More concentrated care linked to adverse outcomes in patients with cirrhosis

A retrospective cohort study looked at patients with cirrhosis who were enrolled in Medicare and had had more than four outpatient visits over 180 days.

Patients with cirrhosis who receive more highly concentrated care may be at higher risk for death and hospitalization, a recent study found.

Researchers performed a retrospective cohort study of patients with cirrhosis who were enrolled in Medicare and had had more than four outpatient visits over 180 days. They collected data on the usual provider of care (UPC) index, defined as the proportion of a patient's visits that are with his or her usual clinician, and the continuity of care (COC) index, which measures care density and dispersion. Both indexes are measured on a scale of 0 to 1. The study's primary outcome was all-cause mortality or liver transplantation, and secondary outcomes were hospital days and 30-day all-cause readmissions per person-year. The study was published Jan. 9 by Clinical Gastroenterology and Hepatology.

Overall, 26,006 patients were included in the study. About half of the patients were men (48.8%), 76.9% were white, and the median age was 69 years. A total of 4,441 patients (17.2%) died, and 41 (0.16%) received a liver transplant. The median COC score for the cohort was 0.40 (interquartile range, 0.26 to 0.60), and the median UPC score was 0.60 (interquartile range, 0.50 to 0.80). Increased care concentration as measured by the COC and UPC scores was associated with higher rates of death and hospitalization. COC and UPC scores in the highest 25th percentile were associated with adjusted hazard ratios of 1.20 (95% CI, 1.10 to 1.31) and 1.14 (95% CI, 1.06 to 1.24) for death, adjusted incidence rate ratios of 1.12 (95% CI, 1.02 to 1.23) and 1.10 (95% CI, 1.01 to 1.20) for hospital days, and adjusted incidence rate ratios of 1.19 (95% CI, 1.06 to 1.34) and 1.12 (95% CI, 1.00 to 1.25) for readmissions, respectively.

The study does not include data on communication among clinicians and may not be generalizable to younger patients, among other limitations. The authors concluded that while care concentration in older patients with cirrhosis appears to be low, increased care concentration was associated with death and increased health care use in their study. Care coordination interventions involving such methods as referral tracking have addressed barriers for patients with some chronic conditions, the authors noted, but care for cirrhosis may have some important differences. “A better understanding of the current state of concentration of care for patients with cirrhosis, and its relationship with outcomes, is warranted,” they wrote.