Quantifying days at home in patients with cirrhosis: A national cohort study

Abstract

Background and aims: Days at home (DAH) is a patient-centric metric developed by the Medicare Payment Advisory Commission, capturing annual health care use, including and beyond hospitalizations and mortality. We quantified DAH and assessed factors associated with DAH differences among patients with cirrhosis.

Approach and results: Using a national claims database (Optum) between 2014 and 2018, we calculated DAH (365 minus mortality, inpatient, observation, postacute, and emergency department days). Among 20,776,597 patients, 63,477 had cirrhosis (median age, 66, 52% males, and 63% non-Hispanic White). Age-adjusted mean DAH for cirrhosis was 335.1 days (95% CI: 335.0 to 335.2) vs 360.1 (95% CI: 360.1 to 360.1) without cirrhosis. In mixed-effects linear regression, adjusted for demographic and clinical characteristics, patients with decompensated cirrhosis spent 15.2 days (95% CI: 14.4 to 15.8) in postacute, emergency, and observation settings and 13.8 days (95% CI: 13.5 to 14.0) hospitalized. Hepatic encephalopathy (-29.2 d, 95% CI: -30.4 to -28.0), ascites (-34.6 d, 95% CI: -35.3 to -33.9), and combined ascites and hepatic encephalopathy (-63.8 d, 95% CI: -65.0 to -62.6) were associated with decreased DAH. Variceal bleeding was not associated with a change in DAH (-0.2 d, 95% CI: -1.6 to +1.1). Among hospitalized patients, during the 365 days after index hospitalization, patients with cirrhosis had fewer age-adjusted DAH (272.8 d, 95% CI: 271.5 to 274.1) than congestive heart failure (288.0 d, 95% CI: 287.7 to 288.3) and chronic obstructive pulmonary disease (296.6 d, 95% CI: 296.3 to 297.0).

Conclusions: In this national study, we found that patients with cirrhosis spend as many, if not more, cumulative days receiving postacute, emergency, and observational care, as hospitalized care. Ultimately, up to 2 months of DAH are lost annually with the onset of liver decompensation. DAH may be a useful metric for patients and health systems alike.

Figure 1.. Age-Adjusted Days Spent at Various Places of Service by Chronic Condition.

Abbreviations: CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease. Within each facet, the first bar represents the sum of the mean home health, emergency department, skilled nursing facility, inpatient psychiatry, inpatient rehabilitation, and observation days, adjusted for age. The second bar represents inpatient days, adjusted for age. Mortality days are not included in this figure. The error bars depict 95% confidence intervals. †Inpatient psychiatry and inpatient rehabilitation days combined due to low proportion of adults within subcohorts with days at these places of service

Figure 2.. Fully-Adjusted Days Spent at Various Places of Service.

Abbreviations: HE, hepatic encephalopathy. The first facet represents compensated cirrhosis, and each subsequent facet represents a different combination of decompensation events. Within each facet, the first bar represents the sum of the mean fully-adjusted home health, emergency department, skilled nursing facility, inpatient psychiatry, inpatient rehabilitation, and observation days. Model is fully adjusted for age, sex, race, year, modified Charlson comorbidity index, hepatocellular carcinoma, decompensation, dialysis, and liver disease etiology. The second bar represents inpatient days. Mortality days are not included in this figure. The error bars depict 95% confidence intervals.

Figure 3.. Effect of Liver Decompensation on Days at Home among Patients with Cirrhosis.

Bar graph represents the mean difference in DAH between compensated cirrhosis and varying combinations of decompensated cirrhosis. Dashed horizontal line at y = 0 represents fully-adjusted mean DAH for compensated cirrhosis (343.8 days). Model is fully adjusted for age, sex, race, year, modified Charlson comorbidity index, hepatocellular carcinoma, decompensation, dialysis, and liver disease etiology. Error bars represent 95% confidence intervals.

Figure 4.. Post-Discharge Age-Adjusted Days at Home by Chronic Condition.

Panel A represents age-adjusted DAH at various post-discharge intervals (30, 90, 180, 365 days) for patients with cirrhosis vs. CHF vs. COPD. In panel B, for each post-discharge interval, the first facet represents the sum of the mean home health, emergency department, skilled nursing facility, inpatient psychiatry, inpatient rehabilitation, and observation days, adjusted for age. The second bar represents inpatient days, adjusted for age. The third bar represents mortality days, adjusted for age. Error bars represent 95% confidence intervals.