Patricia C Valery 15 Nov 2017 - Queensland Health

The burden of cirrhosis in QueenslandPatricia C Valery15 Nov 2017

Epidemiology Prevalence of cirrhosis in Australia Data from comparable countries USA 1% histologically confirmed cirrhosis Costs of chronic liver disease in Australia: 386 million/annum in 2012 ABS and hospital morbidity data: 20% chronic liver disease deaths (1999-2008) 25% hospital admissions QIMR Berghofer Medical Research Institute 2

Aetiologyofcirrhosis QIMR Berghofer Medical Research Institute 3

Natural course of cirrhosisDecades 1 decade 2 is 1 yearLiver disease specific symptomsAdapted from Pellicoro et al NATURE REVIEWS IMMUNOLOGY 2014 QIMR Berghofer Medical Research Institute 4

Later symptoms and signs(decompensated cirrhosis)JaundiceBleeding varicesAscitesEncephalopathy QIMR Berghofer Medical Research Institute 5

Predictors of re-admission QIMR Berghofer Medical Research Institute 6

Using record-linkage methods we aim to:Aim 1: Report population-based age-standardized hospital admissionrates due to cirrhosis during 2008-2016.1a. Describe the demographic and clinical characteristics of cirrhosisrelated hospitalizations during the study period.Aim 2: Examine the risk for readmission within one year from time ofdischarge in patients with cirrhosisAim 3: Examine the patterns of resource utilization and associationswith undesirable patient outcomes (death, re-admissions) QIMR Berghofer Medical Research Institute 7

Establishing the cohort and data acquisition QIMR Berghofer Medical Research Institute 8

Primary diagnosis:alcoholic fibrosis and sclerosis of liver (K70.2)alcoholic cirrhosis of liver (K70.3)toxic liver disease with fibrosis and cirrhosis of liver (K71.7)primary biliary cirrhosis (K74.3)secondary biliary cirrhosis (K74.4)biliary cirrhosis unspecified (K74.5)other and unspecified cirrhosis of liver (K74.6)portal hypertension (K76.6)hepatorenal syndrome (K76.7)alcoholic hepatic failure (K70.4)chronic hepatic failure (K72.1)fibrosis and cirrhosis of liver (K74)oesophageal varices with/without bleeding (I85 I98.3 and I98.2)gastric varices (I86.4)CasedefinitionOROther diagnosis:Procedure code for cirrhosisTAP - abdominal paracentesis (3040600)Banding - endoscopic banding of oesophageal varices (3047602)Banding - endoscopic banding of gastric varices (3047603)TIPS - transjugular intrahepatic portosystemic shunt (9033400)andORPrimary diagnosis: cirrhosis related diagnosis, sign or symptomalcoholic liver disease unspecified (K70.9), sequelae of viral hepatitis (B94.2), secondarythrombocytopenia (D69.5), thrombocytopenia unspecified (D69.6), hypo-osmolality and hyponatraemia(E87.1), hypokalaemia (E87.6), fluid overload (E87.7), disorders of iron metabolism (E83.1), mental andbehavioural disorders due to alcohol (F10), opioids (F11), or sedatives/hypnotics (F13), degeneration ofnervous system due to alcohol (alcoholic encephalopathy; G31.2), alcoholic polyneuropathy (G62.1),alcoholic myopathy (G72.1), encephalopathy unspecified (G93.4), alcoholic gastritis(K29.2), umbilical/ventral hernia (K42, K43), acute peritonitis (K65.0, K65.9), alcoholic hepatitis (K70.1),hepatic failure (K72.9), chronic hepatitis (K73.9), haematemesis (K92.0), melaena (K92.1),gastrointestinal haemorrhage unspecified (K92.2), acute (N17), chronic (N18), or unspecified kidneyfailure (N19), abdominal pain (R10.0, R10.1, R10.3, R10.4), nausea/vomiting (R11), flatulence (R14),fecal incontinence (R15), hepatomegaly (R16.0), splenomegaly (R16.1), hepatomegaly withsplenomegaly (R16.2), unspecified jaundice (R17), ascites (R18), change of bowel habit (R19.4),other fecal abnormalities (R19.5), abnormal findings on diagnostic imaging of liver and biliary tract(R93.2), abnormal results of liver function studies (R94.5), and liver transplant failure and rejection(T86.4).Other diagnosis:and QIMR Berghofer Medical Research Institute 9

Establishing the cohort for Aim 2Inclusion criteria first hospital admission due to cirrhosis during 2012-2015 age 20 years discharged aliveExclusions liver transplant (first admission) interstate/overseas 20 years admitted before 2012 or after 2015 QIMR Berghofer Medical Research Institute 10

Study measures Indigenous statusARIASEIFAClinical factors and procedures ICD 10 AM codes procedure codes (Australian Classification of Health Interventions - ACHI) Comorbidities: Charlson Comorbidity Index Elixhauser score QIMR Berghofer Medical Research Institute 11

