Alcohol treatment discussions and clinical outcomes among patients with alcohol-related cirrhosis.

BACKGROUND: Alcohol cessation is the cornerstone of treatment for alcohol-related cirrhosis. This study evaluated associations between medical conversations about alcohol use disorder (AUD) treatment, AUD treatment engagement, and mortality. METHODS: This retrospective cohort study included all patients with ICD-10 diagnosis codes for cirrhosis and AUD who were engaged in hepatology care in a single healthcare system in 2015. Baseline demographic, medical, liver disease, and AUD treatment data were assessed. AUD treatment discussions and initiation, alcohol cessation, and subsequent 5-year mortality were collected. Multivariable models were used to assess the factors associated with subsequent AUD treatment and 5-year mortality. RESULTS: Among 436 patients with cirrhosis due to alcohol, 65 patients (15%) received AUD treatment at baseline, including 48 (11%) receiving behavioral therapy alone, 11 (2%) receiving pharmacotherapy alone, and 6 (1%) receiving both. Over the first year after a baseline hepatology visit, 37 patients engaged in AUD treatment, 51 were retained in treatment, and 14 stopped treatment. Thirty percent of patients had hepatology-documented AUD treatment recommendations and 26% had primary care-documented AUD treatment recommendations. Most hepatology (86%) and primary care (88%) recommendations discussed behavioral therapy alone. Among patients with ongoing alcohol use at baseline, AUD treatment one year later was significantly, independently associated with AUD treatment discussions with hepatology (adjusted odds ratio (aOR): 3.23, 95% confidence interval (CI): 1.58, 6.89) or primary care (aOR: 2.95; 95% CI: 1.44, 6.15) and negatively associated with having Medicaid insurance (aOR: 0.43, 95% CI: 0.18, 0.93). When treatment was discussed in both settings, high rates of treatment ensued (aOR: 10.72, 95% CI: 3.89, 33.52). Over a 5-year follow-up period, 152 (35%) patients died. Ongoing alcohol use, age, hepatic decompensation, and hepatocellular carcinoma were significantly associated with mortality in the final survival model. CONCLUSION: AUD treatment discussions were documented in less than half of hepatology and primary care encounters in patients with alcohol-related cirrhosis, though such discussions were significantly associated with receipt of AUD treatment.

National frequency, trends, and healthcare burden of care fragmentation in readmissions for end-stage liver disease in the USA.

BACKGROUND: End-stage liver disease (ESLD) patients have frequent readmissions to the same facility or a different hospital (care fragmentation). Care fragmentation results in care delivery from an unfamiliar clinical team or setting, a potential source of suboptimal clinical outcomes. We examined the occurrence, trends, and association between care fragmentation and outcomes during readmissions for ESLD. METHODS: From the Nationwide Readmissions Database (January to September 2010-2014), we followed adult (age ≥18 years) hospitalizations for ESLD who were discharged alive for 90 days. During 30- and 90-day readmissions, we calculated the frequency, determinants, and clinical outcomes of care fragmentation (SAS 9.4). RESULTS: Of the 67,480 ESLD hospitalizations surviving at discharge from 2010-2014, 35% (23,872) and 52% (35,549) were readmitted in 30- and 90-days respectively. During readmissions, the frequencies of care fragmentation were similar (30-day: 25.4% and 90-day: 25.8%) and remained stable from 2010 to 2014 (P trends>0.5). Similarly, factors associated with care fragmentation were consistent across 30- and 90-day readmissions. These included ages: 18-44 years, liver cancer, receipt of liver transplantation, hepatorenal syndrome, prolonged length of stay, and hospitalization in non-teaching facilities. During 30- and 90-day readmissions, care fragmentation was associated with higher risk of mortality (adjusted mean ratio: 1.13[1.03-1.24] and 1.14 [1.06-1.23]; P values<0.0001), prolonged length of stay (4.6-days vs. 4.1-days and 5.2-days vs. 4.6-days; P values<0.0001), and higher hospital charges ($36,884 vs. $28,932 and $37,354 vs. $30,851; P values<0.0001). CONCLUSIONS: Care fragmentation is high among readmissions for ESLD and is associated with poorer outcomes.

Clinical characteristics, predictors, and rates of hospitalized acute cholangitis patients in the United States.

Background: Acute cholangitis (AC) is a relatively uncommon condition, with a mortality rate of 50% without prompt treatment. Our study aimed to assess the impact of demographic and social factors on morbidity, mortality and healthcare utilization of patients with AC in the United States (US). Methods: We used data from the National Inpatient Sample (2016 and 2017). Our study population included all patients with a discharge diagnosis of AC, identified using the International Classification of Diseases, Tenth Revision (ICD-10) code K830. Results: A total of 18,649 patients were hospitalized with a diagnosis of AC, with rates higher among older persons. The incidence increased notably from 142.36 cases per million in 2016 to 144.3 in 2017. The majority (53%) of patients were on Medicare. Age >60 years was associated with greater mortality compared to 0-18 years (odds ratio [OR] 2.56, 95% confidence interval [CI] 1.21-5.43). Hispanic race (OR 1.4, 95%CI 1.15-1.76) and Black race (OR 1.3, 95%CI 1.04-1.63) had an increased mortality compared to White race. Among the factors analyzed, age >60 (OR 3.72, 95%CI 2.93-4.70) and male sex (OR 0.91, 95%CI 0.86-0.98) were found to be significantly associated with endoscopic retrograde cholangiopancreatography (ERCP) during hospitalization. The total charge for hospitalizations in 2016 was $766 million, increasing to $825 million in 2017. Conclusions: The incidence of AC in the US increased slightly year over year. In patients presenting with AC, age and race were associated with mortality while age and sex were associated with the need for ERCP.

