Liver Cirrhosis: Inpatient Mortality Is Decreasing

Lara C. Pullen, PhD

April 24, 2015

Inpatient mortality among patients with cirrhosis has steadily decreased in the United States from 2002 to 2010, despite increases in patient age and medical complexity. Improvements in cirrhosis care that may be specifically related to enhanced interventions for cirrhosis may explain this decrease, according to a new study. Although the study examined mortality for inpatients, mortality among outpatients with cirrhosis is unclear.

Monica L. Schmidt, MPH, from the University of North Carolina Liver Center in Chapel Hill, and colleagues published their analysis of hospitalizations in the May issue of Gastroenterology. They evaluated 781,515 representative hospitalizations of patients with cirrhosis.

The researchers compared data from the patients with cirrhosis with data from equal numbers of hospitalizations of those without cirrhosis and patients with congestive heart failure (CHF), who were matched for age, sex, and discharge year.

The researchers obtained the data from the Healthcare Cost and Utilization Project, National Inpatient Sample. The database was limited by its inability to identify individual patients who were readmitted. The investigators also note that International Classification of Diseases, Ninth Revision, Clinical Modification codes can be inaccurate, especially for liver-related codes other than cirrhosis.

"Nonetheless, our study represents outcomes of a large sampling of hospitalized cirrhotic patients and spans a nation over nearly a decade. The improving inpatient survival despite aging and more medically complex cirrhotic patients is remarkably consistent across several cirrhosis complications and suggests improving cirrhosis care that may extend beyond general improvements in inpatient care. On the other hand, sepsis had an increasing mortality risk, suggesting that cirrhotic patients may need a more tailored approach to sepsis," the authors write.

The inpatient mortality rate decreased over time across all age groups, in patients with and without cirrhosis, and in those with CHF. The absolute decrease in mortality was significantly greater for patients with cirrhosis (from 9.1% to 5.4%) than for those without cirrhosis (from 2.6% to 2.1%) and those with CHF (from 2.5% to 1.4%) (P < .01).

The relative decreases were similar for patients with cirrhosis (41%) and patients with CHF (44%).

After adjustment for comorbidities and length of stay less than 2 days, the independent mortality risk ratio for patients with cirrhosis decreased steadily to 0.50 by 2010 (95% confidence interval [CI], 0.48 - 0.52), despite the patients' increasing age and comorbidities.

Patients With Sepsis Fare Much Worse

The independent mortality risk for sepsis (risk ratio [RR], 4.70; 95% CI, 4.61 - 4.79), however, increased over time and eventually surpassed the risk related to hepatorenal syndrome (HRS) (RR, 3.39; 95% CI, 3.31 - 3.47).

"Cirrhosis patients have particularly poor hemodynamic reserve, with wider perturbations in immune inflammatory and compensatory responses that could hinder survival. Therefore, it is possible that cirrhosis patients are doing much worse with sepsis compared with other patients," the authors explain.

"The surviving sepsis campaign may need guidelines that specifically target cirrhosis patients."

The investigators also describe a noteworthy increase in palliative discharges, from 0.4% in 2002 to 1.7% in 2010 (P < .05).

"Not Possible to Establish Conclusively a Causal Relationship"

The results are consistent with those of previous smaller studies indicating improved survival of patients with cirrhosis over time. A contributing factor may be the fact that several guidelines and reviews published over the past 10 to 15 years have articulated best practice for the management of HRS, spontaneous bacterial peritonitis, variceal bleeds, and hepatocellular carcinoma. The investigators note, however, that they could not find a link between cirrhosis-specific interventions and improved outcomes in their data set.

"[I]t is not possible to establish conclusively a causal relationship between improving cirrhosis-specific care and decreasing in-hospital mortality from this study," Fasiha Kanwal, MD, MSHS, from Baylor College of Medicine in Houston, Texas, writes in an accompanying editorial.

"For example, with the exception of timely paracentesis, the study did not find any associations between receipt of cirrhosis-specific interventions and declining mortality. It is plausible (and perhaps more likely) that the decrease in cirrhosis in-hospital mortality actually represents an improvement in the overall diagnostic and therapeutic care in general and intensive/critical care in particular."

"Others have reported similar temporal decreases in in-hospital mortality in patients admitted for chronic obstructive pulmonary disease, stroke, and upper gastrointestinal bleeding, suggesting that the care of all in-patients, particularly those with serious medical conditions (including those with cirrhosis), might have improved over time," Dr Kanwal explains.

It's also possible that shortened hospital stays have resulted in patients dying outside the hospital, Dr. Kanwal notes.

"[T]he finding that patients with cirrhosis are far more likely to leave the hospital alive now than 10 years ago is welcome news. Yet, there remains much room for improvement. Patients with cirrhosis are 3-4 times more likely to die as in-patients than those with heart failure," Dr Kanwal writes.

The authors conclude by suggesting that further improvements may require a focus on sepsis with increased use of proven therapies as well as the development of new treatments.

The study authors and Dr Kanwal have disclosed no relevant financial relationships.

Gastroenterology. 2015;148:967-977. Abstract

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