Retrospective Cohort Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Oct 27, 2019; 11(10): 701-709
Published online Oct 27, 2019. doi: 10.4254/wjh.v11.i10.701
Impact on 30-d readmissions for cirrhotic patients with ascites after an educational intervention: A pilot study
Nicholas Lim, Otto Sanchez, Andrew Olson
Nicholas Lim, Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN 55455, United States
Otto Sanchez, Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN 55455, United States
Andrew Olson, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN 55455, United States
Author contributions: Lim N and Olson A designed the study; Lim N gathered the data; Sanchez O compiled figures and tables, and performed statistical analysis; Lim N and Olson A wrote the initial and final drafts of the manuscript; All authors have read and approved the final manuscript.
Institutional review board statement: This study was conducted with the approval of the institutional review board at the University of Minnesota, No. 1601S83245.
Informed consent statement: Due to its retrospective nature, informed consent was not required for this study.
Conflict-of-interest statement: The authors have no financial disclosures or conflicts-of-interest to declare.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at nlim@umn.edu. Informed consent was not required due to the retrospective nature of this study but all presented data are anonymized and risk of identification is low.
STROBE statement: The guidelines of the STROBE Statement have been adopted.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Nicholas Lim, MD, Assistant Professor, Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, 420 Delaware St SE, MMC 36, Minneapolis, MN 55455, United States. nlim@umn.edu
Telephone: +1-6-126258999
Received: June 17, 2019
Peer-review started: June 18, 2019
First decision: July 17, 2019
Revised: September 23, 2019
Accepted: October 2, 2019
Article in press: October 2, 2019
Published online: October 27, 2019
Abstract
BACKGROUND

A low proportion of patients admitted to hospital with cirrhosis receive quality care with timely paracentesis an important target for improvement. We hypothesized that a medical educational intervention, delivered to medical residents caring for patients with cirrhosis, would improve quality of care.

AIM

To determine if an educational intervention can improve quality of care in cirrhotic patients admitted to hospital with ascites.

METHODS

We performed a pilot prospective cohort study with time-based randomization over six months at a large teaching hospital. Residents rotating on hospital medicine teams received an educational intervention while residents rotating on hospital medicine teams on alternate months comprised the control group. The primary outcome was provision of quality care- defined as adherence to all quality-based indicators derived from evidence-based practice guidelines- in admissions for patients with cirrhosis and ascites. Patient clinical outcomes- including length of hospital stay (LOS); 30-d readmission; in-hospital mortality and overall mortality- and resident educational outcomes were also evaluated.

RESULTS

Eighty-five admissions (60 unique patients) met inclusion criteria over the study period-46 admissions in the intervention group and 39 admissions in the control group. Thirty-seven admissions were female patients, and 44 admissions were for alcoholic liver disease. Mean model for end-stage liver disease (MELD)-Na score at admission was 25.8. Forty-seven (55.3%) admissions received quality care. There was no difference in the provision of quality care (56.41% vs 54.35%, P = 0.9) between the two groups. 30-d readmission was lower in the intervention group (35% vs 52.78%, P = 0.1) and after correction for age, gender and MELD-Na score [RR = 0.62 (0.39, 1.00), P = 0.05]. No significant differences were seen for LOS, complications, in-hospital mortality or overall mortality between the two groups. Resident medical knowledge and self-efficacy with paracentesis improved after the educational intervention.

CONCLUSION

Medical education has the potential to improve clinical outcomes in patients admitted to hospital with cirrhosis and ascites.

Keywords: Cirrhosis, Education, Paracentesis, Quality

Core tip: Quality care remains relatively low in patients admitted to hospital with cirrhosis. Diagnostic paracentesis in patients with ascites has been identified as a target to improve quality in these patients. We developed and administered an educational intervention focused on paracentesis to medical residents caring for patients with cirrhosis using time-based randomization. After adjustment for model for end-stage liver disease-Na score, age and gender, patients in the intervention group had reduced 30-d readmissions. As health care costs rise, our results justify further study into the use of medical education to improve the delivery of quality care in patients with cirrhosis.