COVID-19 and acute pancreatitis: A systematic review.

We aimed to systematically review the relationship between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and acute pancreatitis (AP). The global pandemic of coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 infection causes respiratory symptoms and notably also affects the gastrointestinal (GI) system. A systematic review of the available literature on the topic was performed with a search key using the terms "SARS COV 2," "Pancreatitis," "COVID-19" and synonyms. The search was conducted on 27 December 2020 using PubMed, EMBASE, CENTRAL, Web of Science, and Scopus. A meta-analysis was not conducted due to the low quality and poor comparability of the studies. We reviewed 66 studies that reported data on patients with polymerase chain reaction-confirmed SARS-CoV-2 infection and AP using the Atlanta Criteria. Our evaluation revealed a wide age range and diverse clinical presentation of COVID-19 with or without symptoms of AP, some of which preceded typical COVID-19 symptoms. We observed a myriad of complications and one study revealed that patients with both conditions were more likely to require mechanical ventilation and had longer lengths of hospital stay compared with patients with AP without COVID-19. Treatment for AP was mostly supportive, with varied therapies employed for COVID-19. Most cases were considered idiopathic and presumed to be SARS-CoV-2-induced as established etiological factors were not reported. AP should be considered in COVID-19 patients, especially in those exhibiting GI symptoms. Evidence to establish a causal relationship between SARS-CoV-2 infection and AP is currently lacking.

Characteristics of opioid prescribing to outpatients with chronic liver diseases: A call for action.

BACKGROUND: Chronic liver disease (CLD) is among the strongest risk factors for adverse prescription opioid-related events. Yet, the current prevalence and factors associated with high-risk opioid prescribing in patients with chronic liver disease (CLD) remain unclear, making it challenging to address opioid safety in this population. Therefore, we aimed to characterize opioid prescribing patterns among patients with CLD. METHODS: This retrospective cohort study included patients with CLD identified at a single medical center and followed for one year from 10/1/2015-9/30/2016. Multivariable, multinomial regression was used identify the patient characteristics, including demographics, medical conditions, and liver-related factors, that were associated with opioid prescriptions and high-risk prescriptions (≥90mg morphine equivalents per day [MME/day] or co-prescribed with benzodiazepines). RESULTS: Nearly half (47%) of 12,425 patients with CLD were prescribed opioids over a one-year period, with 17% of these receiving high-risk prescriptions. The baseline factors significantly associated with high-risk opioid prescriptions included female gender (adjusted incident rate ratio, AIRR = 1.32, 95% CI = 1.14-1.53), Medicaid insurance (AIRR = 1.68, 95% CI = 1.36-2.06), cirrhosis (AIRR = 1.22, 95% CI = 1.04-1.43) and baseline chronic pain (AIRR = 3.40, 95% CI = 2.94-4.01), depression (AIRR = 1.93, 95% CI = 1.60-2.32), anxiety (AIRR = 1.84, 95% CI = 1.53-2.22), substance use disorder (AIRR = 2.16, 95% CI = 1.67-2.79), and Charlson comorbidity score (AIRR = 1.27, 95% CI = 1.22-1.32). Non-alcoholic fatty liver disease was associated with decreased high-risk opioid prescriptions (AIRR = 0.56, 95% CI = 0.47-0.66). CONCLUSION: Opioid medications continue to be prescribed to nearly half of patients with CLD, despite efforts to curtail opioid prescribing due to known adverse events in this population.

Medication Treatment of Active Opioid Use Disorder in Veterans With Cirrhosis.

INTRODUCTION: Although opioid use disorder (OUD) is common in patients with cirrhosis, it is unclear how medication treatment for OUD (MOUD) is used in this population. We aimed to assess the factors associated with MOUD and mortality in a cohort of Veterans with cirrhosis and OUD. METHODS: Within the Veterans Health Administration Corporate Data Warehouse, we developed a cohort of Veterans with cirrhosis and active OUD, using 2 outpatient or 1 inpatient International Classification of Diseases, ninth revision codes from 2011 to 2015 to define each condition. We assessed MOUD initiation with methadone or buprenorphine over the 180 days following the first OUD International Classification of Diseases, ninth revision code in the study period. We fit multivariable regression models to assess the association of sociodemographic and clinical factors with receiving MOUD and the associations between MOUD and subsequent clinical outcomes, including new hepatic decompensation and mortality. RESULTS: Among 5,600 Veterans meeting criteria for active OUD and cirrhosis, 722 (13%) were prescribed MOUD over 180 days of follow-up. In multivariable modeling, MOUD was significantly, positively associated with age (adjusted odds ratio [AOR] per year: 1.04, 95% confidence interval (CI): 1.01-1.07), hepatitis C virus (AOR = 2.15, 95% CI = 1.37-3.35), and other substance use disorders (AOR = 1.47, 95% CI = 1.05-2.04) negatively associated with alcohol use disorder (AOR = 0.70, 95% CI = 0.52-0.95), opioid prescription (AOR = 0.51, 95% CI = 0.38-0.70), and schizophrenia (AOR = 0.59, 95% CI = 0.37-0.95). MOUD was not significantly associated with mortality (adjusted hazards ratio = 1.20, 95% CI = 0.95-1.52) or new hepatic decompensation (OR = 0.57, CI = 0.30-1.09). DISCUSSION: Few Veterans with active OUD and cirrhosis received MOUD, and those with alcohol use disorder, schizophrenia, and previous prescriptions for opioids were least likely to receive these effective therapies.