Strategies That Reduce 90‐Day Readmissions and Inpatient Costs After Liver Transplantation

Abstract

Liver transplantation (LT) is hospital-resource intensive and associated with high rates of readmission. We have previously shown a reduction in 30-day readmission rates by implementing a specifically designed protocol to increase access to outpatient care. The aim of this work is to determine if the strategies that reduce 30-day readmission after LT were effective in also reducing 90-day readmission rates and costs. A protocol was developed to reduce inpatient readmissions after LT that expanded outpatient services and provided alternatives to readmission. The 90-day readmission rates and costs were compared before and after implementing strategies outlined in the protocol. Multivariable analysis was used to control for potential confounding factors. Over the study period, 304 adult primary LTs were performed on patients with a median biological Model for End-Stage Liver Disease of 22. There were 112 (37%) patients who were readmitted within 90 days of transplant. The readmission rates before and after implementation of the protocol were 53% and 26%, respectively (P < 0.001). The most common reason for readmission was elevated liver tests/rejection (24%). In multivariable analysis, the protocol remained associated with avoiding readmission (odds ratio, 0.33; 95% confidence interval, 0.20-0.55; P < 0.001). The median length of stay after transplant before and after protocol implementation was 8 days and 7 days, respectively. A greater proportion of patients were discharged to hospital lodging after protocol implementation (10% versus 19%; P = 0.03). The 90-day readmission costs were reduced by 55%, but the total 90-day costs were reduced by only 2.7% because of higher outpatient costs and index admission costs. In conclusion, 90-day readmission rates and readmission costs can be reduced by improving access to outpatient services and hospital-local lodging. Total 90-day costs were similar between the 2 groups because of higher outpatient costs after the protocol was introduced.

Definition and Prospective Assessment of Functional Recovery After Liver Transplantation: A New Objective Consensus‐Based Metric for Safe Discharge

“…Our LT discharge checklist includes all these items but, in addition, integrates transplant‐specific items (individualized immunosuppression trough levels, compliance with therapeutic education, immunosuppression‐related adverse effects, and postoperative imaging). On the basis of a proposal by Zeidan et al, ( 35 ) discharge safety may be improved by the assistance of a clinical pharmacist (when available) that uses visual aids for therapeutic education. Additionally, improved discharge planning that allows for effective organization of therapeutic education may increase the rate of discharge, even over weekends.…”

Validation of the american quality assessment model and performance improvement to the brazilian transplant

“…Quality management is currently being discussed in health care as a key to transplant outcomes and is beginning to integrate research and add value to patient care. It is expected to promote quality care in the routine of transplant centers with practices defined by the quality management model (14)(15) . American examples are considered effective and favor management for transplant teams (16) .…”

Reducing Posttransplant Readmissions: Tangible Solutions May Be Within Reach

“…Recent national and single-center studies have shown considerable variability in post-LT health care utilization and that much of the cost in the first post-LT year, apart from the transplant hospitalization, is driven by readmissions. (1,2) Zeidan et al, (3) in this issue of Liver Transplantation, provide important follow-up data on the authors' prior work of strategies to reduce health care utilization after LT. (4) Several years ago, the transplant team had convened a multidisciplinary group, including physicians, advanced practice providers, social workers, and dietitians who developed a protocol to reduce readmissions by redefining admission criteria and establishing outpatient alternatives to hospital admission. They employed a systematic approach using the Plan-Do-Study-Act (PDSA) cycle, a well-accepted QI methodology, which has been adapted from industry to health care.…”

“…In summary, the work of Zeidan et al is highly promising and may be readily adopted at other transplant programs. Multiple methodologies for introducing, investigating, and promoting health system changes have been developed, and transplant clinicians should feel empowered to work with hospital administrators and local “quality experts” to improve clinical care and patient outcomes.…”

“…Zeidan et al, in this issue of Liver Transplantation , provide important follow‐up data on the authors’ prior work of strategies to reduce health care utilization after LT . Several years ago, the transplant team had convened a multidisciplinary group, including physicians, advanced practice providers, social workers, and dietitians who developed a protocol to reduce readmissions by redefining admission criteria and establishing outpatient alternatives to hospital admission.…”