Published online Aug 27, 2019. doi: 10.4254/wjh.v11.i8.646
Peer-review started: January 29, 2019
First decision: March 3, 2019
Revised: June 12, 2019
Accepted: July 4, 2019
Article in press: July 5, 2019
Published online: August 27, 2019
Given the increasing concern about the high rates of readmission in cirrhotic patients (CP) after hospital discharge (HD), focus is now being laid on transitional care interventions to try to mediate a reduction. However, prior studies have also demonstrated a possible adverse impact on patient survival with reduced readmissions. Hence additional studies to comprehensively assess post discharge outcomes in CP and to try to improve them are necessary.
It is alarming but true that nearly 53% of CP get readmitted at least once within 3 mo of HD. This implies a tremendous financial and psychosocial burden to our current healthcare system and measures to improve the prognosis of patients after HD warrant attention.
We developed and evaluated a novel strategy for the care of CP at our center called the outpatient telephonic transitional care program (OTTC). The objectives of this study were to determine the effect of OTTC on survival and readmission rates (RR) at different intervals up to 6 mo after HD in CP and thus further explore the relationship of RR to survival.
In this observational study, CP who were treated in our inpatient hepatology service between March 1 and December 31, 2016 were retrospectively assessed. Those who had received the OTTC program formed the intervention arm, and the rest formed concomitant controls. Survival and RR at 1, 3, and 6 mo after HD were compared between the two groups.
In our study, an overall RR of 55% was noted within 3 mo of HD, which correlates with the national average. Interestingly the RR at 1, 3, and 6 mo were comparable between the intervention and control groups. However, the patients who received the OTTC intervention showed markedly better 6 mo survival compared to the controls with a hazard ratio of 0.4 (95% confidence interval: 0.2-0.82; P = 0.012).
In this study, we demonstrated the beneficial impact of a novel transitional care intervention program that provided a survival benefit to CP after HD. In addition, we highlighted an important dissociation between RR and survival, thus shedding further light on the importance of focusing on survival rather than RR as an outcome while assessing post discharge outcomes in CP. Given the high burden on hospitalizations for CP, our novel and easy to implement intervention may now be adopted at multiple centers to further assess its impact and provide improved care for CP.
Our results reaffirm that CP remain at significant risk for readmission and mortality after HD. A focus on providing appropriate transitional care is essential to improve post discharge outcomes. The OTTC program we describe is minimally resource intensive and can afford a survival benefit to CP. The tenets of the OTTC program should be further explored and assessed in other institutions and settings. Continued emphasis on survival rather than RR is warranted because CP demonstrated a dissociation between these parameters.