I just want to say thank you so much for the course directors for this, for allowing me to come up here and share with you some just tips and tricks maybe that I've learned along the way and actually researched for this talk to see what was in the literature to support us in helping reduce hospital readmissions. And if you didn't know, this today marks the first day of NP Week, so happy NP Week to all of you NPs. All right, so we are going to, I don't have, well, I have this disclosure, I serve on the APP Advisory Board for Salines. So this session we're going to talk about three main things, so we're going to talk about some reasons for readmission for the patient with liver disease, so we're going to talk about what probably the top three most common reasons are, talk about some risk factors for readmission, so you've discharged your patient, so who do you need to be thinking of that these are the high-risk people that might be coming back in within the first 30 days of their discharge, and then talk about the cost associated with readmission in this specific patient population. So interestingly to think about, this was part of two different studies just thinking about the amount of cost that it takes for a patient, one of our patients, to be hospitalized but then to come back in for readmission, and about 136,000 patients are hospitalized every year for a chronic liver disease sort of problem. That can equate to $2.5 billion annually. If you think about all the complications that come with cirrhosis, it's a lot, and a lot of our patients, because of those severe complications and their high risk of morbidity and mortality, they frequently need ICU care, and so when we think about that, ICU care is very expensive in our country, and so we want to make sure that we try as best we can not for them to get to ICU, but then also to prevent them from coming back in the hospital again. So specifically thinking about hepatic encephalopathy patients, in some of the data that we found, there was in 2012, there was about 50,000 patients in the United States that were discharged with a diagnosis of hepatic encephalopathy, and the average cost per occurrence, per admission, was about $10,000 per admission. So if you can think about that times that many discharges, that's a lot of money. And we also need to think about, when we think about the hospitalization and readmission piece, not only are we thinking about the medications that we're giving patients at the time of the hospitalization, but thinking about how debilitated they are, so do they need DME, do they need a prescription for Zyfaxan, do they need cost of prescriptions, I mean the list can just go on and on when we get our case manager involved with discharges for these patients. It's always surprising to me to think about the amount of times I order, and they've never had it before, but I order home health PTOT, I order a walker that might be new for them, and so just thinking about all of those little pieces that add up, it does definitely become very costly. So when we think about risk factors for readmission, higher than average for patients with liver disease, these patients definitely are more likely to come back in the hospital purely because they have cirrhosis, and at seven days out, about 14% of these patients are likely to come back into the hospital, at 30 days, about 37% are likely to come back into the hospital. Thinking about the people at risk, so hospitals with a lower cirrhosis volume are more likely to come back in the hospital. If you think about it, those patients may not, the center, the providers in that center may not be as comfortable dealing with the cirrhosis complications as comfortably as an outpatient, so they're like, whatever, just get them back in the hospital. And so that is definitely a risk factor for readmission. Patients with alcoholic liver disease or a viral hepatitis were found in the literature to have a risk factor for readmission, as well as patients who already have complications of cirrhosis, such as patients with ascites or needing paracentesis, who have hepatocellular carcinoma and significant hyponatremia. Those patients definitely should be on your radar to need to come back in. And then there was significant risk factor for readmission for patients who are in urban or academic hospitals. Not really quite sure about the academic piece. I know in my own center, we're an academic center, and we have some readmissions, but I'd like to think that we try to keep them out of hospital as long as they can, but I think with the amount of severity of illness of a patient with cirrhosis, sometimes you just don't want to wait, and they are at high risk of infection, and we all know that that infection can progress very significantly and very quickly to sepsis, and so I think some of us err on the caution of being safe rather than sorry many times. And then patients who are discharged to home, to a short-term hospital or other facility. It seemed that patients who were very ill, who were discharged to a short-term hospital or a rehab hospital, where maybe the center was not as comfortable with caring for the complications of cirrhosis, were more at risk for coming back in. So this was a study done by Dr. Tapper and associates, discussing the rates of and reasons for hospital readmission in patients with cirrhosis. And if you look at some of the reasons why over here, you can see this grouping over here is patients with alcoholic cirrhosis. This one shows patients, a cohort of about 2,000 patients without complications. This shows a cohort of patients with a little over 4,000 patients who had complications. So when I say complications, what I'm talking about are encephalopathy, ascites, as well as debility, some of the other complications that we deal with. So for those patients, the most common reasons why they came back in for the ones without complications was infection, cirrhotic complications, and substance abuse. I thought that was a pretty interesting top three there. And then the patients with complications, so these patients do already have varices or hepatic encephalopathy or ascites, and their top three reasons was infection, substance abuse, and then the top was the cirrhotic complications. So that kind of makes sense, right? They already have those complications, it's likely they're going to have them again. And so if you think about that, that probably would be why they would come back into the hospital. Now in this grouping over here, these are reasons for hospital readmissions for patients with non-alcoholic cirrhosis, without complications, and then again with complications. So this is your non-alcoholic grouping. And for these patients without complications, their top three was heart