Electronic alert about lactulose linked to lower readmissions in patients with cirrhosis
The alert, which encouraged clinicians to prescribe rifaximin for patients with cirrhosis and hepatic encephalopathy who were on lactulose, increased uptake of rifaximin in such patients.
An interruptive alert in the electronic ordering system was associated with increased uptake of rifaximin for patients with cirrhosis and hepatic encephalopathy who were on lactulose and reduced their risk of 30-day readmission, a recent study found.
The researchers had previously shown that standardized lactulose dosing combined with prompts for rifaximin use was associated with significantly reduced readmissions. In the current study, they evaluated the impact of an electronic medical record alert to indicate rifaximin for patients with cirrhosis and hepatic encephalopathy who were on lactulose. They developed the two best-practice advisory alerts and deployed them first on gastroenterology and nonteaching hospitalist services, and subsequently for the remainder of hospital services (e.g., internal medicine with housestaff, family medicine, and cardiology). Results were published online on Jan. 12 by the American Journal of Gastroenterology.
In-hospital rifaximin use was stable on the gastroenterology and hospitalist services throughout the study period (73.5% preintervention vs. 74.5% postintervention; adjusted odds ratio [OR], 1.04 [95% CI, 0.95 to 1.13]). On the other services, rifaximin use increased from 52.6% before the intervention to 71.1% after the intervention (adjusted OR, 1.20; 95% CI, 1.09 to 1.31). While rifaximin ordered after the alert was mostly label concordant, with 80% new prescriptions and 15% continued home prescriptions, 5% of prescriptions were potentially inappropriate. When rifaximin was not ordered, it was because lactulose was deemed sufficient by the clinician (or used for constipation).
The researchers prospectively tracked 30-day readmissions for all live, nonhospice discharges for adults with cirrhosis from Jan. 1. 2019, to Dec. 30, 2020. On the gastroenterology and hospitalist services, the 30-day readmission rate decreased from 17.4% to 9.3% during the intervention period (adjusted OR, 0.92; 95% CI, 0.87 to 0.96). On the other services, the 30-day readmission rate decreased from 9.7% to 8.5% (adjusted OR, 0.97; 95% CI, 0.94 to 1.00). Overall, the intervention was associated with a significantly lower risk of readmission (adjusted subdistribution hazard ratio, 0.77; 95% CI, 0.65 to 0.91). It was also associated with a lower readmission risk in patients with hepatic encephalopathy specifically (adjusted subdistribution hazard ratio, 0.63; 95% CI, 0.48 to 0.82). However, as the number of readmissions decreased, the proportion of readmissions primarily attributable to hepatic encephalopathy remained stable.
Among other limitations, the authors noted that the findings may not be generalizable to other settings because the study was a single-center quality improvement intervention. The study also found a slight decrease in mortality, and while the authors noted that they could not confirm a survival benefit, this did show that readmissions were not lower as a function of higher mortality, they said.