Hospitalist/hepatologist comanagement best for chronic liver disease
FROM THE JOURNAL OF CLINICAL GASTROENTEROLOGY
Patients with chronic liver disease who are hospitalized for spontaneous bacterial peritonitis were more likely to be treated according to evidence-based guidelines if their care was comanaged by a hospitalist and a hepatologist, rather than the traditional approach, according to a report in the Journal of Clinical Gastroenterology.
In a study comparing outcomes before the implementation of a hospitalist/hepatologist comanagement program with those afterward at one medical center, the comanaged care improved adherence to a variety of recommendations, such as performing diagnostic paracentesis within 24 hours, administering albumin appropriately, and providing ongoing peritonitis prophylaxis at discharge, said Dr. Archita P. Desai of the section of gastroenterology, hepatology, and nutrition, University of Chicago Medical Center, and her associates.
"No study to date has evaluated the quality of comanaged hospitalist care for complex medical subspecialty patients," they noted.
Dr. Desai and her colleagues performed a chart review of 56 adults with chronic liver disease (CLD) who were admitted either during the 2 years before the comanagement program was implemented (January 2004 through June 2006) or the 4 years afterward (July 2006 through December 2010). A total of 26 patients received conventional care during the earlier period, and 30 received joint care under the new comanagement program during the latter.
The two study groups were similar regarding patient age, sex, race, etiology of cirrhosis, serum bilirubin levels, serum INR (international normalized ratio), end-stage liver disease scores, and percentage with bacteremia and/or variceal hemorrhage.
With the comanagement program, patients were admitted to a hepatology unit by a hospitalist team comprising an academic hospitalist and several nurse practitioners and physician assistants. The hepatology team included a hepatologist, a gastroenterology fellow, and internal medicine residents and medical students rotating through the unit.
Both teams evaluated patients separately but met for daily "sit-down" rounds in the early afternoon to discuss the cases.
Patients in the new program were significantly more likely to undergo paracentesis within 24 hours (100% vs. 79%), to receive albumin appropriately while hospitalized (97% vs. 65%), and to receive at discharge medication to prevent further peritonitis (91% vs. 32%).
Patients under comanagement also were less likely to receive fresh-frozen plasma, which is contraindicated, and more likely to have antibiotic therapy initiated within 6 hours of presentation (J. Clin. Gastroenterol. 2013 [doi:10.1097/MCG.0b013e3182a87f70]).
The two groups were similar regarding other processes of care such as the choice of appropriate antibiotics, the use of DVT prophylaxis while confined to bed, and the offer of pneumococcal vaccination at discharge.
There was a statistical trend, which did not reach significance, for comanaged patients to have a lower rate of transfer to an ICU (27% vs 17%). Similarly, there was a nonsignificant trend toward a lower inpatient mortality with comanaged 13%) than with conventional (27%) care.
Mortality at 30 days after discharge also was lower after comanagement than conventional care (0% vs 5.3%). However, this trend also didn’t reach statistical significance because 30-day mortality data were missing for a substantial number of patients in both study groups.
"We speculate that the close interactions between the primary inpatient team and the hepatology team during formal daily rounds facilitated structured communication between the hospitalist and the hepatology teams, and likely played a significant role in the intervention," Dr. Desai and her associates said.
In addition, comanagement allowed the hepatology team to be more involved with detailed discharge planning specifically related to liver disease, "which in turn improves transition to outpatient care, a time of vulnerability for these complex patients," they said.
Both the length of stay and the total cost of hospitalization tended to be higher under the comanagement program. However, "overall care may be more cost-effective after considering variables such as improved access to specialty-specific resources in the short term and the prospect of increasing transplantation rates earlier in the course of disease, which in the long term leads to the prevention of costly complications," the investigators noted.
This study was supported by the University of Chicago’s Liver Research Fund. No financial conflicts of interest were reported.