Underutilization of Hospice in Inpatients with Cirrhosis: The NACSELD Experience.,Digestive Diseases and Sciences

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Underutilization of Hospice in Inpatients with Cirrhosis: The NACSELD Experience.
Digestive Diseases and Sciences ( IF 3.1 ) Pub Date : 2020-03-07 , DOI: 10.1007/s10620-020-06168-8
Jacqueline G O'Leary _{1,

2} , Puneeta Tandon ₃ , K Rajender Reddy ₄ , Scott W Biggins ₅ , Florence Wong ₆ , Patrick S Kamath ₇ , Guadalupe Garcia-Tsao ₈ , Benedict Maliakkal ₉ , Jennifer Lai ₁₀ , Michael Fallon ₁₁ , Hugo E Vargas ₁₂ , Paul Thuluvath ₁₃ , Ram Subramanian ₁₄ , Leroy R Thacker ₁₅ , Jasmohan S Bajaj ₁₆

Affiliation

Department of Medicine, Dallas VA Medical Center, Dallas, TX, USA.
Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA.
Department of Medicine, University of Alberta, Edmonton, AB, Canada.
Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
Department of Medicine, University of Washington, Seattle, WA, USA.
Department of Medicine, University of Toronto, Toronto, ON, Canada.
Department of Medicine, Mayo Clinic, Rochester, MN, USA.
Department of Medicine, Yale University, New Haven, CT, USA.
Department of Medicine, University of Rochester, Rochester, NY, USA.
Department of Medicine, University of California, San Francisco, CA, USA.
Department of Medicine, University of Texas, Health Science Center, Houston, TX, USA.
Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA.
Department of Medicine, Mercy Medical Center, University of Maryland School of Medicine, Baltimore, MD, USA.
Department of Medicine, Emory University, Atlanta, GA, USA.
Department of Biostatistics, McGuire VA Medical Center, Virginia Commonwealth University, Richmond, VA, USA.
Department of Medicine, McGuire VA Medical Center, Virginia Commonwealth University, Richmond, VA, USA.

Abstract

Background

Little is known about patients discharged to hospice following hospitalization for complications of cirrhosis.

Aim

We sought to understand the current pattern of hospice utilization in patients with cirrhosis by evaluating the North American Consortium for the Study of End-stage Liver Disease (NACSELD) cohort.

Methods

Patients with cirrhosis from 14 tertiary-care hepatology centers across North America non-electively hospitalized and prospectively enrolled were evaluated. Exclusion criteria included HIV infection, transplantation or non-hepatic malignancy. Random computer-based propensity score matching was undertaken in a 1:2 ratio based on admission MELD score ± 3 points.

Results

Totally, 2718 patients were enrolled, 5% (N = 132) were discharged to hospice, 6% (N = 171) died, and the rest were discharged alive. Patients discharged to hospice were older (60 vs. 57 years, p = 0.04), less likely to have had SBP (13% vs. 28%, p = 0.002) and be listed for liver transplantation (11% vs. 26%, p = 0.0007). Features, on multivariable modeling, associated with increased probability of discharge to hospice as opposed to being discharged alive: grade-3–4 hepatic encephalopathy, a higher Child–Turcotte–Pugh (CTP) score, and a higher discharge serum creatinine; however, a higher serum sodium, being listed for transplant and being prescribed rifaximin or a statin were protective from hospice discharge.

Conclusion

Patients with more advanced liver disease, hepatic encephalopathy, renal dysfunction, and those not candidates for liver transplantation were more likely to be discharged to hospice. However, in this sick multinational cohort of cirrhotic inpatients, it seems that hospice is markedly underutilized (5%) since 25% of patients not discharged to hospice died within 6 months.

中文翻译：

肝硬化住院患者临终关怀的利用不足：NACSELD 经验。

摘要

背景

对于因肝硬化并发症住院后出院到临终关怀的患者知之甚少。

目标

我们试图通过评估北美终末期肝病研究联盟 (NACSELD) 队列来了解肝硬化患者临终关怀的当前使用模式。

方法

评估了来自北美 14 个三级护理肝病中心的非选择性住院和前瞻性入组的肝硬化患者。排除标准包括 HIV 感染、移植或非肝脏恶性肿瘤。基于入院 MELD 评分 ± 3 分，以 1:2 的比例进行随机基于计算机的倾向评分匹配。

结果

共有2718名患者入组，5%（N =132）出院到临终关怀，6%（N =171）死亡，其余存活出院。出院到临终关怀的患者年龄较大（60 岁对 57 岁，p = 0.04），患有 SBP 的可能性较小（13% 对 28%，p = 0.002）并被列入肝移植名单（11% 对 26%，p = 0.0007)。特征，在多变量模型中，与出院而不是活着出院的可能性增加相关：3-4 级肝性脑病、更高的 Child-Turcotte-Pugh (CTP) 评分和更高的出院血清肌酐；然而，较高的血清钠，被列入移植名单并开具利福昔明或他汀类药物，可以防止临终关怀出院。