Targets to improve quality of care for patients with hepatic encephalopathy: data from a multi-centre cohort

Jasmohan S. Bajaj, Jacqueline G. O’Leary, Puneeta Tandon, Florence Wong, Patrick Sequeira Kamath, Scott W. Biggins, Guadalupe Garcia-Tsao, Jennifer Lai, Michael B. Fallon, Paul J. Thuluvath, Hugo E Vargas, Benedict Maliakkal, Ram M. Subramanian, Leroy R. Thacker, K. Rajender Reddy

Research output: Contribution to journalArticle

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Abstract

Background: Hepatic encephalopathy (HE) can adversely affect outcomes in both in-patients and out-patients with cirrhosis. Aim: To define targets for improving quality of care in HE management in the multi-centre North American Consortium for End-Stage Liver Disease (NACSELD) cohort. Method: NACSELD in-patient cohort was analysed for (a) medication-associated precipitants, (b) aspiration pneumonia development, (c) HE medication changes, and (d) 90-day HE recurrence/readmissions. Comparisons were made between patients on no-therapy, lactulose only, rifaximin only or both. Ninety-day HE-readmission analysis was adjusted for MELD score. Results: Two thousand eight hundred and ten patients (1102 no-therapy, 659 lactulose, 154 rifaximin, 859 both) were included. HE on admission, and HE rates during hospitalisation were highest in those on lactulose only or dual therapy compared to no-therapy or rifaximin only (P < 0.001). Medications were the most prevalent precipitants (32%; 21% lactulose over/underuse, 5% benzodiazepines, 4% opioids, 1% rifaximin underuse, 1% hypnotics). Patients with medication-associated precipitants had a better prognosis compared to other precipitants. A total of 23% (n = 217) reached grade 3/4 HE, of which 16% developed HE-related aspiration pneumonia. Two thousand four hundred and twenty patients were discharged alive without liver transplant (790 no-therapy, 639 lactulose, 136 rifaximin, 855 both); 12.5% (n = 99) of no-therapy patients did not receive a discharge HE therapy renewal. Ninety-day HE-related readmissions were seen in 16% of patients (9% no-therapy, 9% rifaximin only, lactulose only 18%, dual 21%, <0.001), which persisted despite MELD adjustment (P = 0.009). Conclusion: Several targets to improve HE management were identified in a large cohort of hospitalised cirrhotic patients. Interventions to decrease medication-precipitated HE, prevention of aspiration pneumonia, and optimisation of HE medications are warranted.

Original languageEnglish (US)
JournalAlimentary Pharmacology and Therapeutics
DOIs
StatePublished - Jan 1 2019

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Hepatic Encephalopathy
Quality of Health Care
rifaximin
Lactulose
Aspiration Pneumonia
End Stage Liver Disease
Therapeutics
Hypnotics and Sedatives
Benzodiazepines
Opioid Analgesics

ASJC Scopus subject areas

  • Hepatology
  • Gastroenterology
  • Pharmacology (medical)

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Targets to improve quality of care for patients with hepatic encephalopathy : data from a multi-centre cohort. / Bajaj, Jasmohan S.; O’Leary, Jacqueline G.; Tandon, Puneeta; Wong, Florence; Kamath, Patrick Sequeira; Biggins, Scott W.; Garcia-Tsao, Guadalupe; Lai, Jennifer; Fallon, Michael B.; Thuluvath, Paul J.; Vargas, Hugo E; Maliakkal, Benedict; Subramanian, Ram M.; Thacker, Leroy R.; Reddy, K. Rajender.

In: Alimentary Pharmacology and Therapeutics, 01.01.2019.

Research output: Contribution to journalArticle

Bajaj, JS, O’Leary, JG, Tandon, P, Wong, F, Kamath, PS, Biggins, SW, Garcia-Tsao, G, Lai, J, Fallon, MB, Thuluvath, PJ, Vargas, HE, Maliakkal, B, Subramanian, RM, Thacker, LR & Reddy, KR 2019, 'Targets to improve quality of care for patients with hepatic encephalopathy: data from a multi-centre cohort', Alimentary Pharmacology and Therapeutics. https://doi.org/10.1111/apt.15265
Bajaj, Jasmohan S. ; O’Leary, Jacqueline G. ; Tandon, Puneeta ; Wong, Florence ; Kamath, Patrick Sequeira ; Biggins, Scott W. ; Garcia-Tsao, Guadalupe ; Lai, Jennifer ; Fallon, Michael B. ; Thuluvath, Paul J. ; Vargas, Hugo E ; Maliakkal, Benedict ; Subramanian, Ram M. ; Thacker, Leroy R. ; Reddy, K. Rajender. / Targets to improve quality of care for patients with hepatic encephalopathy : data from a multi-centre cohort. In: Alimentary Pharmacology and Therapeutics. 2019.
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abstract = "Background: Hepatic encephalopathy (HE) can adversely affect outcomes in both in-patients and out-patients with cirrhosis. Aim: To define targets for improving quality of care in HE management in the multi-centre North American Consortium for End-Stage Liver Disease (NACSELD) cohort. Method: NACSELD in-patient cohort was analysed for (a) medication-associated precipitants, (b) aspiration pneumonia development, (c) HE medication changes, and (d) 90-day HE recurrence/readmissions. Comparisons were made between patients on no-therapy, lactulose only, rifaximin only or both. Ninety-day HE-readmission analysis was adjusted for MELD score. Results: Two thousand eight hundred and ten patients (1102 no-therapy, 659 lactulose, 154 rifaximin, 859 both) were included. HE on admission, and HE rates during hospitalisation were highest in those on lactulose only or dual therapy compared to no-therapy or rifaximin only (P < 0.001). Medications were the most prevalent precipitants (32{\%}; 21{\%} lactulose over/underuse, 5{\%} benzodiazepines, 4{\%} opioids, 1{\%} rifaximin underuse, 1{\%} hypnotics). Patients with medication-associated precipitants had a better prognosis compared to other precipitants. A total of 23{\%} (n = 217) reached grade 3/4 HE, of which 16{\%} developed HE-related aspiration pneumonia. Two thousand four hundred and twenty patients were discharged alive without liver transplant (790 no-therapy, 639 lactulose, 136 rifaximin, 855 both); 12.5{\%} (n = 99) of no-therapy patients did not receive a discharge HE therapy renewal. Ninety-day HE-related readmissions were seen in 16{\%} of patients (9{\%} no-therapy, 9{\%} rifaximin only, lactulose only 18{\%}, dual 21{\%}, <0.001), which persisted despite MELD adjustment (P = 0.009). Conclusion: Several targets to improve HE management were identified in a large cohort of hospitalised cirrhotic patients. Interventions to decrease medication-precipitated HE, prevention of aspiration pneumonia, and optimisation of HE medications are warranted.",
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T1 - Targets to improve quality of care for patients with hepatic encephalopathy

