Identifying Patients With Hepatic Encephalopathy Using Administrative Data in the ICD-10 Era.

Hepatic encephalopathy (HE) is a common complication of cirrhosis resulting in relapsing-remitting mental status changes ranging from deficits in executive function to coma. Incident HE is associated with an abrupt increase in mortality1 and frequent hospitalization.2 To further the understanding of the burden and impact of HE at the population level, valid algorithms are required to identify patients in administrative data. An International Classification of Diseases (ICD)-9 code is specific for HE (572.2), offering a 0.92 positive predictive value (PPV) and 0.36 negative predictive value (NPV).3 When applied in an algorithm to patients with ICD-9 codes for cirrhosis (eg, 571.5), Kanwal et al4 found a PPV and NPV of 0.86 and 0.87. Unfortunately, the switch to ICD-10 in 2015 rendered algorithms validated using ICD-9 invalid. Kaplan et al5 previously showed that lactulose and rifaximin use correlated with grade of HE for Child classification. Herein, we validate a diagnostic coding algorithm for HE using ICD-10 and medication records.

Deprescribing medications that may increase the risk of hepatic encephalopathy: A qualitative study of patients with cirrhosis and their doctors.

BACKGROUND AND AIMS: Multiple medications are associated with an increased risk of incident hepatic encephalopathy. Despite this known risk, medications such as opioids, benzodiazepines, gabapentin/pregabalin, and/or proton pump inhibitors are increasingly prescribed to persons with cirrhosis. Deprescribing is a promising intervention to reduce the burden of hepatic encephalopathy. Given that deprescribing has not been trialed in cirrhosis, we evaluated the barriers and facilitators to safe and successful deprescribing in cirrhosis. METHODS: We conducted, transcribed, and analyzed semi-structured interviews using qualitative methodology with 22 subjects. This included eight patients with cirrhosis and recent use of opiates, benzodiazepines, gabapentin/Lyrica, and/or proton pump inhibitors as well as 14 providers (primary care, transplant surgery, transplant hepatology). Interviews explored opinions, behaviors, and understanding surrounding the risks and benefits of deprescribing. RESULTS: Major provider-specific barriers included deferred responsibility of the deprescribing process, knowledge gaps regarding the risk of hepatic encephalopathy associated with medications (e.g., proton pump inhibitors) as well as the safe method of deprescription (i.e., benzodiazepines), and time constraints. Patient-specific barriers included knowledge gaps regarding the cirrhosis-specific risks of their medications and anxiety about the recurrence of symptoms after medication discontinuation. Patients uniformly reported trust in their provider's opinions on risks and wished for more comprehensive education during or after visits. Providers uniformly reported support for deprescription resources including pharmacist or nurse outreach. CONCLUSION: Given knowledge of medication risks related to hepatic encephalopathy in patients with cirrhosis, deprescribing is universally seen as important. Knowledge gaps, inaction, and uncertainty regarding feasible alternatives prevent meaningful implementation of deprescription. Trials of protocolized pharmacy-based deprescribing outreach and patient-facing education on risks are warranted.

Comprehensive Health-State Utilities in Contemporary Patients With Cirrhosis.

Cost-effectiveness analysis depends on generalizable health-state utilities. Unfortunately, the available utilities for cirrhosis are dated, may not reflect contemporary patients, and do not capture the impact of cirrhosis symptoms. We aimed to determine health-state utilities for cirrhosis, using both the standard gamble (SG) and visual analog scale (VAS). We prospectively enrolled 305 patients. Disease severity (Child-Pugh [Child] class, Model for End-Stage Liver Disease with sodium [MELD-Na] scores), symptom burden (sleep quality, cramps, falls, pruritus), and disability (activities of daily living) were assessed. Multivariable models were constructed to determine independent clinical associations with utility values. The mean age was 57 ± 13 years, 54% were men, 30% had nonalcoholic steatohepatitis, 26% had alcohol-related cirrhosis, 49% were Child class A, and the median MELD-Na score was 12 (interquartile range [IQR], 8-18). VAS displayed a normal distribution with a wider range than SG. The Child-specific SG-derived utilities had a median value of 0.85 (IQR, 0.68-0.98) for Child A, 0.78 (IQR, 0.58-0.93) for Child B, and 0.78 (IQR, 0.58-0.93) for Child C. VAS-derived utilities had a median value of 0.70 (IQR, 0.60-0.85) for Child A, 0.61 (IQR, 0.50-0.75) for Child B, and 0.55 (IQR, 0.40-0.70) for Child C. VAS and SG were weakly correlated (Spearman's rank correlation coefficient, 0.12; 95% confidence interval, 0.006-0.23). In multivariable models, disability, muscle cramps, and MELD-Na were significantly associated with SG utilities. More clinical covariates were significantly associated with the VAS utilities, including poor sleep, MELD-Na, disability, falls, cramps, and ascites. Conclusion: We provide health-state utilities for contemporary patients with cirrhosis as well as estimates of the independent impact of specific symptoms on each patient's reported utility.