disease, infections, and cirrhotic complications. And then the top three in this group who already had existing complications of cirrhosis were infections, cancer, which I found that interesting as well, or because of a cirrhotic complication. So this was a multi-state grouping study taking patients from California, Georgia, I'm sorry, California, Florida, Massachusetts, Mississippi, and New York. And they observed the overall 30 and 90 day readmission rates and found that about 12.9% and then 21.2% respectively were re-hospitalized. In this next study, looking at a validated risk model for prediction of early readmission in patients with hepatic encephalopathy by Dr. Krueger and his team, there's three different groupings here that you will see. So based on the predictors of readmission, a novel scoring system was used to stratify a patient's risk for readmission. And so they grouped them into low risk and to high risk. Those in the low risk group had a risk of 29.1% of readmission, whereas the high risk group had a 40% risk of readmission. Compared to the low risk group, the high risk group had a 1.65 times the odds of readmission, which is pretty significant. The first group, the bar graph there over on your left, will show the cost of hospitalization in cirrhosis patients admitted with hepatic encephalopathy. And this is from 2013. They used the Nationwide Readmission Database to get this information. Comparing index readmission and total calendar year cost, they looked at those admitted and not readmitted. And if you look in the readmitted column, the cost associated with that patient being admitted and readmitted and then the cost of their cost index was about $64,000. If you look at the patient who was not readmitted, it's about half that. It's about $31,000. So readmission is costly. And so if we can avoid that, then that is really our best way to go. If you look at the middle area, this is a Kaplan-Meir curves image showing the survival probability in patients with hepatic encephalopathy compared to those readmitted versus not readmitted within 30 days. Patients readmitted within 30 days of index hospitalization had significantly lower calendar year survival compared to those who were not readmitted within 30 days. And then on your far right, this last picture shows the causes of 30-day readmission rates of patients who came in with encephalopathy. And the top causes include the peritonitis, it's your blue big piece of the pie there, gastrointestinal hemorrhage, viral hepatitis, and then chronic liver disease and or cirrhosis. So in conclusion from this study, we can gather that approximately one-third of patients with HE will be readmitted within 30 days. Early readmission, AKI, and ascites are among the modifiable risk factors that we can think about that can predict a calendar year mortality. Hepatic encephalopathy patients with refractory ascites and or AKI are neither candidates for diuretics nor tips and therefore required repeat paracentesis. So if we start focusing on those modifiable risk factors, I think we can move the needle a little bit for this patient group. So thinking about what is the cost. So we talked about that a little bit and thinking about just the billions of dollars every year that is significantly spent in healthcare expenditure on patients with chronic liver disease. And thinking about every time a patient comes into the hospital, that's about another $10,000 or so. And then readmission, you saw that bar graph, it was up double to the amount from $30,000 up to $60,000. So it is very costly. So in another study done by Winn and Associates was entitled The Annual Burden and Cost of Hospitalization for High Need, High Cost Patients with Chronic GI and Liver Diseases. And they did break it up into the GI pieces as well as the chronic liver disease pieces and so I just gathered information from the chronic liver disease part. Average length of stay for those patients was about seven days. It ranged from anywhere from three to 14. And then the cost per hospitalization for these patients was about $20,000. Patients for admission was GI bleed, renal failure, neuropsychiatric illnesses, which could have been hepatic encephalopathy but could have been other reasons, and infections. Patients that were at high risk for this study were low income patients, patients with depression, obesity, other comorbidities such as cardiovascular risk factors, younger age, and male. According to the nationwide readmission database, about $103 billion is spent on the management of GI and chronic liver disease patients, which 62% is attributed to inpatient care versus 20% to ambulatory care. So having some sort of pathway to manage the patient as best you can in the outpatient setting really would be beneficial, I think, for us as providers to think about that in our organizations. So this next study, a nutritional assessment in inpatients with cirrhosis can be improved after training and is associated with lower readmission. So if any of you know me, you know that nutrition is one of my very exciting passions with our patients with liver disease. And I just love talking about nutrition and how we can optimize that for our patients. I've seen it where we have optimized nutrition for our patients with cirrhosis, and I've seen their outcomes improve, and I've seen their infections improve quicker. And it's just, I don't think we put enough value on it. And so this was a study that was done in 2019, published in Liver Transplantation. And what they did was they looked at a retrospective and a prospective group. And what they did was they evaluated inpatients, their current nutritional status, was trying to find out if nutrition was consulted, and then they listed some recommendations that they could in that piece for those patients at that time. After they got that data, they provided some education. So if you think about quality improvement project, this is kind of one of those sorts of things. And so they provided nutrition education to health staff, hospitalists, consultants, dieticians about what the current practice guidelines look like for a patient with cirrhosis and what should we be doing right now with our latest practice guidelines. And then they did a prospective look at, okay, after this education was done, did it make a difference? So this is the difference. So if you look at the retrospective numbers here, there's about 110 patients. And then in the prospective group, there was 29. The number of patients that were seen in the retrospective group were 73, 15 in the prospective group. But if you look at the liver-related admissions, readmissions, 72 patients or 65% were readmitted prior to receiving that education. After the education, half of the patients, 51%, were readmitted. But