Winters Adam C, May Folasade P, Wang Yun, Shao Paul, Yang Liu, Patel Arpan A
Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA.
Drug Alcohol Depend Rep. 2021 Nov 17;1:100004. doi: 10.1016/j.dadr.2021.100004. eCollection 2021 Dec.
The burden of alcohol-associated liver disease (ALD) in the United States (US) has continued to worsen in the background of rising rates of alcohol use disorder. Patients with ALD present to care at a late stage, often with the sequela of liver decompensation, such as gastrointestinal bleeding and infection. ALD is now the leading indication for liver transplantation. We aimed to measure the quality of care delivered to hospitalized patients with alcoholic hepatitis (AH) across 3 domains: 1) alcohol-use disorder (AUD) care, 2) inpatient cirrhosis care, and 3) alcohol-associated liver disease (ALD) care-and observe associations between quality of care and outcomes.
We included hospital encounters between January 1, 2016 and January 1, 2019 to a large, diverse integrated health system for AH with active alcohol use within the prior 60 days. The diagnosis of AH was determined based on previously published clinical and laboratory criteria. Quality indicator (QI) pass rates were calculated as the proportion of patients eligible for each indicator who received the QI within the timeframe specified. We then evaluated the association between the receipt of all QIs and 6-month mortality, as well as AUD-specific QIs and 30-day readmission.
Of the 179 patients, the median age was 47 years-old, 59.2% were male and 49.2% were non-Hispanic White. The median Model for End-Stage Liver Disease-Sodium score was 25, while the median discriminant function was 33. Patients were followed for an average of 21 months. Overall, 14% of patients died during the index hospitalization while 17.3% died following discharge and 24.8% were re-admitted within 30-days. QI pass-rates were variable across the different domains. Few patients received AUD care-pass rates for receipt of pharmacotherapy and behavioral therapy at 6 months were only 19.1% and 35.1%, respectively. There was a significant association between receiving behavioral therapy and 6-month mortality-3% vs 18%, = 0.05.
The quality of care received during hospital encounters for AH is variable, and AUD-specific therapy is low. Future quality of care initiatives are warranted to link patients to AUD treatment to ensure optimal care and maximize patients survival in this at-risk population.
在美国,酒精使用障碍发病率上升的背景下,酒精性肝病(ALD)的负担持续加重。ALD患者往往在疾病晚期才就医,常伴有肝脏失代偿的后遗症,如胃肠道出血和感染。ALD目前是肝移植的主要指征。我们旨在衡量住院酒精性肝炎(AH)患者在三个领域接受的医疗质量:1)酒精使用障碍(AUD)护理;2)住院肝硬化护理;3)酒精性肝病(ALD)护理,并观察护理质量与结局之间的关联。
我们纳入了2016年1月1日至2019年1月1日期间,一家大型多元化综合医疗系统中,在过去60天内有活跃酒精使用的AH患者的住院病历。AH的诊断根据先前发表的临床和实验室标准确定。质量指标(QI)通过率计算为在指定时间范围内符合每个指标的患者中接受该QI的比例。然后,我们评估了所有QI的接受情况与6个月死亡率之间的关联,以及特定于AUD的QI与30天再入院率之间的关联。
179例患者中,中位年龄为47岁,59.2%为男性,49.2%为非西班牙裔白人。终末期肝病-钠评分中位数为25,判别函数中位数为33。患者平均随访21个月。总体而言,14%的患者在首次住院期间死亡,17.3%在出院后死亡,24.8%在30天内再次入院。不同领域的QI通过率各不相同。很少有患者接受AUD护理——6个月时接受药物治疗和行为治疗的通过率分别仅为19.1%和35.1%。接受行为治疗与六个月死亡率之间存在显著关联——分别为3%和18%,P = 0.05。
AH患者住院期间接受的护理质量参差不齐,且特定于AUD的治疗水平较低。未来有必要开展护理质量改进措施,将患者与AUD治疗联系起来,以确保为这一高危人群提供最佳护理并最大限度提高患者生存率。