LOS, length of stay; PPACA, Patient Protection and Medicare Affordable Care Act. The Patient Protection and Medicare Affordable Care Act (PPACA) is designed to improve the quality and reduce the costs of our health care system. With the Supreme Court recently upholding the tenets of PPACA, hospital readmissions will be further scrutinized: first, payments from the Centers for Medicare and Medicaid Services will be restricted for 3 conditions (pneumonia, heart failure, and myocardial infarction), and later, these restrictions will be broadened to all readmissions that are deemed to be avoidable.1 Liver transplantation, a high-cost service prone to readmissions in the first year after transplantation, is a likely target. In this issue of Liver Transplantation, Pereira et al.2 examine the clinical factors predicting readmission after liver transplantation. They report the largest single-center experience to date and assess readmissions for 766 patients who underwent transplantation between 2003 and 2010. The authors have identified a 45% 30-day readmission rate and disease-specific predictors: portal vein thrombosis before transplantation, hospitalization within 90 days before liver transplantation, renal insufficiency (creatinine > 1.9 mg/dL), and hypoalbuminemia (albumin < 2 mg/dL). Other predictors of rehospitalization include postoperative complications and low educational attainment (high school or less). Some of these parameters have previously been shown to lead to higher readmission rates in nontransplant patients.3 The authors have also found that elderly recipients (>60 years old), higher Model for End-Stage Liver Disease scores (>19), preoperative encephalopathy, and marked muscle wasting are associated with a higher requirement for institutional care (eg, a skilled nursing facility) after discharge. These observations, gleaned from a large, single-center cohort, add important knowledge about factors associated with higher readmission rates after liver transplantation. Notwithstanding the laudable intentions behind PPACA provisions and the threat of future penalties imposed by the Centers for Medicare and Medicaid Services on the basis of those provisions, it is important to note that there are subtle but important confounding issues that may affect the present and future recording and reporting of readmission rates. For example, it is intuitive that shortening the original length of stay (LOS) after a procedure without the establishment of safety nets akin to medical homes will result in a higher readmission rate simply because if the LOS is longer, complications after transplantation will be managed during the original admission instead of requiring readmission within a few days of discharge. In addition, there is a recent trend showing a sharp rise in observation status for Medicare beneficiaries associated with a sharp decline in admission status.4 Although observation is expected to last <48 hours, there is no Medicare rule for how long patients can remain in this status, so observation status can be used to avoid any penalty associated with readmissions. Finally, for non-Medicare beneficiaries, payments for transplant services are already bundled so that case rates include certain readmissions and especially those related to transplant episodes.5, 6 These contractual agreements include the sharing of financial risk with the provider: both LOS and readmission costs are bundled into case rates. This is particularly relevant to the transplant patient population because infectious complications in immunosuppressed patients are probably best avoided by reductions in LOS according to what we know about the transmission of infections in the acute care setting.7 Thus, linking readmission rates to LOS should be viewed as a crucial component of any analysis of readmissions. Another point worth noting is that although costs and payments may be unlinked by some of the PPACA provisions (especially those that financially penalize providers for readmissions), these provisions do not drive out costs, which are shifted to the provider and ultimately find their way back to the payer and the employer or patient through higher premiums. Therefore, a cautionary note needs to be embedded into any study that analyzes reductions in payments. Other implications of this study are worth noting. In 2007, the Medicare Payment Advisory Commission reported a 17.6% 30-day readmission rate for Medicare patients and also asserted that 80% of the costs ($12 billion) resulted from preventable readmissions. In the current study, Pereira et al.2 report an almost 3-fold readmission rate (45%) for their cohort of liver transplant recipients, but the authors do not assess whether these readmissions were preventable. This is particularly important because only preventable complications are theoretically actionable.8 However, the authors' findings of predictors of readmission may serve as a proxy for unpreventable readmissions and may lead to the use of these factors in an assessment of whether specific readmissions are preventable or not. The authors indirectly suggest that some of these risk factors (a high Model for End-Stage Liver Disease score, renal insufficiency, pretransplant portal vein thrombosis, and pretransplant hospitalization) might be used to risk-adjust for readmission rates. This is relevant to this patient population because the national allocation policy prioritizes the sickest patients, and sicker liver patients are known to have higher costs and readmission rates.9 Moreover, this discussion should also include the use of marginal donors because they are also prone to postoperative complications and readmissions.10 Although there is clearly an association between readmissions and complications after transplantation, these 2 issues should be considered separately when their preventability is being assessed. An Office of Inspector General report from 2010 estimated that 44% of the complications11 in Medicare and Medicaid patients were preventable.11 Although the issue of preventability has not been analyzed specifically in patients after liver transplantation, it is clear that the cost of some of these complications is incrementally higher in liver transplant recipients versus other patient populations. For instance, charges for an admission for pneumonia, which have