Challenge accepted: Confronting readmissions for our patients with cirrhosis
Authors: Elliot B. Tapper
Journal: Hepatology (2016)

Potential conflict of interest: Nothing to report. See Article on Page 200 Defining the Readmission Problem As clinicians caring for patients with cirrhosis, our overarching goals are to prevent complications and to enhance the quality our patients' lives. The current regulatory environment has added an additional focus: We must measure the quality of care that we provide, including hospital readmission rate. Repeated hospitalizations are dangerous and place great strain on payers and caregivers. To correct the problem, the Center for Medicare and Medicaid Services (CMS) began assessing penalties of up to 3% on reimbursements in 2013 for hospitals with excessive readmissions. As a result, two of every three hospitals faced penalties in 2015. Though readmissions of patients with cirrhosis are not included in the CMS final rule, this is likely a matter of time. Every readmission has the potential to highlight deficiencies of care, directing the way to quality improvement. At the same time, some readmissions are necessary for good care and hence unavoidable. At issue is whether there are specific interventions capable of preventing rehospitalization for patients with cirrhosis. Unfortunately, these data are limited. The first and crucial step is to define the risk of readmissions after hospitalization. We have known for several years that rapid readmissions are common: roughly 14% at 1 week and 37% at 1 month.1 Now, in this issue of Hepatology, Bajaj et al. provide the first multicenter report confirming that, at 53% in 90 days, the readmission rate for patients with cirrhosis remains unacceptably high.3 What This Article Adds This study provides four novel findings. First, geography plays no role. Ninety‐day readmission rates are remarkably similar in four regions of North America, suggesting common features of cirrhosis care in all locations. Second, the cause for readmission is often different from the index admission, underscoring the complexity of cirrhosis and "reflecting an evolving disease course during the hospitalization."3 Third, as previously reported by this group, nosocomial infections are a major cause of morbidity and mortality for patients with cirrhosis4 and, not surprisingly, are strongly associated with readmissions. Fourth, the use of proton pump inhibitors (PPIs) is independently associated with readmissions, perhaps related to an effect on the host microbiome that may favor the emergence of nosocomial pathogens and increase the risk of hepatic encephalopathy (HE).5 Given the overprescription of PPIs, this association provides a potential intervention to reduce morbidity, including readmissions. Additionally, these data confirm previous findings. First, HE is a significant driver of readmissions.6 Second, statistical models to predict the risk of readmission performed poorly in this multicenter study, just as they have in past single‐center studies.2 Readmissions that are not predictable are, by definition, not preventable and suggest that policy and reimbursement rules based on these events may not be justified for this population. The generalizability of the study from Bajaj et al. must also be interpreted in the context of its study design. Importantly, these patients were selected and consented by the coauthors. The high readmission rate, like the proportion of patients with nosocomial infections (> 50%) and the high caliber of the participating institutions, reflects the complexity of the study population. Additionally, whereas a 90‐day horizon may be appropriate for patients with cirrhosis, these data contrast with the 30‐day metrics published elsewhere (and tracked by CMS).1 Confronting the Problem Two assumptions may prove helpful as we respond to the readmissions problem. First, rehospitalization can be low or high value. Payers view all readmissions as low value, whereas patients or physicians may see some differently. From this perspective, the value of a readmission is based, in large part, on its preventability. Low‐value examples include readmissions for HE attributable to nonadherence, symptomatic ascites because outpatient paracentesis is unavailable, or renal injury after unmonitored diuretic initiation. But readmissions may also reflect progressive illness and not necessarily failures of care. Renal/metabolic issues (22% of readmissions),3 such as volume overload, hyponatremia, and diuretic complications, often reflect progressive hepatorenal decompensation for which we lack effective therapies to forestall. Furthermore, it is unclear whether alternatives to hospitalization for these reasons such as day care at an infusion center are cost‐effective or safe. Similarly, patients with cirrhosis are prone to infections, which comprise 16% of readmissions.3 Some may be preventable through selective peritonitis prophylaxis or PPI stewardship. However, these measures have not been proven to mitigate the balance of our patients' infection risks. The reactions from caregivers on the day of readmission are often instructive—in the case of encephalopathy or symptomatic ascites, it is worry then frustration; for infections, worry and then relief. Second, we must not reinvent the wheel.7 Many interventions to improve care and prevent readmissions have been tried, with variable efficacy and cost (Fig. 1). Inpatient care pathways or checklists are easy to implement,9 but adherence is variable and effects are transient.6 These pitfalls can be overcome using electronic decision supports and templated notes.6 Rifaximin, for example, is associated with a reduced risk of readmission for HE. In a prospective study, electronic decision support to promote rifaximin use, but not a paper checklist, was shown to decrease readmissions.6 Similarly, systematically communicating discharge plans to outpatient physicians at discharge is straightforward, but fails to reduce readmissions.8 Conversely, assigning each patient to a discharge planning nurse to coordinate care from admission forward is costly, but successful.7 Numerous efforts seeking to improve care coordination have been trialed unsuccessfully, including intensified case management, postdischarge phone calls, telemonitoring by nurses, home visits, and early primary care visits.7 Unfortunately, these costly measures, even when combined, do not reduce readmissions because they do not provide an alternative to hospitalization.7 By contrast, Morando et al. reduced readmissions in a small cohort of patients with cirrhosis by combining comprehensive outreach programs with "day hospitals" that provided timely multidisciplinary evaluation and procedures (e.g., endoscopy, paracentesis, and transfusions).11Figure 1: Categorizing readmissions based on cost and efficacy. Interventions can be prioritized using this stylized rubric that considers the ease and cost of implementation as well as the effect on absolute numbers of readmissions. Low‐cost/high‐efficacy interventions should be implemented whereas low‐effifcacy/high‐cost interventions should be avoided. Low‐cost/low‐efficacy or high‐cost/high‐efficacy interventions should be considered in the context of the available resources for implementation. Question marks are presented for the interventions suggested by the article that require confirmation.3 "Virtual discharge wards" are comprehensive outreach and care‐coordination programs.Caution is warranted as we adapt interventions designed in other settings into models of care for patients with cirrhosis. First, successes from small studies often fail when developed for larger cohorts.7 Second, most studies do not report adverse events.7 It is essential that we evaluate each intervention with reference to our primary outcomes. What is the value, for example, of an intervention that increased readmissions but decreased the risk of transplant delisting? Or decreased readmissions but increased mortality? Interventions can be valuable by capturing decompensating illness early and increasing "high‐value" readmissions where alternatives are unavailable or by decreasing "low‐value" readmissions. Conclusion The data from Bajaj et al.3 represent the end of the beginning for the cirrhosis readmission story. We know the rates (high), the correlates (Model for End‐Stage Liver Disease, HE), and that our ability to predict readmissions is limited at best. Now, this important article has moved us from single‐center studies to multicenter collaborations. We cannot go back. Our task is to operationalize their data to design multicenter quality improvement programs with multiple outcome measures: not just readmissions, but mortality, transplantation and quality of life. That is the challenge.