Thread by @ebtapper

30-day Readmissions!

They can teach us a lot about the management of #cirrhosis
AND
Highlight the systems of care that benefit patients with cirrhosis

Join me for a #livertwitter #tweetorial?

Aims:
1. What
2. Why
3. How to address

#QI #meded

Readmissions are:
1. Common. >1⃣in4⃣ pts readmitted by 30days (Fig1) cghjournal.org/article/S1542-…)
2. Costly. >$700 million/year
3. Morbid. Independently associated w/⬆️risk of death (Fig2)
4. Barely predictable. No matter what variables go in2 the model the AUROC ~0.6-0.7 (Fig3)

Q: Why do patients with #cirrhosis get readmitted so frequently?

A: Why people with #cirrhosis get readmitted

1. See this highly scientific formula(Fig1)
2. Nationally representative risk factors(Fig2)
3. Reasons 4 readmission (limitation: administrative data)(Fig3)
🤔Lots of factors are missing from quantitative studies of readmission risk

So what can we do?

Two things reduce readmissions:

1⃣Optimized outpatient resources/mgmt.
2⃣Prevention of recurrent HE

First, Imagine you are a PCP

It's Friday, 4pm
Pt w/cirrhosis comes 4 post-DC followup
They are... lookin not great
U send 2 ED.
It's SBP. U saved a life!
Also, they r readmitted

Death and readmission are competing risks!

Second, here is the truth re: readmission prevention

1⃣Not all readmits are bad! 0% readmit = too low
2⃣Lots has been tried, few things successful(Fig1)
3⃣Success follows this sophisticated formula(Fig2)

Systems of care that⬇️readmissions

1. Day hospital! (Note: para access, relapse prevention, improved HE tx)(Fig1)
2. Available day-case paracentesis slots(Fig2)
3. Early followup ALONE:⬆️readmit but⬇️mortality(Fig3)
4. But!! possible that APPs add some magic(Fig4)

How can we treat hepatic encephalopathy better?

Step 1. Prescribe lactulose! Many people go home without scripts(Fig1)
Step 2. 🛑bad meds. No good reason 4 PPI?Thro In🗑️!(Fig2) Same 4 benzos/etc
Step 3. Lactulose+Rifaximin⬇️readmits in ppl w/HE on lactulose.(Fig3, nb:myCOI)

Now, should we penalize readmissions?

No
1. Patients with #cirrhosis get left behind. Ask @rrosenblattmd (Fig1)
2. The cirrhosis data is conclusive. To SAFELY reduce readmissions, invest in outpatient resources. But don’t just take it from me.(Fig2) nejm.org/doi/full/10.10…

To summarize:
🌟Readmits r common
🌟HE causes them. Treat it. Discuss lactulose dosing w/caregivers
🌟The ED saves lives. But there's a better place 2 send pts 4 paras
🌟Invest in outpatient para slots, DC clinics w/APPs, etoh relapse prevention
QI review cghjournal.org/article/S1542-…

This concludes a readmissions tweetorial. I hope you enjoyed it!
This topic is near to my❤️, having hooked me on #cirrhosis QI & launched my career:ncbi.nlm.nih.gov/pmc/articles/P…

The reasons are about as well defined as they can be. It's time to do something about them!