Disparities in Care for Low-Income Patients with Cirrhosis: Implementing an Innovative Outpatient Clinic for Refractory Ascites in a Safety Net Hospital.

BACKGROUND: Disparities in life-saving interventions for low-income patients with cirrhosis necessitate innovative models of care. AIM: To implement a novel generalist-led FLuid ASPiration (FLASP) clinic to reduce emergency department (ED) care for refractory ascites. SETTING: A large safety net hospital in Los Angeles. PARTICIPANTS: MediCal patients with paracentesis in the ED from 6/1/2020 to 1/31/2021 or in FLASP clinic or the ED from 3/1/2021 to 4/30/2022. PROGRAM DESCRIPTION: According to RE-AIM, adoption obtained administrative endorsement and oriented ED staff. Reach engaged ED staff and eligible patients with timely access to FLASP. Implementation trained FLASP clinicians in safer, guideline-based paracentesis, facilitated timely access, and offered patient education and support. PROGRAM EVALUATION: After FLASP clinic opened, significantly fewer ED visits were made by patients discharged after paracentesis [rate ratio (RR) of 0.33 (95% CI 0.28, 0.40, p < 0.0001)] but not if subsequently hospitalized (RR = 0.88, 95% CI 0.70, 1.11). Among 2685 paracenteses in 225 FLASP patients, complications were infrequent: 39 (1.5%) spontaneous bacterial peritonitis, 265 (9.9%) acute kidney injury, and 2 (< 0.001%) hypotension. FLASP patients rated satisfaction highly on a Likert-type question. DISCUSSION: Patients with refractory ascites in large safety net hospitals may benefit from an outpatient procedure clinic instead of ED care.

Transitioning from the Emergency Department to a General Internist Outpatient Clinic for Paracentesis: A Qualitative Inquiry.

BACKGROUND: Repeated paracentesis for ascites can place significant demands on the emergency department (ED). A new general internist-led outpatient procedure clinic to alleviate this demand required ED staff and patients to accept this transition of care. AIM: This qualitative study evaluates barriers and facilitators to implementing the FLuid ASPiration (FLASP) clinic in a safety net hospital. METHODS: The FLASP clinic opened during the COVID-19 pandemic in March 2021. From February to April 2022, semi-structured interviews were conducted with: 10 ED physicians and nurses; 5 FLASP clinic patients; and 4 patients receiving paracentesis in the ED. Interviews were recorded, transcribed, and analyzed using a Grounded Theory approach for themes categorized by Theory of Planned Behavior (TPB) domains including: attitudes/knowledge; social norms; and logistics. RESULTS: Thematic analysis found that ED staff appreciated reduced demand for paracentesis, but barriers included: lack of knowledge; concerns about unstable patients and patient expectations (norms); and scheduling logistics. FLASP clinic patients had only favorable themes: belief in clinic safety; positive relationship with staff; and clinic efficiency. Patients using the ED for paracentesis expressed only concerns: possible need for testing or hospitalization; care usually in the ED; and unclear clinic scheduling. CONCLUSION: This study reveals challenges to transitioning sites of care for paracentesis including the need for greater ED staff education and standardizing methods to triage patients to appropriate site of care. Greater support and education of ED patients about the benefits of an outpatient procedure clinic may also reduce ED burden for paracentesis.

Transitioning from the Emergency Department to a General Internist Outpatient Clinic for Paracentesis: A Qualitative.

Background: Repeated paracentesis for ascites can place significant demands on the emergency department (ED). A new general internist-led outpatient procedure clinic to alleviate this demand required ED staff and patients to accept this transition of care. Aim: This qualitative study evaluates barriers and facilitators to implementing the FLuid ASPiration (FLASP) clinic in a safety net hospital. Methods: The FLASP clinic opened during the COVID-19 pandemic in March 2021. From February to April 2022, semi-structured interviews were conducted with: 10 ED physicians and nurses; 5 FLASP clinic patients; and 4 patients receiving paracentesis in the ED. Interviews were recorded, transcribed, and analyzed using a Grounded Theory approach for themes categorized by Theory of Planned Behavior (TPB) domains including: attitudes/knowledge; social norms; and logistics. Results: Thematic analysis found that ED staff appreciated reduced demand for paracentesis, but barriers included: lack of knowledge; concerns about unstable patients and patient expectations (norms); and scheduling logistics. FLASP clinic patients had only favorable themes: belief in clinic safety; positive relationship with staff; and clinic efficiency. Patients using the ED for paracentesis expressed only concerns: possible need for testing or hospitalization; care usually in the ED; and unclear clinic scheduling. Conclusion: This study reveals challenges to transitioning sites of care for paracentesis including the need for greater ED staff education and standardizing methods to triage patients to appropriate site of care. Greater support and education of ED patients about the benefits of an outpatient procedure clinic may also reduce ED burden for paracentesis.

Association between frailty status and complications in patients undergoing surgical excision of malignant esophageal neoplasms.

