title: Variation among United States hospitals in inpatient mortality for cirrhosis.
abstract: OBJECTIVE
  Little is known about geographic variations in health care for patients with cirrhosis. We studied geographic and hospital-level variations in care of patients with cirrhosis in the United States by using inpatient mortality as an outcome for comparing hospitals. We also aimed to identify features of patients and hospitals associated with lower mortality.
  
  
  METHODS
  We used the 2009 U.S. Nationwide Inpatient Sample to identify patients with cirrhosis, which were based on the International Classification of Diseases, 9th Revision-Clinical Modification diagnosis codes for cirrhosis or 1 of its complications (ascites, hepatorenal syndrome, upper gastrointestinal bleeding, portal hypertension, or hepatic encephalopathy). Multilevel modeling was performed to measure variance among hospitals.
  
  
  RESULTS
  There were 102,155 admissions for cirrhosis in 2009, compared with 74,417 in 2003. Overall inpatient mortality was 6.6%. On multivariable-adjusted logistic regression, patients hospitalized in the Midwest had the lowest odds ratio (OR) of inpatient mortality (OR, 0.54; P < .001). Patients who were transferred from other hospitals (OR, 1.49; P < .001) or had hepatic encephalopathy (OR, 1.28; P < .001), upper gastrointestinal bleeding (OR, 1.74; P < .001), or alcoholic liver disease (OR, 1.23; P = .03) had higher odds of inpatient mortality than patients without these features. Those who received liver transplants had substantially lower odds of inpatient mortality (OR, 0.21; P < .001). Multilevel modeling showed that 4% of the variation in mortality could be accounted for at the hospital level (P < .001). Adjusted mortality among hospitals ranged from 1.2% to 14.2%.
  
  
  CONCLUSIONS
  Inpatient cirrhosis mortality varies considerably among U.S. hospitals. Further research is needed to identify hospital-level and provider-level practices that could be modified to improve outcomes.
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan. Electronic address: jmelling@med.umich.edu.
authors.forename: Jessica L
authors.initials: JL
authors.lastname: Mellinger
authors.affiliation: Department of Family Medicine, University of Michigan, Ann Arbor, Michigan.
authors.forename: Caroline R
authors.initials: CR
authors.lastname: Richardson
authors.affiliation: Section of Transplantation Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan.
authors.forename: Amit K
authors.initials: AK
authors.lastname: Mathur
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Volk
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006761:Hospitals; D006801:Humans; D007297:Inpatients; D008103:Liver Cirrhosis / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: Chronic Liver Disease; NIS; Regional Variation; Survival