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Aliment Pharmacol Ther. 2019 Apr 29. doi: 10.1111/apt.15265. [Epub ahead of print]

Targets to improve quality of care for patients with hepatic encephalopathy: data from a multi-centre cohort.

Author information

1
Richmond, Virginia.
2
Dallas, Texas.
3
Edmonton, AB, Canada.
4
Toronto, ON, Canada.
5
Rochester, Minnesota.
6
Seattle, Washington.
7
Colorado, Colorado.
8
West Haven, Connecticut.
9
San Francisco, California.
10
Phoenix, Arizona.
11
Houston, Texas.
12
Baltimore, Maryland.
13
Scottsdale, Arizona.
14
Memphis, Tennessee.
15
Rochester, New York.
16
Atlanta, Georgia.
17
Philadelphia, Pennsylvania.

Abstract

BACKGROUND:

Hepatic encephalopathy (HE) can adversely affect outcomes in both in-patients and out-patients with cirrhosis.

AIM:

To define targets for improving quality of care in HE management in the multi-centre North American Consortium for End-Stage Liver Disease (NACSELD) cohort.

METHOD:

NACSELD in-patient cohort was analysed for (a) medication-associated precipitants, (b) aspiration pneumonia development, (c) HE medication changes, and (d) 90-day HE recurrence/readmissions. Comparisons were made between patients on no-therapy, lactulose only, rifaximin only or both. Ninety-day HE-readmission analysis was adjusted for MELD score.

RESULTS:

Two thousand eight hundred and ten patients (1102 no-therapy, 659 lactulose, 154 rifaximin, 859 both) were included. HE on admission, and HE rates during hospitalisation were highest in those on lactulose only or dual therapy compared to no-therapy or rifaximin only (P < 0.001). Medications were the most prevalent precipitants (32%; 21% lactulose over/underuse, 5% benzodiazepines, 4% opioids, 1% rifaximin underuse, 1% hypnotics). Patients with medication-associated precipitants had a better prognosis compared to other precipitants. A total of 23% (n = 217) reached grade 3/4 HE, of which 16% developed HE-related aspiration pneumonia. Two thousand four hundred and twenty patients were discharged alive without liver transplant (790 no-therapy, 639 lactulose, 136 rifaximin, 855 both); 12.5% (n = 99) of no-therapy patients did not receive a discharge HE therapy renewal. Ninety-day HE-related readmissions were seen in 16% of patients (9% no-therapy, 9% rifaximin only, lactulose only 18%, dual 21%, <0.001), which persisted despite MELD adjustment (P = 0.009).

CONCLUSION:

Several targets to improve HE management were identified in a large cohort of hospitalised cirrhotic patients. Interventions to decrease medication-precipitated HE, prevention of aspiration pneumonia, and optimisation of HE medications are warranted.

PMID:
31032966
DOI:
10.1111/apt.15265

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