Adherence to an acute care bundle within the first 24 h of hospital admission affects outcomes for patients with decompensated cirrhosis

Background and Aim: Complications related to chronic liver disease (CLD) have led to an increased burden on health services. Despite an improved evidence base to support management of complications, suboptimal care persists. Initiatives to improve care for patients with cirrhosis are needed. The decompensated cirrhosis acute care bundle (ACB), developed by the British Society of Gastroenterology (BSG), has been proposed as a roadmap for improved care quality, but its impact on patient outcomes has not been demonstrated nor has its relevance to Australian populations. We aimed to assess whether adherence to the BSG-ACB in the first 24 h of hospital admission was associated with improved outcomes. Methods: We performed a single-center, retrospective, observational study of adult patients with decompensated Child–Pugh (CP) B or C cirrhosis admitted to a metropolitan tertiary referral hospital between June 1, 2016, and January 31, 2019. Adherence to the BSG-ACB was assessed for each component, scored, and then ranked. Relative adherence was assessed as tertiles from most to least adherent with the BSG-ACB. Palliative patients were excluded. The primary outcome was mortality (logistic regression). Secondary outcomes were rate of hospital readmission, readmission within 28 days, and time to readmission (Kaplan–Meier analysis). BSG-ACB adherence was assessed in a univariate analysis, then included in a multivariate analysis adjusting for other possible predictors of mortality. Results: A total of 159 admissions with decompensated CP B/C cirrhosis were identified and followed up for a mean of 328 days (SD, 283 days). Of these patients, 74.2% were male, 43.4% has CP-B cirrhosis, and 56.1% had CP-C cirrhossi. The median Model for End-Stage Liver Disease (MELD) score was 18 (IQR, 14–23). Etiology of CLD was alcohol-related in 65.4% of patients, non-alcoholic steatohepatitis in 18.9%, viral hepatitis in 11.9%, and other causes in 3.7%. Study mortality was 30.8%. Mortality was highest in patients in the least ACB-adherent tertile (41.5%), compared with the middle (32.1%) and most adherent tertiles (18.9%) (P = 0.040). On multivariate analysis, the only independent predictors of patient mortality were ACB adherence (P = 0.015), MELD score (P = 0.030), and male sex (P = 0.001) and inclusion of ACB adherence attenuated the effect of liver disease severity on mortality. Forty-six percent of patients were readmitted within the study period. No significant difference in readmission rate was observed; however, patients in the most adherent tertile may have had a longer time until readmission when compared with the least adherent tertile (most adherent, 105 days [95% CI, 63–147]; middle and least adherent tertiles, 81 days [95% CI, 56–106]; P = 0.227). Readmission at 28 days was 14.5% in the cohort. Patients readmitted within 28 days had lower compliance scores than those not readmitted (ACB compliance score, 69% vs 76% in those not readmitted), but this failed to reach statistical significance (P = 0.087). Conclusion: Adherence to a quality-of-care bundle reduced mortality in patients with decompensated liver disease, independent of the severity of their liver disease. Adoption of an ACB early in admission could help reduce health care burden.