Hospital Readmissions in Patients with Cirrhosis: A Systematic Review

Statistical Analysis

Analyses were performed using Stata 13.1 (StataCorp LP, College Station, Texas). We determined the pooled proportion of patients with 30-day readmission using a random-effects model, with the Freeman–Tukey double-arcsine transformation for meta-analysis of proportions.¹² We investigated the heterogeneity by stratifying analyses according to prespecified study characteristics, including “broad” versus “focused.” However, the readmission risk was not different in the stratified analysis; therefore, we chose to pool the findings. For point estimates, 95% confidence intervals (CIs) were calculated, and a P-value < .05 was considered statistically significant.

RESULTS

Search Results

The initial search yielded 1363 records, of which 173 full-text articles were assessed for eligibility. Twenty-seven articles representing 26 studies of 180,049 patients were included (Figure 1).^13-39

Study Characteristics

Two studies were performed in Australia, 4 in Europe, and the remainder in North America. Twenty one of the 26 studies were retrospective cohort studies (Table 1). Twenty studies were single-center studies (of which half were performed at transplant centers), and 4 of the 6 multicenter studies were based on administrative data with large samples (173,254 patients). The inclusion/exclusion criteria varied widely (Supplementary Material). Some studies only included patients admitted for specific cirrhosis complications, while others included those admitted for any reason. Two studies excluded patients admitted in the prior 30 days, and 6 excluded patients discharged to hospice. The mean risk of bias score was 7.5 (SD 1.3) out of a possible 9 points, with most lacking an adequate description of follow-up and several lacking adjustment for confounders.

The mean age of patients ranged from 53 to 65 years, and males comprised 56%–78% (except for 4 Veterans Affairs studies). The mean MELD score ranged from 12 to 23. Hepatitis C accounted for 14%–100% of cirrhosis, alcohol accounted for 25%–67%, and nonalcoholic fatty liver disease accounted for 0%–20%. Hepatocellular carcinoma was present in 6%–30% of the patients. Reasons for the index admission varied widely and were dependent on the inclusion/exclusion criteria.

Outcomes

Thirty-day readmissions ranged from 10% to 50%, with a pooled estimate of 26% (95% CI, 22%-30%; Figure 2). Five studies reported 90-day readmissions, ranging from 21% to 71%.^{29,31,33,35,36} Only 4 of the 20 single-center studies captured readmissions at centers aside from the index admission hospital. Two studies assessed readmission preventability: 1 through independent chart review by 2 physicians (22% preventable), the other based on the judgement of 1 physician (37%).^16,26 Reasons for readmission were reported in 12 studies and were highly variable: hepatic encephalopathy in 6%–100%, ascites/volume overload in 2%–38%, and decompensated liver disease (without further elaboration) in 25%–100%. The studies that focused on single risk factors or interventions reported a wide range of possible readmission risk factors, ranging from biomarkers to clinical processes of care. Although multiple putative risk factors were reported, few conclusions can be drawn due to the heterogeneity in the findings. In 5 studies, 90-day mortality was reported and ranged from 10.3% to 18.6%. The relationship between readmission and subsequent mortality was examined in 5 studies, and all were statistically significant.^{14,16,20,33,38}

Readmission and MELD

The MELD score was examined in numerous studies as a risk factor for readmissions and was found to be significantly associated with readmission in most studies (Table 2). Notably, even small differences in the MELD score are associated with a higher risk for readmission, though no cutoff point can be discerned. In addition, this association is seen regardless whether the MELD score is assessed at index admission or discharge. Several studies did not report the absolute differences in the MELD score listed in Table 2, but did find associations between increased MELD score and readmission in adjusted models.^16,20,27,34 One study found that a higher MELD score was associated with decreased readmissions over 6 months, but this study did not account for the competing risk of death.³⁷

DISCUSSION

Hospital readmission is a costly and common problem in the US.² In addition to the negative impact that readmissions have on patients’ lives,⁴⁰ readmissions are increasingly being used to measure quality. Unplanned 30-day readmissions are posted publicly, and excess readmissions for high-risk conditions are penalized through HRRP.³ Although HRRP does not currently include cirrhosis, the program has expanded to include several conditions that were not included in the initial iteration. Whether cirrhosis will be included in future iterations remains to be seen; however, increasing scrutiny is likely to continue. Of specific populations at risk, patients with cirrhosis are particularly vulnerable due to several features. Ascites management often requires hospitalization due to diuretic titration and poor access to paracentesis, and hepatic encephalopathy treatment requires complex lactulose titration.¹⁶ Other features of cirrhosis, such as gastrointestinal bleeding, infections, and renal failure, also place patients at risk of poor outcomes. The resulting readmission burden is high, with a pooled 30-day readmission rate of 26%. Other associated outcomes are also poor, with a consistent relationship between readmission and subsequent mortality.