Division of Gastroenterology and Hepatology, New York Presbyterian Hospital/Weill Cornell Medical College.
Department of Medicine, Memorial Sloan Kettering Cancer Center.
J Clin Gastroenterol. 2023 Oct 1;57(9):951-955. doi: 10.1097/MCG.0000000000001787.
Hospital admissions for patients with cirrhosis continue to increase. In New York City, 25% to 30% of hospitalized cirrhotics are readmitted within 30 days. Rehospitalization is associated with increased mortality, poor quality of life, and financial burden to patients, hospitals, and payers. Preventable readmissions are partially accounted for by a well-documented quality gap between evidence-based guidelines for cirrhosis management and real-world adherence to these recommendations.
We performed a prospective cohort study that compared outcomes among cirrhotic patients admitted to 4 internal medicine teams over a 6-month period. An electronic medical record (EMR) note template that outlined best-practice measures for cirrhotics was developed. Inpatient providers on 2 teams were instructed to include it in daily progress notes and discharge summaries. The recommended practices included diagnostic paracentesis and diuretics for ascites, rifaximin, and lactulose for hepatic encephalopathy, beta blockers for esophageal varices, and antibiotic prophylaxis for spontaneous bacterial peritonitis. The remaining 2 teams continued the standard of care for cirrhotic patients. The primary outcome was 30-day readmissions. Secondary outcomes included in-hospital mortality, 30-day mortality, length of stay, and adherence to best-practice guidelines.
Over a 6-month period, 108 cirrhotic patients were admitted, 83 in the interventional group and 25 in the control group. MELD-Na scores on admission did not differ between the groups (20.1 vs. 21.1, P =0.56). Thirty-day readmissions were not significantly different between the interventional and control groups (19.3% vs. 24%, P =0.61). However, 30-day mortality was significantly lower in the interventional group (8.4% vs. 28%, P =0.01). There was no difference between the 2 groups in in-hospital mortality (4.8% vs. 0%, P =0.27), 90-day mortality (15.7% vs. 28.0%, P =0.17) or length of stay (10.2 vs. 12.6 d, P =0.34). Adherence to best-practice metrics was similar between the groups, except for rates of diagnostic paracentesis, which were higher in the interventional group (98% vs. 80%, P =0.01).
Implementation of an EMR note template with cirrhosis best practices was associated with lower 30-day mortality and higher rates of diagnostic paracentesis among admitted patients with cirrhosis. These findings suggest that the integration of best-practice measures into the EMR may improve outcomes in hospitalized cirrhotic patients. Larger studies are required to validate these findings.
因肝硬化住院的患者人数持续增加。在纽约市，30%的肝硬化住院患者在 30 天内再次住院。再次住院与死亡率增加、生活质量下降以及患者、医院和支付方的经济负担有关。部分可预防的再次住院是由肝硬化管理循证指南与实际遵循这些建议之间存在的有据可查的质量差距造成的。
我们进行了一项前瞻性队列研究，比较了在 6 个月期间入住 4 个内科团队的肝硬化患者的结局。开发了一个电子病历（EMR）记录模板，概述了肝硬化患者的最佳实践措施。指导 2 个团队的住院医生将其纳入日常进度记录和出院小结。推荐的做法包括对腹水进行诊断性穿刺和利尿剂、肝性脑病使用利福昔明和乳果糖、食管静脉曲张使用β受体阻滞剂以及自发性细菌性腹膜炎使用抗生素预防。其余 2 个团队继续为肝硬化患者提供标准护理。主要结局是 30 天内再次住院。次要结局包括院内死亡率、30 天死亡率、住院时间和最佳实践指南的依从性。
在 6 个月期间，共收治了 108 例肝硬化患者，其中 83 例在干预组，25 例在对照组。两组入院时 MELD-Na 评分无差异（20.1 比 21.1，P=0.56）。干预组和对照组 30 天内再次住院率无显著差异（19.3%比 24%，P=0.61）。然而，干预组 30 天死亡率显著降低（8.4%比 28%，P=0.01）。两组院内死亡率无差异（4.8%比 0%，P=0.27）、90 天死亡率（15.7%比 28.0%，P=0.17）或住院时间（10.2 比 12.6 天，P=0.34）。两组最佳实践指标的依从性相似，除诊断性穿刺率外，干预组较高（98%比 80%，P=0.01）。
在肝硬化患者中实施带有肝硬化最佳实践的 EMR 记录模板与较低的 30 天死亡率和更高的诊断性穿刺率相关。这些发现表明，将最佳实践措施纳入 EMR 可能会改善住院肝硬化患者的结局。需要更大规模的研究来验证这些发现。
