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Abstract Details
Underutilization of Hospice in Inpatients with Cirrhosis: The NACSELD Experience
Dig Dis Sci. 2020 Mar 7. doi: 10.1007/s10620-020-06168-8. Online ahead of print.
Jacqueline G O'Leary12, Puneeta Tandon3, K Rajender Reddy4, Scott W Biggins5, Florence Wong6, Patrick S Kamath7, Guadalupe Garcia-Tsao8, Benedict Maliakkal9, Jennifer Lai10, Michael Fallon11, Hugo E Vargas12, Paul Thuluvath13, Ram Subramanian14, Leroy R Thacker15, Jasmohan S Bajaj16
Author information
1Department of Medicine, Dallas VA Medical Center, Dallas, TX, USA. dr_jackieo@yahoo.com.
2Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA. dr_jackieo@yahoo.com.
3Department of Medicine, University of Alberta, Edmonton, AB, Canada.
4Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
5Department of Medicine, University of Washington, Seattle, WA, USA.
6Department of Medicine, University of Toronto, Toronto, ON, Canada.
7Department of Medicine, Mayo Clinic, Rochester, MN, USA.
8Department of Medicine, Yale University, New Haven, CT, USA.
9Department of Medicine, University of Rochester, Rochester, NY, USA.
10Department of Medicine, University of California, San Francisco, CA, USA.
11Department of Medicine, University of Texas, Health Science Center, Houston, TX, USA.
12Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA.
13Department of Medicine, Mercy Medical Center, University of Maryland School of Medicine, Baltimore, MD, USA.
14Department of Medicine, Emory University, Atlanta, GA, USA.
15Department of Biostatistics, McGuire VA Medical Center, Virginia Commonwealth University, Richmond, VA, USA.
16Department of Medicine, McGuire VA Medical Center, Virginia Commonwealth University, Richmond, VA, USA
Abstract
Background: Little is known about patients discharged to hospice following hospitalization for complications of cirrhosis.
Aim: We sought to understand the current pattern of hospice utilization in patients with cirrhosis by evaluating the North American Consortium for the Study of End-stage Liver Disease (NACSELD) cohort.
Methods: Patients with cirrhosis from 14 tertiary-care hepatology centers across North America non-electively hospitalized and prospectively enrolled were evaluated. Exclusion criteria included HIV infection, transplantation or non-hepatic malignancy. Random computer-based propensity score matching was undertaken in a 1:2 ratio based on admission MELD score ± 3 points.
Results: Totally, 2718 patients were enrolled, 5% (N = 132) were discharged to hospice, 6% (N = 171) died, and the rest were discharged alive. Patients discharged to hospice were older (60 vs. 57 years, p = 0.04), less likely to have had SBP (13% vs. 28%, p = 0.002) and be listed for liver transplantation (11% vs. 26%, p = 0.0007). Features, on multivariable modeling, associated with increased probability of discharge to hospice as opposed to being discharged alive: grade-3-4 hepatic encephalopathy, a higher Child-Turcotte-Pugh (CTP) score, and a higher discharge serum creatinine; however, a higher serum sodium, being listed for transplant and being prescribed rifaximin or a statin were protective from hospice discharge.
Conclusion: Patients with more advanced liver disease, hepatic encephalopathy, renal dysfunction, and those not candidates for liver transplantation were more likely to be discharged to hospice. However, in this sick multinational cohort of cirrhotic inpatients, it seems that hospice is markedly underutilized (5%) since 25% of patients not discharged to hospice died within 6 months.