Early paracentesis, diuretics improve ascites outcomes

Last Updated: 2016-01-14

By Laura Newman

NEW YORK (Reuters Health) - For patients hospitalized with ascites, adherence to three quality indicators (QIs) reduces 30-day readmission rates and lowers 90-day mortality, a new study suggests.

Patients who underwent paracentesis within 30 days of the diagnosis of ascites or during their index hospitalization were both far less likely to have a 30-day emergent readmission, and discharge with a diuretic cut 90-day mortality significantly.

"The clinical implications for patients seem clear; when physicians are cognizant of the quality indicators for patients with ascites and implement them, then patients are likely to have better outcomes," senior author Dr. William Sievert told Reuters Health by email.

"We found that in our own practice we were only performing a paracentesis for new-onset ascites in around 75% of cases, so clearly we will strive to do better in this regard. We were better at early diuretic prescribing; this happened in around 85%," he added.

Dr. Sievert, of Monash Health in Victoria, Australia, and colleagues reported their findings online January 5 in the American Journal of Gastroenterology.

In a review of records for 302 patients hospitalized with new-onset cirrhotic ascites between 2000 and 2012, the research team examined adherence to eight cirrhosis-specific quality of care indicators:

1) The percentage with new-onset ascites who underwent abdominal paracentesis within 30 days of diagnosis;

2) The percentage who underwent abdominal paracentesis during the index hospitalization;

3) The percentage who had an ascetic fluid cell count and differential during their hospital stay;

4) Among patients with spontaneous bacterial peritonitis (SBP), the percentage who received antibiotics within 24 hours before or after ascetic fluid analysis;

5) Among SBP patients alive at discharge, the percentage who received long-term outpatient antibiotics for secondary prophylaxis within 30 days of discharge;

6) The percentage of patients with gastrointestinal bleeds who got antibiotics during their index hospitalization;

7) Among patients with ascitic fluid total protein <1 g/dl and serum bilirubin >2.5 mg/dl, the percentage who received long-term outpatient antibiotics (for primary prophylaxis) within 3 to 30 days;

8) The percentage of patients with normal renal function who received diuretics within 30 days of ascites diagnosis.

The goal was to learn how each quality indicator affected the natural history of patients hospitalized with new-onset cirrhosis-related ascites.

In fact, the relative risk for a 30-day emergent readmission was significantly lower in patients who had abdominal paracentesis within 30 days of diagnosis (RR 0.41, p=0.004) or during the index hospitalization (RR 0.57, p=0.006).

The only other intervention that helped improve patient outcomes was a discharge prescription of diuretics, which was linked to lower 90-day mortality (OR 0.28, p=0.01).

"An important caveat regarding the impact of the QIs in practices is that our patients had very advanced liver disease so there may be limitations to the overall benefit of QI adherence simply because of the serious nature of the underlying cirrhosis," Dr. Sievert said.

Another important finding was that 71% of patients were being readmitted for recurrent ascites within 90 days. The review also revealed an overall mortality of 46%, with 30-day readmission a strong predictor of 90-day mortality.

Dr. Sievert explained: "Adherence to early abdominal paracentesis within 30 days or in the index hospitalization and early initiation of diuretics offered the most benefit, given that 40% of the unplanned 30-day readmissions were to the (intensive care unit)."

Dr. Sievert and colleagues emphasize that patient self-care is critically important if outcomes are to improve further. Notably, he points to the launch of dedicated liver-specific ambulatory care clinics and smartphone apps that would increase engagement between patients and care teams.

Dr. Fasiha Kanwal of Baylor College of Medicine, Houston, Texas, who led the team developing the quality indicator panel but who wasn't involved in the current study, told Reuters Health by email, "There are several studies that have used the quality indicators to assess quality of care for patients with cirrhosis. So far, these indicators are not routinely used to track performance in the U.S. Few early efforts are under way in order to implement these indicators as part of routine care."

SOURCE: http://bit.ly/1Pe8w4C

Am J Gastroenterol 2016.