Measures of comorbidities1- Charlson Comorbidity Index (CCI) 2- Elixhauser scoreCharlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity inlongitudinal studies: development and validation. J Chronic Dis 1987; 40(5): 373-83.Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. MedCare 1998; 36(1): 8-27. QIMR Berghofer Medical Research Institute 12

Child-Turcotte PughModel for End stage Liver Disease(MELD score)jaundiceAlternative severity score (severity of liver disease) Items: Encephalopathy Ascites Jaundice Hepatorenal syndrome Gastrointestinal bleeding Total score range from 0-5 QIMR Berghofer Medical Research Institute 13

Data analysis Outcome: readmission within 12 months (ever vs. never) Chi-square tests (Fisher exact test when cell counts were 5) and T tests Poisson regression to calculate relative risk (95%CI) used the person time of follow up as the denominator the vce(robust ) option was used to obtain robust standard errors for the parameterestimates to control for mild violation of underlying assumptions Covariates included in the model: age group, gender, severity of liver disease, Elixhausercount (5 groups), alcohol abuse and access to a pharmacist during index admission QIMR Berghofer Medical Research Institute 14

ResultsTotal: 3,491 cases 77% 50 years or older67% male9% Aboriginal and Torres Strait Islander38% increase in total number of cases from 2012 to 2016N 1,141 readmitted within one yearReadmission rate 32.7% (95%CI 31.1-34.2) QIMR Berghofer Medical Research Institute 15

Demographic characteristics by re-admission statusmixed males IndigenousAustralians QIMR Berghofer Medical Research Institute 16

mixed English QIMR Berghofer Medical Research Institute 17

Health system factors at index admission public alliedhealth QIMR Berghofer Medical Research Institute 18

Presumed aetiology and/or cofactors autoimmune ds. alcohol QIMR Berghofer Medical Research Institute 19

Comorbidities comorbidities QIMR Berghofer Medical Research Institute 20

Cirrhosis-related complications and procedures ascites complications ascites bleeding QIMR Berghofer Medical Research Institute 21

Demographic and health system factors QIMR Berghofer Medical Research Institute 22

Clinical factors QIMR Berghofer Medical Research Institute 23

Comorbidities QIMR Berghofer Medical Research Institute 24

Strengths and limitations Near complete state-wide sample of patients with cirrhosisReliable source of clinical and socio-demographic dataWe used widely used or validated coding algorithms for cirrhosis and comorbiditiesCode lists for aetiology/cofactors checked by clinicians/clinical coding personnel The data is only as good as the codingAdministrative data is not collected to address research questionsLack of data on severity of liver disease (MELD, Child-Pugh)Smaller hospitals may have limited coding resourcesPotential misclassification of presumed aetiology, co-factors and comorbiditiesCross-border flow of patients: while we excluded patients who usually live interstate oroverseas, we were unable to report on Queensland residents who were treated interstate QIMR Berghofer Medical Research Institute 25

Summary of findings Male predominance50 yearsNumber of cases increased by 38% (workforce implications)1/3 of patients readmit at least once within 1 year Factors predicting readmission: Age Male gender Access to pharmacist and dietician Alcohol excess Liver disease severity – cirrhosis complications and associated procedures Comorbidities Autoimmune diseaseThere are opportunities for reducing readmissions: addressing alcohol consumption providing alternatives to re-hospitalization QIMR Berghofer Medical Research Institute 26

AcknowledgmentsOther investigators EE PowellL MarquartT RahmanPJ ClarkSM McPhailR SkoienZ GuPrincess Alexandra HospitalQIMR Berghofer Medical Research InstituteThe Prince Charles HospitalMater Hospital, Brisbane / QIMR Berghofer Medical Research InstituteInst. Health and Biomedical Innovation and School of Public Health & Social Work, QUTRoyal Brisbane and Women’s HospitalEthnic Community Council QueenslandFunding PCV was supported by a NHMRC fellowship (#1083090) BDHP supported the data acquisitionContact details: Patricia.Valery@qimrberghofer.edu.au QIMR Berghofer Medical Research Institute 27

QIMR Berghofer Medical Research Institute 28

N 2796 (80%)N 695 (20%) QIMR Berghofer Medical Research Institute 29

Elixhauserlist ofcomorbidities QIMR Berghofer Medical Research Institute 30

Elixhauser comorbidities QIMR Berghofer Medical Research Institute 31

secondary biliary cirrhosis (K74.4) biliary cirrhosis unspecified (K74.5) other and unspecified cirrhosis of liver (K74.6) portal hypertension (K76.6) hepatorenal syndrome (K76.7) alcoholic hepatic failure (K70.4) chronic hepatic failure (K72.1) fibrosis and cirrhosis of liver (K74) oesophageal varices with/without bleeding (I85 I98.3 and I98.2 .