Background: Research within the last decade highlights the patients' frailty status as an important predictor of esophageal cancer outcomes, but the literature evaluating frailty's role in these patients remains limited. We evaluated the role of frailty in patients undergoing resection of malignant esophageal neoplasms. Methods: We used the Nationwide Readmissions Database from 2016 and 2017 to identify patients who underwent excision of a malignant esophageal neoplasm. Patient frailty was queried using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Propensity score matching identified 289 frail patients and 281 non-frail patients. Mann-Whitney U testing was performed and receiver operating characteristic (ROC) curves were created, following the creation of logistic regression models for predicting discharge disposition. The area under the curve (AUC) served as a proxy for model performance. Results: Frail patients had significantly more nonroutine discharges, longer inpatient lengths of stay, higher costs, more acute infections, posthemorrhagic anemia and deep vein thrombosis, and greater mortality (P<0.05). No significant differences were found between the 2 cohorts with respect to readmission rates, pulmonary embolism or dysphagia. Predictive models for patient discharge disposition demonstrated that frailty status in combination with age resulted in better ROC curves (AUC: 0.652) compared to models using age alone (AUC: 0.601). Conclusions: Frailty was found to be significantly correlated with higher rates of inpatient medical complications following esophagectomy. The inclusion of patient frailty status in predictive models for discharge disposition resulted in a better predictive capacity compared to those using age alone.

CXC-chemokine regulation and neutrophil trafficking in hepatic ischemia-reperfusion injury in P-selectin/ICAM-1 deficient mice.

BACKGROUND: Neutrophil adhesion and migration are critical in hepatic ischemia and reperfusion injury (I/R). P-selectin and the intercellular adhesion molecule (ICAM)-1 can mediate neutrophil-endothelial cell interactions, neutrophil migration, and the interactions of neutrophils with hepatocytes in the liver. Despite very strong preclinical data, recent clinical trials failed to show a protective effect of anti-adhesion therapy in reperfusion injury, indicating that the length of injury might be a critical factor in neutrophil infiltration. Therefore, the aim of this study was to assess the role of P-selectin and ICAM-1 in neutrophil infiltration and liver injury during early and late phases of liver I/R. METHODS: Adult male wild-type and P-selectin/ICAM-1-deficient (P/I null) mice underwent 90 minutes of partial liver ischemia followed by various periods of reperfusion (6, 15 h, and a survival study). Liver injury was assessed by plasma level of alanine aminotransferase (ALT) and histopathology. The plasma cytokines, TNF-alpha, IL-6, MIP-2 and KC, were measured by ELISA. RESULTS: Reperfusion caused significant hepatocellular injury in both wild-type and P/I null mice as was determined by plasma ALT levels and liver histopathology. The injury was associated with a marked neutrophil infiltration into the ischemic livers of both wild-type and P/I null mice. Although the levels of ALT and neutrophil infiltration were slightly lower in the P/I null mice compared with the wild-type mice the differences were not statistically significant. The plasma cytokine data of TNF-alpha and IL-6 followed a similar pattern to ALT data, and no significant difference was found between the wild-type and P/I null groups. In contrast, a significant difference in KC and MIP-2 chemokine levels was observed between the wild-type and P/I null mice. Additionally, the survival study showed a trend towards increased survival in the P/I null group. CONCLUSION: While ICAM-1 and P-selectin does not appear to be critical for neutrophil infiltration and I/R injury in the liver, they may regulate CXC-chemokine production. Blockage of these adhesion molecules may improve survival and remote organ injury that often accompanies liver I/R injury, through chemokine regulation.

Sex differences in inflammatory cytokine production in hepatic ischemia-reperfusion.

BACKGROUND: The inflammatory response to hepatic ischemia-reperfusion (I/R) is associated with an increase in cytokine production. Studies have documented that sex hormones modulate both the innate and adaptive immune responses, and that females are more robust than males. The aim of this study was to determine whether a sex difference in cytokine response to hepatic I/R exists under normal pathophysiologic condition without hormone intervention. METHODS: Adult C57BL/6 mice underwent 90 min of hepatic ischemia followed by various reperfusion periods (0, 1.5, 3, 6 hr). Plasma cytokine TNF-alpha, IL-6, MIP-2, and KC were measured. Liver injury was assessed by plasma alanine transaminase (ALT) levels and liver histopathology. RESULTS: A reperfusion time-dependent increase in hepatocellular injury was observed in both males and females, as indicated by increasing levels of plasma ALT and liver histopathology. The plasma cytokines were significantly increased in both female and male I/R groups compared to their respective sham counterparts. However, there was a significant difference in cytokine kinetics between the female and male I/R groups. Female mice initially had a higher level of IL-6, KC, and MIP-2 in response to I/R, which began to decline after 3 hr of reperfusion and were significantly lower than the male I/R counterparts by 6 hr of reperfusion. In contrast, the hepatocellular injury and TNF production were only moderately lower in female IR than male IR. CONCLUSION: The study underscores role of the gender in differential inflammatory cytokine expression in response to hepatic I/R, which may reflect the host response outcome.