Rate of Mortality After ED Discharge for Cirrhosis Doubles That of Heart Failure

Patients with cirrhosis had higher rates of emergency department (ED) visits and nearly twice as high post-discharge 90-day mortality rates compared with patients with congestive heart failure or chronic obstructive pulmonary disease (COPD), according to a retrospective cohort study.

In an age-adjusted analysis, rates of ED visits were 1.72 per person-year for those with cirrhosis compared with 0.46 for those without cirrhosis, 1.66 for those with congestive heart failure, and 1.22 for those with COPD, reported Brian Lee, MD, MAS, of the University of Southern California in Los Angeles, and colleagues.

Age-adjusted 90-day mortality rates were 12.2% in those with cirrhosis versus 4.8% for those without cirrhosis, 6.9% for those with congestive heart failure, and 6.3% for those with COPD, they wrote in Clinical Gastroenterology and Hepatology.

Moreover, ED visits for non-liver-related causes compared with liver-related causes were more likely to lead to discharge home among patients with compensated (52.8% vs 39.2%) and decompensated (42.2% vs 29.5%) cirrhosis.

These findings have implications for both institutions and for policy, Lee and team noted.

“At the institutional level, our findings provide foundational evidence for the development of ED-based risk-stratification tools and structures that incentivize outpatient follow-up,” they wrote. “Further, we find that alcohol etiology and non-liver comorbidities are among the factors that may be important to consider when risk-stratifying patients with cirrhosis in the ED.”

These findings also “highlight the need for increased awareness by all medical professionals and researchers regarding the risk for poor outcomes among patients with cirrhosis presenting with medical issues that may not be directly liver-related,” they added.

“At the policy level, our finding that patients with cirrhosis are high ED utilizers supports legislation that promotes ED-based interventions,” they wrote. “For example, the ED may be a useful place for multidisciplinary teams to ‘case-find’ patients with liver disease and intervene accordingly.”

Andrew Scanga, MD, of the Liver and Kidney Transplant Clinic Operations at Vanderbilt University in Nashville, told MedPage Today that the large size of the study provided “significant validity and generalizable applicability of the results,” though he was unsurprised by the findings.

“When patients develop decompensated cirrhosis characterized by ascites, variceal bleeding, or encephalopathy, their mortality risk increases greatly,” Scanga said. “Sometimes if the underlying cause of their cirrhosis can be addressed, their disease can be stabilized and avoid the need for transplantation.”

However, not all treatments for managing cirrhosis complications improve hepatic function, whereas congestive heart failure or COPD management usually does improve cardiac or lung function, he noted. Rather, treating complications of cirrhosis “can improve overall functional status, short-term survival, and increase chances of making it to transplant,” even while the disease often remains progressive.

“For those with decompensated cirrhosis that do not improve by addressing the underlying cause of their disease, the only cure is a transplant, which is not an option or possible for many due to limited organ supply and/or comorbidities that would result in a poor outcome,” he added.

Notably, in an exploratory analysis of patients who remained alive and were not readmitted for 30 days after ED discharge, those without any outpatient follow-up had higher 90-day mortality (22%) than those with both primary care and gastroenterology/hepatology follow-up within 30 days (7.9%).

These findings show the importance of follow-up with primary care and a specialist for cirrhosis for patients discharged from the ED, Scanga said.

“Often, these patients need fairly intensive lab monitoring following discharge, and review of medications to make sure they are taking them correctly,” he explained. “I agree with the authors that developing a model to identify those at highest risk and an intervention to assist with follow-up will help outcomes and likely reduce ED and hospital readmissions.”

For this study, Lee and colleagues used data from Optum’s de-identified Clinformatics Data Mart Database for 38,419,650 patients with at least 180 enrollment days from 2008-2022, of whom 198,439 had cirrhosis. They looked at ED visits and 90-day mortality rates for these patients compared with 1,817,628 patients with congestive heart failure and 2,394,037 patients with COPD.

Analyses were adjusted for age, sex, race, education, net worth, number of adults at home, year, modified Charlson Comorbidity Index, hepatocellular carcinoma, decompensation, dialysis, and etiology.

A notable limitation of the study was its lack of granularity, particularly with respect to socioeconomic variables “that likely play a strong role in outcomes,” Scanga said. “In particular, the database does not include the uninsured or under-insured, and I fear the outcomes would be much worse if they were able to be included in the analysis.”