Weekend admissions with ascites are associated with delayed paracentesis: A nationwide analysis of the 'weekend effect'.

INTRODUCTION AND OBJECTIVES: Weekend admissions has previously been associated with worse outcomes in conditions requiring specialists. Our study aimed to determine in-hospital outcomes in patients with ascites admitted over the weekends versus weekdays. Time to paracentesis from admission was studied as current guidelines recommend paracentesis within 24h for all patients admitted with worsening ascites or signs and symptoms of sepsis/hepatic encephalopathy (HE). PATIENTS: We analyzed 70 million discharges from the 2005-2014 National Inpatient Sample to include all adult patients admitted non-electively for ascites, spontaneous bacterial peritonitis (SBP), and HE with ascites with cirrhosis as a secondary diagnosis. The outcomes were in-hospital mortality, complication rates, and resource utilization. Odds ratios (OR) and means were adjusted for confounders using multivariate regression analysis models. RESULTS: Out of the total 195,083 ascites/SBP/HE-related hospitalizations, 47,383 (24.2%) occurred on weekends. Weekend group had a higher number of patients on Medicare and had higher comorbidity burden. There was no difference in mortality rate, total complication rates, length of stay or total hospitalization charges between the patients admitted on the weekend or weekdays. However, patients admitted over the weekends were less likely to undergo paracentesis (OR 0.89) and paracentesis within 24h of admission (OR 0.71). The mean time to paracentesis was 2.96 days for weekend admissions vs. 2.73 days for weekday admissions. CONCLUSIONS: We observed a statistically significant "weekend effect" in the duration to undergo paracentesis in patients with ascites/SBP/HE-related hospitalizations. However, it did not affect the patient's length of stay, hospitalization charges, and in-hospital mortality.

A Multicenter Evaluation of Adherence to 4 Major Elements of the Baveno Guidelines and Outcomes for Patients With Acute Variceal Hemorrhage.

GOALS: To determine the rate of and outcomes associated with guideline adherence in the care of acute variceal hemorrhage (AVH). BACKGROUND: Four major elements of high-quality care for AVH defined by the Baveno consensus (VI) include timely endoscopy (≤12 h), antibiotics, and somatostatin analogs before endoscopy and band ligation as primary therapy for esophageal varices. STUDY: We retrospectively evaluated 239 consecutive admissions of 211 patients with AVH admitted to 2 centers in Massachusetts from 2010 to 2015. The primary outcome was 6-week mortality; secondary outcomes included treatment failure (shock, hemoglobin drop by 3 g/dL, hematemesis, death ≤5 d), length of stay, and 30-day readmission. RESULTS: Guideline adherence was variable: endoscopy ≤12 hours (79.9%), antibiotics (84.9%), band ligation (78.7%), and somatostatin analogs (90.8%). However, only 150 (62.8%) received care that was adherent to all indicated criteria. The 6-week mortality rate was 22.6%. Treatment failure occurred in 50 (21.0%) admissions. Among the 198 patients who survived to discharge, 41 (20.7%) were readmitted within 30 days. Octreotide before endoscopy was associated with a reduction in 30-day readmission (18.4% vs. 42.1%; P=0.03), whereas banding of esophageal varices was associated with a reduced risk of treatment failure (15.0% vs. 50.0%; P≤0.001). However, adherence to quality metrics did not significantly reduce the risk of death within 6 weeks. CONCLUSIONS: Adherence to quality metrics may not reduce the risk of mortality but could improve secondary outcomes of AVH. Variation in practice should be addressed through quality improvement interventions.

Open access colonoscopy: Critical appraisal of indications, quality metrics and outcomes.

INTRODUCTION: In an era of cost containment and measurement of value, screening for colon cancer represents a clear target for better accountability. Bundling payment is a real possibility and will likely have to rely on open-access colonoscopy (OAC). OAC is a method to allow patients to undergo endoscopy without prior evaluation by a gastroenterologist. We conducted a cross-sectional study to evaluate the indications and outcomes among patients scheduled for OAC or traditional colonoscopy at a tertiary medical center. We hypothesized that outcomes in OAC patients would be similar to those from traditional referral modes. METHOD: Using a standardized data abstraction form, we documented indications for colonoscopy, clinical outcomes (complications, emergency room visits, phone calls), and compliance with quality indicators (QI) in a random sample of 1000 patients who underwent an outpatient colonoscopy at an academic medical center in 2013. We compared baseline characteristics and outcomes between two cohorts: OAC vs. patients who were scheduled after previous evaluation by a gastroenterologist or physician assistant or non-open access colonoscopy (NOAC). RESULTS: Patients in the OAC group were more likely to be male, non-Hispanic, to be privately insured, and to have screening (vs. diagnostic) indication. However they were significantly less likely than those in the NOAC group to have a procedure performed once scheduled, (45.5% vs. 66.9%, p<0.001), due to no-show (24/178 or 13.5% vs. 60/822 or 7.3%), cancellation (56/178 or 31.5 vs. 156/822 or 19.0%), and non-compliance (9/178 or 5.1% vs. 20/822 or 2.4%). There were no clinically meaningful differences between groups with respect to outcomes such as polyp detection (35.6% OE vs. 39.5% NOE, p=0.54), postoperative call to GI practice (5.5% vs. 2.5%, p=0.41), or QI metrics such as documentation of prep quality (99.8% vs. 98.8%, p=0.24). CONCLUSION: Patients undergoing OAC are more likely to have a screening colonoscopy but with overall similar clinical outcomes and compliance with QI to patients scheduled as NOAC. OAC remains handicapped by high cancellation and no-show rates.