been estimated to be $40,000 for nontransplant patients, may be as high as $100,000 for liver transplant recipients.13 It is, therefore, important to investigate the incremental costs of preventable complications in this patient population. The observation that low educational attainment is associated with higher readmission rates in both this patient population and other patient populations also merits further attention. Clearly, setting expectations can result in shorter LOSs and lower readmission rates, but it requires, especially in the setting of complex procedures and episodes of care, linguistically and culturally congruent educational interventions.14 Although this study does not explore the association between race and/or ethnicity and readmission rates, the provision of culturally and linguistically competent care will likely improve outcomes and reduce readmission rates in liver transplant recipients, as it has in other care settings.15, 16
We sought to assess the potential association between history of bariatric surgery and graft rejection among solid organ transplant (SOT) recipients. We conducted a single-center retrospective study of adult (age ≥18 years) SOT recipients (2000-2015) at a large tertiary care transplant network with graft rejection and bariatric surgery history according to the international classification of diseases 9th revision. Data were analyzed using ANOVA, Chi Square, Fisher Exact tests, and logistic regression. Of 4363 SOT recipients, 72.6% had a history of graft rejection and 55 (1.3%) had a history of bariatric surgery. On univariate analysis, patients with graft rejection were more likely to have a history of bariatric surgery than those without organ rejection (1.5% vs. 0.7%, p=0.015). In multivariable analysis adjusted for age, transplant organ type, and history of calcineurin-based immunosuppression, there was increased odds of rejection among those with a history of bariatric surgery (Odds Ratio (OR): 3.01, 95% Confidence Interval (CI):0.98-4.46, p=0.05). However, when adjusted for body mass index at transplant, the association was attenuated (OR:3.48, CI:0.81-14.9, p=0.10). Our single-center data indicate that the relationship between a history of bariatric surgery and graft rejection after SOT may be explained by obesity.
Medication nonadherence after liver transplantation (LT) is associated with adverse clinical outcomes such as graft rejection and graft loss. Few studies have examined nonadherence and its impact on clinical outcomes in LT. The study objectives were (1) to evaluate medication understanding (with treatment knowledge and demonstrated regimen use scores) and medication adherence or nonadherence to entire regimens among LT recipients and (2) to examine associations of these exposures with clinical outcomes. We conducted a 2-site study of 105 recipients between 2011 and 2012 at 2 transplant centers in Chicago, IL and Atlanta, GA. Data were collected via detailed, in-person interviews and medical record reviews. Study participants were middle-aged and predominantly male; 15% of the sample had limited literacy. On average, patients were taking 11 medications [standard deviation (SD) = 4], and 39% had undergone a medication change within the last month. The average scores for the entire medication regimen were 86% (SD = 22%) for treatment knowledge and 78% (SD = 22%) for demonstrated regimen use. The mean score for self-reported nonadherence to the entire regimen was 14% (SD = 20%), whereas 32% of the patients were nonadherent according to tacrolimus levels. In multivariate analyses, lower income, less time since transplantation, a higher number of medications, and limited literacy were inversely associated with treatment knowledge scores (all P < 0.05), whereas limited literacy was associated with nonadherence according to tacrolimus levels (P < 0.05). In multivariate models, higher scores for treatment knowledge [incidence rate ratio (IRR) = 0.85, 95% confidence interval (CI) = 0.74-0.97] and demonstrated regimen use (IRR = 0.87, 95% confidence interval = 0.77-0.98) were independently associated with 15% and 13% reductions in the number of posttransplant rehospitalizations, respectively. Inadequate treatment knowledge and improper regimen use may be significant determinants of unintentional nonadherence among LT recipients and are associated with adverse clinical outcomes.
Abstract Objective Cognitive impairment, detected in up to 80% of patients with liver cirrhosis, is associated with negative health outcomes but is underdiagnosed in the clinical setting due to the lack of practical testing method. This single‐center prospective observational study aimed to test the feasibility and prognostic utility of in‐clinic cognitive assessment of patients with liver cirrhosis using the NIH Toolbox cognition battery (NIHTB). Methods Patients recruited from a hepatology/transplant clinic underwent cognitive assessments using West‐Haven Grade (WHG) and NIHTB between November 2016 and August 2018 and were prospectively followed until December 2018. The primary outcome was a composite end point of hospitalization related to overt hepatic encephalopathy (OHE) and all‐cause mortality during follow‐up, evaluated by a Cox proportional hazards regression model that adjusted for a priori covariates (age and MELD‐Na). Results Among 127 patients (median age 60 years, 48 [38%] women) assessed, cognitive performance was significantly impaired in 82 [78%] patients with WHG 0 and 22 [100%] patients with WHG 1 and 2. Over a median of 347 days follow‐up, 18 OHE and 8 deaths were observed. Lower cognitive performance was associated with an increased risk of OHE/death adjusting for age and MELD‐Na. Subclinical cognitive impairment detected by NIH Toolbox in WHG 0 patients was significantly associated with greater mortality. Median time to complete the two prognostically informative NIH Toolbox tests was 9.4 min. Interpretation NIH Toolbox may enable a rapid cognitive screening in the outpatient setting and identify patients at high risk for death and hospitalization for severe encephalopathy.
Liver cirrhosis is a chronic disease that is known as a "silent killer" and its true prevalence is difficult to describe. It is imperative to accurately characterize the prevalence of cirrhosis because of its increasing healthcare burden.
