Hospital Readmissions in Patients with Cirrhosis: A Systematic Review

Cirrhosis is a morbid condition characterized by complications such as ascites, gastrointestinal bleeding, and hepatic encephalopathy. These complications frequently require hospitalization, which is a substantial burden to the healthcare system. In 2012, liver disease was responsible for nearly 250,000 admissions across the United States, costing $3 billion.¹ Despite this substantial resource utilization, outcomes remain poor, with an inpatient mortality of 6%. For those that survive, many experience hospital readmission.

More generally, early readmission reflects poor quality of care in the US. In 2004, 30-day readmissions occurred in nearly 20% of Medicare beneficiaries and costed over $17 billion.² In response to this problem, the Affordable Care Act established the Hospital Readmissions Reduction Program (HRRP), which reduces Centers for Medicare & Medicaid Services (CMS) payments to hospitals with excess 30-day readmissions for high-risk conditions, including pneumonia and heart failure.³ Heart failure, in particular, has been the subject of numerous studies detailing risk factors and interventions to predict and prevent readmission.^4-6 Based on this extensive evidence, guidelines recommend disease management programs to reduce readmissions in this population.⁷ In contrast, readmission in the cirrhosis population has received limited attention.

We therefore conducted a systematic review aiming to examine the range of readmission risk noted in the literature, with a focus on the model for end-stage liver disease (MELD) score as a risk factor for readmission.

Search Strategy

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for conducting and reporting systematic reviews.⁸ A literature search was performed by a medical librarian using the following databases: Ovid MEDLINE, PubMed, EMBASE, CINAHL, the full Cochrane Library, Scopus, Google Scholar, and ClinicalTrials.gov. All the databases were searched from 2000 to May 2017. We did not include older reports because the review focused on contemporary care; earlier studies may not reflect current cirrhosis management. To ensure literature saturation, included articles’ reference lists were reviewed.

Search strategies were developed by combining database-specific subject headings and keywords for readmissions with those for cirrhosis or its complications (Supplementary Material). Google Scholar and ClinicalTrials.gov were searched using keywords only. All results were limited to the English language and those published in 2000 or later, but no other limits were applied.

Identified records were reviewed based on strict criteria. We excluded case reports, case series, reviews, editorials, letters, and meeting abstracts without final peer-reviewed publication. We also excluded studies of pediatric populations (age < 18 years), patients without cirrhosis, and patients with liver transplants. We excluded studies in which patients were not hospitalized at study onset and those where the index admission was for an elective procedure. Because our interest was to identify factors associated with early readmission, we excluded studies that did not report readmissions within 90 days or those with a mean or median follow-up of less than 30 days. We also excluded studies that did not examine the association between readmission and at least 1 independent variable or intervention. Duplicate reports of a common sample were excluded unless the duplicate provided additional information, and such reports were examined together in our synthesis.

Two authors identified potentially eligible records by independently screening titles and abstracts. At this stage, records that did not meet the eligibility criteria were excluded, and the reasons for exclusion were not recorded. Records with disagreement were retained for full-text review. After this initial exclusion of records, the remaining full-text records were reviewed independently. For this full-text review, we recorded exclusion reasons and disagreements were resolved through discussion.

Data Collection

Data were abstracted from each study by 2 authors independently and recorded in a REDCap database.⁹ Discrepancies were resolved through discussion. We recorded study characteristics, including study design, setting, population (including the inclusion/exclusion criteria, sample size, and patient and hospitalization characteristics), interventions, and comparisons. To facilitate comparisons across studies, we employed validated methods to approximate means and standard deviations (SD).¹⁰ We recorded detailed information on outcomes including readmissions, preventability, independent variables, and mortality. Studies that focused on a single independent factor or intervention were classified as “focused,” while those that examined multiple factors were classified as “broad.” We used the Newcastle–Ottawa Scale to assess the risk of bias in each study.¹¹ This instrument uses a 9-point scale to gauge methodological quality based on selection, group comparability, and exposure/outcome assessment.