Impact of geography on organ allocation: Beyond the distance to the transplantation center.

AIM: To illustrate the application and utility of Geographic Information System (GIS) in exploring patterns of liver transplantation. Specifically, we aim to describe the geographic distribution of transplant registrations and identify disparities in access to liver transplantation across United Network of Organ Sharing (UNOS) region 1. METHODS: Based on UNOS data, the number of listed transplant candidates by ZIP code from 2003 to 2012 for Region 1 was obtained. Choropleth (color-coded) maps were used to visualize the geographic distribution of transplant registrations across the region. Spatial interaction analysis was used to analyze the geographic pattern of total transplant registrations by ZIP code. Factors tested included ZIP code log population and log distance from each ZIP code to the nearest transplant center; ZIP code population density; distance from the nearest city over 50000; and dummy variables for state residence and location in the southern portion of the region. RESULTS: Visualization of transplant registrations revealed geographic disparities in organ allocation across Region 1. The total number of registrations was highest in the southern portion of the region. Spatial interaction analysis, after adjusting for the size of the underlying population, revealed statistically significant clustering of high and low rates in several geographic areas could not be predicted based solely on distance to the transplant center or density of population. CONCLUSION: GIS represents a new method to evaluate the access to liver transplantation within one region and can be used to identify the presence of disparities and reasons for their existence in order to alleviate them.

Outcomes associated with a mandatory gastroenterology consultation to improve the quality of care of patients hospitalized with decompensated cirrhosis.

BACKGROUND AND AIMS: Patients with decompensated cirrhosis (DC) have significant morbidity and resource utilization. In a cohort of patients with DC undergoing usual care (UC) in 2009, we demonstrated that quality indicators (QI) were met <50% of the time. We established a gastroenterology mandatory consultation (MC) to improve the care of patients with DC. We sought to evaluate the impact of the MC intervention on adherence to QI, and compared outcomes to UC. METHODS: This was a prospective cohort study with historic control examining all admissions in a year for DC at an academic medical center. All admissions were seen by a gastroenterologist encouraged to implement QIs (MC). Scores were calculated for each group per admission as the proportion of QIs met versus QIs for which the patient was eligible. QI scores were examined as a function of group assignment multivariable fractional logit regression. We evaluated the impact of the intervention on compliance with QIs, length of stay (LOS), 30-day readmission, and inpatient death. RESULTS: Three hundred three patients were observed in 695 hospitalizations (149 patients in 379 admissions [UC]; 154 patients in 316 admissions [MC]). The QI score was significantly higher in the MC group than the UC group (77.0% vs 46.0%, P < 0.001), reflecting better management of ascites and documentation of transplant evaluation. The management of variceal bleeding improved also but did not reach statistical significance. CONCLUSION: The MC intervention was associated with greater adherence to recommended care but was not powered to detect difference in LOS, readmission, or mortality rates.

Measurement of the quality of care of patients admitted with decompensated cirrhosis.

BACKGROUND & AIMS: Process-based quality measures are increasingly used to evaluate hospital performance. However, practices vary, and patients with cirrhosis are a challenge to manage, given their risks of mortality, morbidity, and resources utilization. In 2010, process-based quality measures were developed to improve the care of these patients. We examined adherence with these quality measures for a cohort of patients admitted with decompensated cirrhosis in 2009. METHODS: We performed a retrospective analysis of all patients admitted to a tertiary-care hospital with decompensated cirrhosis in 2009 (n = 149,379) hospitalizations. Quality indicator (QI) scores were calculated for each admission as a fraction, i.e., the number of quality markers met divided by the number of possible quality indices, given the patient's presentation (range, 0-1). QI scores were correlated with patient characteristics and clinical outcomes (30-day readmission; inpatient death). RESULTS: Quality indicators were met 45% of the time (95% confidence interval, 40-51%). In multivariable analysis, QI scores were significantly lower among non-English-speaking patients and those who had congestive heart failure. QI scores were higher among patients with gastrointestinal bleeding or encephalopathy-related admission to the hospital. QI scores were not associated with inpatient mortality or 30-day readmission. CONCLUSION: There is substantial opportunity to improve the care of patients hospitalized for decompensated cirrhosis. Additional research is needed to identify effective strategies for closing gaps in care. Adherence to quality measures did not affect clinical outcomes, but if easily measured in other settings could be used to compare hospitals and practices.

Hepatitis C treatment eligibility in an urban population with and without HIV coinfection.

In an urban referral clinic, 182 hepatitis C-infected adults including 110 (60%) with HIV coinfection were evaluated for pegylated interferon and ribavirin therapy. Overall, only 33% were eligible for treatment. Considering all patients together, the major barriers to treatment were nonadherence with the evaluation process (23%), refusal of treatment (10%), active substance abuse (9%), and medical contraindication (8%). There was a trend toward a higher rate of treatment eligibility in HIV coinfected patients (39% vs. 25%; p = 0.07), who were significantly more likely to be adherent with the evaluation process compared to those with hepatitis C alone (86% vs. 63%; p = <0.001). Acceptance of antiviral therapy for hepatitis C was similar between eligible persons with and without HIV. These findings highlight the need to develop interventions to improve adherence and to manage substance abuse and other comorbidities in order to maximize the impact of interferon and ribavirin therapy on urban patients with hepatitis C.