title: Could Adherence to Quality of Care Indicators for Hospitalized Patients With Cirrhosis-Related Ascites Improve Clinical Outcomes?
abstract: OBJECTIVE
  The diagnosis of cirrhotic ascites is associated with significant morbidity, mortality, and reduced health-related quality of life. Adherence by health professionals to quality indicators (QIs) of care for ascites is low. We evaluated the effect of adherence to ascites QIs on clinical outcomes for patients hospitalized with new onset cirrhotic ascites.
  
  
  METHODS
  The medical records of 302 patients admitted with new onset cirrhotic ascites were interrogated for demographic and clinical data and adherence to eight Delphi panel-derived QIs for ascites management. Associations between adherence to each QI and 30-day emergent readmission and 90-day mortality were analyzed.
  
  
  RESULTS
  The majority of patients were males (68.9%) over 50 years of age (mean 57±12.83 years) with alcohol-related cirrhosis (59%). Twenty-nine percent were readmitted within 30 days. Patients who received an abdominal paracentesis within 30 days of ascites diagnosis (QI 1, relative risk (RR) 0.41, P=0.004) or during index hospitalization (QI 2, RR 0.57, P=0.006) were significantly less likely to experience a 30-day emergent readmission. Baseline serum bilirubin >2.5 mg/dl was associated with increased 30-day cirrhosis-related readmission (RR 1.51, P=0.03). A total of 18.5% of patients died within 90 days of index admission; median interval to death was 139 days (37-562 days). Pneumonia was the most frequent cause of death. Independent predictors of 90-day mortality included older age (odds ratio (OR) 1.03, P=0.03), increased Model for End-stage Liver Disease (MELD)-Na score (OR 1.06, P=0.05), primary SBP prophylaxis (QI 7, OR 2.30, P=0.04), and readmission within 30 days (OR 30.26, P<0.001). Discharge prescription of diuretics (QI 8, OR 0.28, P=0.01) was associated with reduced 90-day mortality.
  
  
  CONCLUSIONS
  Early paracentesis in patients with new onset cirrhotic ascites lowers 30-day readmission rates, and early initiation of diuretic therapy lowers 90-day mortality.
authors.affiliation: Department of Gastroenterology and Hepatology, Monash Health, Clayton, Victoria, Australia.|School of Clinical Sciences, Monash University, Clayton, Victoria, Australia.
authors.forename: Suong
authors.initials: S
authors.lastname: Le
authors.affiliation: Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
authors.forename: Tim
authors.initials: T
authors.lastname: Spelman
authors.affiliation: Department of General Medicine, Monash Health, Clayton, Victoria, Australia.
authors.forename: Chia-Pei
authors.initials: CP
authors.lastname: Chong
authors.affiliation: School of Clinical Sciences, Monash University, Clayton, Victoria, Australia.
authors.forename: Phil
authors.initials: P
authors.lastname: Ha
authors.affiliation: School of Clinical Sciences, Monash University, Clayton, Victoria, Australia.
authors.forename: Lukas
authors.initials: L
authors.lastname: Sahhar
authors.affiliation: School of Clinical Sciences, Monash University, Clayton, Victoria, Australia.
authors.forename: Julian
authors.initials: J
authors.lastname: Lim
authors.affiliation: School of Clinical Sciences, Monash University, Clayton, Victoria, Australia.
authors.forename: Tony
authors.initials: T
authors.lastname: He
authors.affiliation: Department of General Medicine, Monash Health, Clayton, Victoria, Australia.
authors.forename: Neel
authors.initials: N
authors.lastname: Heerasing
authors.affiliation: Department of Gastroenterology and Hepatology, Monash Health, Clayton, Victoria, Australia.|School of Clinical Sciences, Monash University, Clayton, Victoria, Australia.
authors.forename: William
authors.initials: W
authors.lastname: Sievert
mesh_terms: D001201:Ascites / Q000209:etiology / Q000401:mortality / Q000628:therapy; D015331:Cohort Studies; D005260:Female; D019983:Guideline Adherence; D006760:Hospitalization; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications / Q000401:mortality / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission / Q000706:statistics & numerical data; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D016896:Treatment Outcome