that's a pretty good decline from where it was pre-education. And then patients specifically with GI bleeding, HE without infection, those numbers definitely declined, even looking at that by a percentage rather than pure numbers since the number size was larger. And then liver-related, unrelated, pardon me, readmissions, that went up a little bit. But it's just interesting to see how it compared with that just purely nutrition-based education that was provided. And the second study, or another study, looked at targets to improve quality care for patients with hepatic encephalopathy. So we know that hepatic encephalopathy, ascites, and GI bleeding probably are the most top, some of the top reasons why patients come back in. And so in thinking about this, this is HE as a result, as a cause of readmission, and whether or not they were giving no treatment for their encephalopathy, or they were given encephalopathy, or they were given lactulose, rifaximin, or lactulose and rifaximin. And then looking at HE during the readmission and then what they were prescribed. So what's interesting is that, pardon me, let me find my mouse over here. It gets kind of crazy with this mouse. So the aim for this study was to define targets for improving quality of care in HE management in a multi-center study. Comparisons were made between patients on no therapy, lactulose only, rifaximin, and both. And then 90-day HE readmission analysis was looked at. Several targets were identified to improve HE management, and some of them included to reduce the incidence of medication-precipitated HE, so taking away those medications which may cause more confusion, like certain anti-nausea medications in the hospital. Sometimes Phenergan is used, or promethazine, or Xanax for anxiety, things like that we would definitely want to try to avoid in this specific patient population. So those are the kind of medication-precipitated things that it was referring to. Prevention of aspiration pneumonia and optimization of the HE medications, such as the lactulose and the rifaximin. In another study done by Tapper and associates, there was a quality improvement initiative that looked at how do we reduce 30-day rate of readmission for patients with cirrhosis. And some of the key takeaways that I found from this study was that all the patients who had a good outcome, they were given rifaximin. There was goal-driven therapy for overt HE, so specifically looking at, of course, every patient is different, and so one dose of lactulose for one person is not going to be the same dose that should be given to your next patient. So thinking about the individualized therapy, but then also goal-driven therapy. I have so many times patients in the hospital where our nursing staff have been trained and taught that if they have X amount of BMs, then we titrate their lactulose and we back off. And I take exception to that to some degree, because sometimes a patient still has a very distinct flap, they are still very, very confused, and they've had 12 valve movements in the past 24 hours. So in those cases, we can't just always look at the number of valve movements. We really have to take the whole picture into consideration. And so at that time, I try to do some more education and really hone in on what does the patient look like, and if they're still really out of their mind with confusion, then we do still need to onboard that lactulose even more. And so what are the goals with this patient? And so making sure that all the team members are involved with that and are on the same page with what the goals should be. And then timely treatment of SBP and then prophylaxis for those who meet criteria. So this one's kind of an exciting one that I like to share with associates and APPs. So this was another study done by Tapper. I am just really talking about him a lot, aren't I? But this was another one where he looked at the quality and outcomes of care provided to patients with cirrhosis by advanced practice providers. So what he did was he looked at screening for HCC, he looked at endoscopy screening for varices, and whether or not a patient was on rifaximin after discharge for HE. And interestingly, he found that with APP involvement, there was an improvement in care for the patient. So the results were that the patient would have more often would have HCC screening and have that box checked off. They had increased varice screening as appropriate per our practice guidelines. And there was a decrease in 30-day readmission. So I am a huge proponent of the care team model. And our physicians at our center, our nurse practitioners, PAs, nursing, we all have a piece to play in the care of our patients. And understanding your role within the care team is hugely important, and definitely, when done well and successfully, can improve the care of our patients and just help them be better. And so I think it works, and it can work. And I think that this article also definitely shows that, that that can and does happen. So what are some key takeaways that I would want to leave you with? So there are significant patient outcomes and significant health expenditure when thinking of readmission for the patient with cirrhosis. We need to think about ways of how to keep them out of the hospital. So not only how to keep them out of ICU, which the ICU care is very costly, but then also how to keep them out of the hospital. One thing that I've thought of that we haven't implemented at my center, but I hope one day that we will, is thinking about some sort of urgent care or care transition sort of model where we don't just automatically have a reflex of sending them to the ER to have the ER staff look at them, but we have some urgent care appointments within our transplant center where we can have them come in, see, do the diuretics just need to be adjusted? Do we need to talk about the fluid restriction a little bit more? Are there other ways that we can keep them out of the hospital without having that knee jerk reaction of sending them to the emergency room? And then know what you contribute to the practice. So again, citing some of these resources and things that are in the literature of specific outcomes of how you do contribute to your practice and things that you can learn to better do that and make those contributions. What quality initiatives can be done? Can you think about any sort of quality improvement project? Thinking about having encephalopathy patients or hospital readmission, or again, an education initiative like we talked about earlier. And we know that APPs engaged in the care of this population has proven to contribute to better patient outcomes. With that, I thank you.

hospital readmissions

liver disease

costs

risks

cirrhosis

substance abuse