title: Predicting the discharge status after liver transplantation at a single center: a new approach for a new era.
abstract: The aim of this study was to develop a tool for preoperatively predicting the need of a patient to attend an extended care facility after orthotopic liver transplantation (OLT). A multidisciplinary group, which included 2 transplant surgeons, 2 transplant nurses, 1 nurse manager, 2 physical therapists, 1 case manager, 1 home health care professional, 1 rehabilitation physician, and 1 statistician, met to identify preoperative factors relevant to discharge planning. The parameters that were examined as potential predictors of the discharge status were as follows: age, sex, language, Karnofsky score, OLT alone (versus a combined procedure), creatinine, bilirubin, international normalized ratio (INR), albumin, body mass index (BMI), Child-Turcotte-Pugh score, chemical Model for End-Stage Liver Disease score, renal dialysis, location before transplantation, comorbidities (encephalopathy, ascites, hydrothorax, and hepatopulmonary syndrome), diabetes mellitus (DM), cardiac ejection fraction and right ventricular systolic pressure, sex and availability of the primary caregiver, donor risk index, and donor characteristics. Between January 2004 and April 2010, 730 of 777 patients (94%) underwent only liver transplantation, and 47 patients (6%) underwent combined procedures. Five hundred nineteen patients (67%) were discharged home, 215 (28%) were discharged to a facility, and 43 (6%) died early after OLT. A multivariate logistic regression analysis identified the following parameters as significantly influencing the discharge status: a low Karnofsky score, an older age, female sex, an INR of 2.0, a creatinine level of 2.0 mg/dL, DM, a high bilirubin level, a low albumin level, a low or high BMI, and renal dialysis before OLT. The nomogram was prospectively validated with a population of 126 OLT recipients with a concordance index of 0.813. In conclusion, a new approach to improving the efficiency of hospital care is essential. We believe that this tool will aid in reducing lengths of stay and improving the experience of patients by facilitating early discharge planning.
authors.affiliation: Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA. kellyd@ccf.org
authors.forename: Dympna M
authors.initials: DM
authors.lastname: Kelly
authors.forename: Renee
authors.initials: R
authors.lastname: Bennett
authors.forename: Nancy
authors.initials: N
authors.lastname: Brown
authors.forename: Judy
authors.initials: J
authors.lastname: McCoy
authors.forename: Derek
authors.initials: D
authors.lastname: Boerner
authors.forename: Changhong
authors.initials: C
authors.lastname: Yu
authors.forename: Bijan
authors.initials: B
authors.lastname: Eghtesad
authors.forename: Wael
authors.initials: W
authors.lastname: Barsoum
authors.forename: John J
authors.initials: JJ
authors.lastname: Fung
authors.forename: Michael W
authors.initials: MW
authors.lastname: Kattan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D015992:Body Mass Index; D003266:Continuity of Patient Care; D058625:End Stage Liver Disease / Q000628:therapy*; D005260:Female; D006801:Humans; D033183:Interdisciplinary Communication; D016031:Liver Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D017146:Models, Organizational; D010351:Patient Discharge; D016896:Treatment Outcome