Decreasing mortality among patients hospitalized with cirrhosis in the United States from 2002 through 2010

Abstract

Background & aims: It is not clear whether evidence-based recommendations for inpatient care of patients with cirrhosis are implemented widely or are effective in the community. We investigated changes in inpatient outcomes and associated features over time.

Methods: By using the Healthcare Cost and Utilization Project, National Inpatient Sample, we analyzed 781,515 hospitalizations of patients with cirrhosis from 2002 through 2010. We compared data with those from equal numbers of hospitalizations of patients without cirrhosis and patients with congestive heart failure (CHF), matched for age, sex, and year of discharge. The primary outcome was a change in discharge status over time. Factors associated with outcomes were analyzed by Poisson modeling.

Results: The mortality of patients with and without cirrhosis, and patients with CHF, decreased over time. The absolute decrease was significantly greater for patients with cirrhosis (from 9.1% to 5.4%) than for patients without cirrhosis (from 2.6% to 2.1%) or patients with CHF (from 2.5% to 1.4%) (P < .01). However, relative decreases were similar for patients with cirrhosis (41%) and patients with CHF (44%). For patients with cirrhosis, the independent mortality risk ratio decreased steadily to 0.50 by 2010 (95% confidence interval, 0.48-0.52), despite patients' increasing age and comorbidities. Hepatorenal syndrome, hepatocellular carcinoma, variceal bleeding, and spontaneous bacterial peritonitis were associated with a higher mortality rate, but the independent mortality risks for each decreased steadily. Sepsis was associated strongly with increased mortality, and the risk increased over time.

Conclusions: Among patients with cirrhosis in the United States, inpatient mortality decreased steadily from 2002 through 2010, despite increases in patient age and medical complexity. Improvements in cirrhosis care may have contributed to increases in patient survival beyond those attributable to general improvements in inpatient care. Further improvements might require an increased use of proven therapies and the development of new treatments-particularly for sepsis.

Keywords: Decompensation; Liver Failure; Predictors; Renal Failure.

Figure 1

Inpatient mortality from 2002 to 2010 for cirrhotic patients, NC patients, and NC patients with CHF. NC and NC-CHF patients were matched 1:1 with cirrhotic patients on age, sex, and year of discharge. The decrease in mortality for patients with cirrhosis was significantly more than that in the NC and NC-CHF cohorts.

Figure 2

Inpatient mortality from 2002 to 2010 for cirrhotic patients by age group.

Figure 3

Incident risk ratios for cirrhosis complications or interventions, each year from 2002 to 2010. Derived from interaction terms (eg, HRS × 2002, × 2003, to × 2010; sepsis × 2002, × 2003, to 2010) in Poisson model for inpatient mortality. (Para = paracentesis).