Hospitalization Rates in a Longitudinal US Cohort of Insured Patients with Cirrhosis

Abstract

Background: Hospitalization rates are not well described among patients with cirrhosis compared to those with other leading non-cancerous chronic diseases such as chronic obstructive pulmonary disease (COPD) and heart failure (HF). We aim to describe the hospitalization rates, risk factors, and indications for admission among insured US patients with cirrhosis.

Methods: In this longitudinal, retrospective cohort study of 352,227 adult patients with cirrhosis from 2011-2021 identified by claims data from a large national insurer were compared with random samples of over one million COPD and HF patients. Hospitalizations were identified from claims data. Risk factors were estimated by multivariate logistic regression. Causes of admission were organized using the Healthcare Cost and Utilization Project (HCUP) Clinical Classification Software. Analyses were stratified by compensated and decompensated cirrhosis states, by the presence of clinical decompensations (ascites, HE, SBP, variceal bleeding, HPS, or HRS).

Findings: Among 352,227 patients with cirrhosis the mean [SD] follow-up time was 4·7 [3·1] years; age 63·1 [13·0] years, 158,230 [44·9%] female, and 154,202 [43·8%] commercially insured. 160,644 (46%) experienced hepatic decompensation during the observation period. Annually, 27·8% of the total cirrhotic population was hospitalized, compared to 21·6% for COPD and 28·0% for HF. Patients with decompensated cirrhosis were hospitalized at over twice the rate of those with compensated cirrhosis (18·8% vs. 42·5%, P<0·001). Compared to patients with alcohol-related cirrhosis, those with HCV cirrhosis (OR 0·70, 95%CI 0·68-0·72, P<0·001) and NASH cirrhosis (OR 0·69, 95%CI 0·68-0·71, P<0·001) had reduced risk of hospitalizations. The leading cause of admission among patients with cirrhosis was septicemia (10·5% of admissions), similar to COPD (9·6%) and HF (9·7%).

Interpretation: Patients with cirrhosis have high hospitalization rates, in comparison to other common, burdensome chronic diseases. Improving care for patients with cirrhosis and reducing hospitalizations should be a focus for quality improvement efforts and policymakers.

Funding: This study was supported by R01DK131164 (Ladner/Manski). Dr. Hasjim was supported by NIH grant T32DK077662-15 (PD: Ladner/Green). Dr. VanWagner was supported by the National Heart, Lung, and Blood Institute K23 HL136891 and R56 HL155093 grant. Praneet Polineni was supported by the Steven J. Stryker, MD, Gastrointestinal Surgery Research and Education Endowment. Dr. Duarte was supported by NIH grant R01DK130294.

Declaration of Interest: Dr. VanWagner serves as an advisor for Numares, Novo-Nordisk and Gerson Lehrman Group, receives grant support from W.L. Gore & Associates and provides expert witness services outside the submitted work. Other authors have no conflicts of interests to disclose.

Ethical Approval: This retrospective longitudinal cohort study was deemed exempt from review by the Northwestern University Institutional Review Board. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cohort studies.

Keywords: Cirrhosis, hospitalizations, heart failure, COPD, epidemiology