Department of Anesthesiology and Perioperative Medicine.
Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.
Liver Transpl. 2018 Oct;24(10):1398-1410. doi: 10.1002/lt.25055.
Cardiovascular disease (CVD) is a leading cause of post-liver transplant death, and variable care patterns may affect outcomes. We aimed to describe epidemiology and outcomes of inpatient CVD care across US hospitals. Using a merged data set from the 2002-2011 Nationwide Inpatient Sample and the American Hospital Association Annual Survey, we evaluated liver transplant patients admitted primarily with myocardial infarction (MI), stroke (cerebrovascular accident [CVA]), congestive heart failure (CHF), dysrhythmias, cardiac arrest (CA), or malignant hypertension. Patient-level data include demographics, Charlson comorbidity index, and CVD diagnoses. Facility-level variables included ownership status, payer-mix, hospital resources, teaching status, and physician/nursing-to-bed ratios. We used generalized estimating equations to evaluate patient- and hospital-level factors associated with mortality. There were 4763 hospitalizations that occurred in 153 facilities (transplant hospitals, n = 80). CVD hospitalizations increased overall by 115% over the decade (P < 0.01). CVA and MI declined over time (both P < 0.05), but CHF and dysrhythmia grew significantly (both P < 0.03); a total of 19% of hospitalizations were for multiple CVD diagnoses. Transplant hospitals had lower comorbidity patients (P < 0.001) and greater resource intensity including presence of cardiac intensive care unit, interventional radiology, operating rooms, teaching status, and nursing density (all P < 0.01). Transplant and nontransplant hospitals had similar unadjusted mortality (overall, 3.9%, P = 0.55; by diagnosis, all P > 0.07). Transplant hospitals had significantly longer overall length of stay, higher total costs, and more high-cost hospitalizations (all P < 0.05). After risk adjustment, transplant hospitals were associated with higher mortality and high-cost hospitalizations. In conclusion, CVD after liver transplant is evolving and responsible for growing rates of inpatient care. Transplant hospitals are associated with poor outcomes, even after risk adjustment for patient and hospital characteristics, which may be attributable to selective referral of certain patient phenotypes but could also be related to differences in quality of care. Further study is warranted.
心血管疾病（CVD）是肝移植后死亡的主要原因，不同的护理模式可能会影响结果。我们旨在描述美国医院住院患者 CVD 护理的流行病学和结果。我们使用 2002-2011 年全国住院患者样本和美国医院协会年度调查的合并数据集，评估了主要因心肌梗死（MI）、中风（脑血管意外[CVA]）、充血性心力衰竭（CHF）、心律失常、心脏骤停（CA）或恶性高血压入院的肝移植患者。患者水平数据包括人口统计学、Charlson 合并症指数和 CVD 诊断。设施水平变量包括所有权状况、支付者组合、医院资源、教学地位和医生/护士与床位比例。我们使用广义估计方程评估与死亡率相关的患者和医院水平因素。在 153 家医院（移植医院，n=80）共发生了 4763 例住院治疗。在这十年中，CVD 住院治疗总体增加了 115%（P<0.01）。随着时间的推移，CVA 和 MI 有所减少（均 P<0.05），但 CHF 和心律失常显著增加（均 P<0.03）；总共 19%的住院治疗是为了多种 CVD 诊断。移植医院的患者合并症较少（P<0.001），资源强度更大，包括心脏重症监护病房、介入放射学、手术室、教学地位和护理密度（均 P<0.01）。移植医院和非移植医院的未调整死亡率相似（总体为 3.9%，P=0.55；按诊断计算，均 P>0.07）。移植医院的总住院时间、总费用和高费用住院治疗均显著更长（均 P<0.05）。在风险调整后，移植医院与死亡率和高费用住院治疗相关。总之，肝移植后 CVD 不断发展，导致住院治疗率不断上升。即使在考虑患者和医院特征的风险调整后，移植医院也与较差的结果相关，这可能归因于某些患者表型的选择性转诊，但也可能与护理质量的差异有关。需要进一步研究。
