < .001) and histologic signs of progression (adjusted odds ratio, 4.02; P = .004). CONCLUSIONS: The presence of MDBs in liver biopsy samples from patients with CHC is associated independently with fibrosis progression. Gain of MDBs over time is associated with decompensation and progression to cirrhosis; and occurs most frequently among diabetic patients. MDBs might be used as prognostic factors for patients with CHC.
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Hepatitis C Crónica/mortalidad , Hepatitis C Crónica/patología , Hepatocitos/patología , Cuerpos de Inclusión/patología , Hígado/patología , Adulto , Biopsia , Estudios Transversales , Femenino , Histocitoquímica , Humanos , Cirrosis Hepática/patología , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Pronóstico , Resultado del TratamientoRESUMEN
BACKGROUND: Surveillance for hepatocellular carcinoma (HCC) is recommended in patients with cirrhosis, but earlier studies suggest that it is used less than one-third of the time. Patient factors associated with surveillance rates are incompletely understood. GOALS: The aims of our study were to determine HCC surveillance rates in a tertiary-care center and to identify patient predictors of receiving surveillance. STUDY: Patients with Child A or B cirrhosis seen in the University of Michigan liver clinics between October 2008 and March 2009 were enrolled to complete a self-administered survey. Surveillance rates and clinical data were extracted from the patient electronic medical record. RESULTS: Of the 160 patients enrolled, 74.4% had HCC surveillance performed in the past year. On multivariate analysis, predictors of receiving surveillance included male sex (odds ratio 7.1, 95% confidence interval, 1.2-43.2) and patient involvement in their care (odds ratio 3.4, 95% confidence interval, 1.5-7.9). Patients expressed high levels of concern regarding HCC, desired more information from their physicians, and wanted to be more involved in their care. CONCLUSIONS: HCC surveillance rates in a tertiary-care center were significantly higher than earlier reported rates. Direct patient involvement in decisions regarding HCC surveillance may help to improve surveillance rates.