T2 - data from a multi-centre cohort

AU - Bajaj, Jasmohan S.

AU - O’Leary, Jacqueline G.

AU - Tandon, Puneeta

AU - Wong, Florence

AU - Kamath, Patrick Sequeira

AU - Biggins, Scott W.

AU - Garcia-Tsao, Guadalupe

AU - Lai, Jennifer

AU - Fallon, Michael B.

AU - Thuluvath, Paul J.

AU - Vargas, Hugo E

AU - Maliakkal, Benedict

AU - Subramanian, Ram M.

AU - Thacker, Leroy R.

AU - Reddy, K. Rajender

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Background: Hepatic encephalopathy (HE) can adversely affect outcomes in both in-patients and out-patients with cirrhosis. Aim: To define targets for improving quality of care in HE management in the multi-centre North American Consortium for End-Stage Liver Disease (NACSELD) cohort. Method: NACSELD in-patient cohort was analysed for (a) medication-associated precipitants, (b) aspiration pneumonia development, (c) HE medication changes, and (d) 90-day HE recurrence/readmissions. Comparisons were made between patients on no-therapy, lactulose only, rifaximin only or both. Ninety-day HE-readmission analysis was adjusted for MELD score. Results: Two thousand eight hundred and ten patients (1102 no-therapy, 659 lactulose, 154 rifaximin, 859 both) were included. HE on admission, and HE rates during hospitalisation were highest in those on lactulose only or dual therapy compared to no-therapy or rifaximin only (P < 0.001). Medications were the most prevalent precipitants (32%; 21% lactulose over/underuse, 5% benzodiazepines, 4% opioids, 1% rifaximin underuse, 1% hypnotics). Patients with medication-associated precipitants had a better prognosis compared to other precipitants. A total of 23% (n = 217) reached grade 3/4 HE, of which 16% developed HE-related aspiration pneumonia. Two thousand four hundred and twenty patients were discharged alive without liver transplant (790 no-therapy, 639 lactulose, 136 rifaximin, 855 both); 12.5% (n = 99) of no-therapy patients did not receive a discharge HE therapy renewal. Ninety-day HE-related readmissions were seen in 16% of patients (9% no-therapy, 9% rifaximin only, lactulose only 18%, dual 21%, <0.001), which persisted despite MELD adjustment (P = 0.009). Conclusion: Several targets to improve HE management were identified in a large cohort of hospitalised cirrhotic patients. Interventions to decrease medication-precipitated HE, prevention of aspiration pneumonia, and optimisation of HE medications are warranted.

AB - Background: Hepatic encephalopathy (HE) can adversely affect outcomes in both in-patients and out-patients with cirrhosis. Aim: To define targets for improving quality of care in HE management in the multi-centre North American Consortium for End-Stage Liver Disease (NACSELD) cohort. Method: NACSELD in-patient cohort was analysed for (a) medication-associated precipitants, (b) aspiration pneumonia development, (c) HE medication changes, and (d) 90-day HE recurrence/readmissions. Comparisons were made between patients on no-therapy, lactulose only, rifaximin only or both. Ninety-day HE-readmission analysis was adjusted for MELD score. Results: Two thousand eight hundred and ten patients (1102 no-therapy, 659 lactulose, 154 rifaximin, 859 both) were included. HE on admission, and HE rates during hospitalisation were highest in those on lactulose only or dual therapy compared to no-therapy or rifaximin only (P < 0.001). Medications were the most prevalent precipitants (32%; 21% lactulose over/underuse, 5% benzodiazepines, 4% opioids, 1% rifaximin underuse, 1% hypnotics). Patients with medication-associated precipitants had a better prognosis compared to other precipitants. A total of 23% (n = 217) reached grade 3/4 HE, of which 16% developed HE-related aspiration pneumonia. Two thousand four hundred and twenty patients were discharged alive without liver transplant (790 no-therapy, 639 lactulose, 136 rifaximin, 855 both); 12.5% (n = 99) of no-therapy patients did not receive a discharge HE therapy renewal. Ninety-day HE-related readmissions were seen in 16% of patients (9% no-therapy, 9% rifaximin only, lactulose only 18%, dual 21%, <0.001), which persisted despite MELD adjustment (P = 0.009). Conclusion: Several targets to improve HE management were identified in a large cohort of hospitalised cirrhotic patients. Interventions to decrease medication-precipitated HE, prevention of aspiration pneumonia, and optimisation of HE medications are warranted.

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