title: A Quality Improvement Initiative Reduces 30-Day Rate of Readmission for Patients With Cirrhosis.
abstract: OBJECTIVE
  Many hospitalized patients with cirrhosis are readmitted to the hospital within 30 days, particularly those with hepatic encephalopathy (HE). We performed a prospective study to assess the effects of a quality improvement protocol on readmission to a transplant center's liver unit within 30 days.
  
  
  METHODS
  We studied the effects of a quality improvement program in 824 unique patients with decompensated cirrhosis or receiving liver transplants (mean Model for End-Stage Liver Disease score, 17.7 ± 7.4) admitted to an inpatient hepatology unit from 2010 through 2013. The study had a year-long control period (626 admissions receiving usual care) and 2 intervention phases: a hand-held checklist phase (470 admissions) and an electronic phase that incorporated the checklist items into the electronic provider order entry system (624 admissions). The intervention phases included goal-directed lactulose therapy and rifaximin for overt HE, and prompts for antibiotic prophylaxis of spontaneous bacterial peritonitis. The primary endpoint was the difference in 30-day readmissions between the control and intervention phases. Trends in 30-day readmissions were compared with those of patients with decompensated cirrhosis admitted at another center.
  
  
  RESULTS
  During the electronic phase, study subjects had 40% lower adjusted odds of 30-day readmission than during the control period. The slope of the decline in readmissions over time was significantly greater than for patients at the other center (P < .0001). The proportion of patients with greater than grade 2 HE and 30-day readmission was 48.9% (66 of 135) in the control period versus 26.0% (27 of 104) in the electronic phase (P = .0003). Treatment of HE with rifaximin and secondary prophylaxis of spontaneous bacterial peritonitis with antibiotics (on discharge) were associated with lower adjusted odds of readmission (odds ratios, 0.39 and 0.40, respectively). The electronic phase was associated with 1.34 fewer hospital days for HE compared with the control period (P = .01).
  
  
  CONCLUSIONS
  In a prospective study, a quality improvement initiative that included electronic decision support reduced readmissions of patients with cirrhosis to the hospital within 30 days.
authors.affiliation: Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. Electronic address: etapper@bidmc.harvard.edu.
authors.forename: Elliot B
authors.initials: EB
authors.lastname: Tapper
authors.affiliation: Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Daniel
authors.initials: D
authors.lastname: Finkelstein
authors.affiliation: Cardiovascular Epidemiology Research Unit, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
authors.forename: Murray A
authors.initials: MA
authors.lastname: Mittleman
authors.affiliation: Decision Support, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
authors.forename: Gail
authors.initials: G
authors.lastname: Piatkowski
authors.affiliation: Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Matthew
authors.initials: M
authors.lastname: Chang
authors.affiliation: Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
authors.forename: Michelle
authors.initials: M
authors.lastname: Lai
mesh_terms: D000328:Adult; D000368:Aged; D019072:Antibiotic Prophylaxis / Q000379:methods; D005260:Female; D005765:Gastrointestinal Agents / Q000008:administration & dosage*; D006501:Hepatic Encephalopathy / Q000188:drug therapy*; D006801:Humans; D007792:Lactulose / Q000008:administration & dosage*; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission; D011446:Prospective Studies; D058996:Quality Improvement; D012294:Rifamycins / Q000008:administration & dosage*; D000078262:Rifaximin; D016896:Treatment Outcome
chemical_list: D005765:Gastrointestinal Agents; D012294:Rifamycins; D007792:Lactulose; D000078262:Rifaximin
keywords: Clinical Trial; HE; MELD; SBP