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      Use of Palliative Care Consultation for Patients with End-Stage Liver Disease: Survey of Liver Transplant Service Providers

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      Journal of Palliative Medicine
      Mary Ann Liebert Inc

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          Abstract

          <p id="d8694477e215"> <b> <i>Background/Aim:</i> </b> Palliative care services (PCS) are recommended to enhance quality of care for hospitalized patients. </p><p id="d8694477e223"> <b> <i>Methods:</i> </b> We evaluated the attitudes of liver transplant (LT) providers and perceived barriers to PCS for their patients by conducting a web-based survey of intensive care unit nurses, postgraduate year 1 (PGY1) physician trainees, nurse practitioners, fellows, and attending physicians on the LT service at an academic medical center. </p><p id="d8694477e231"> <b> <i>Results:</i> </b> The response rate was 44% (88/200). Providers agreed that LT and PCS are not mutually exclusive (86%, <i>n</i> = 76). Respondents reported confusion regarding criteria and timing for referral to PCS. Most suggested that referral is appropriate when death is imminent (78%, <i>n</i> = 69). Many providers felt that patients' depression (66%, <i>n</i> = 58) was poorly managed, although few identified that PCS were consulted for depression (28%, <i>n</i> = 25). Overall, 84% ( <i>n</i> = 74) identified attending physicians as the main barrier to involving PCS, and attendings (93%, <i>n</i> = 82) were more likely than PGY1 (67%, <i>n</i> = 59) and nurses (55%, <i>n</i> = 48) to describe PCS as end-of-life care ( <i>p</i> = 0.03). Nearly all LT providers agreed that patients welcomed goals of care discussions (83%, <i>n</i> = 73), were grateful for PCS (96%, <i>n</i> = 85), and received higher quality care with PCS (96%, <i>n</i> = 85). </p><p id="d8694477e277"> <b> <i>Conclusion:</i> </b> LT providers overwhelmingly report that PCS benefit patients and are consistent with LT goals even while patients are listed for LT. Barriers to PCS include confusion over referral criteria and describing PCS as end-of-life care by attending physicians. PCS teams may expand access for LT patients by establishing clear criteria for PCS referral and targeting educational interventions about palliative care to attendings. </p>

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          Hospital readmissions among patients with decompensated cirrhosis.

          Early rehospitalizations have been well characterized in many disease states, but not among patients with cirrhosis. The aims of this study were to identify the frequency, costs, predictors, and preventable causes of hospital readmissions among patients with decompensated cirrhosis. Rates of readmission were calculated for 402 patients discharged after one of the following complications of cirrhosis: ascites, spontaneous bacterial peritonitis, renal failure, hepatic encephalopathy, or variceal hemorrhage. Costs of readmissions were calculated using the hospital accounting system. Predictors of time to first readmission were determined using Cox regression, and predictors of hospitalization rate/person-years were determined using negative binomial regression. The independent association between readmission rate and mortality was determined using Cox regression. Admissions within 30 days of discharge were assessed by two reviewers to determine if preventable. Overall, 276 (69%) subjects had at least one nonelective readmission, with a median time to first readmission of 67 days. By 1 week after discharge, 14% of subjects had been readmitted, and 37% were readmitted within 1 month. The mean costs for readmissions within 1 week and between weeks 1 and 4 were $28,898 and $20,581, respectively. During a median follow-up of 203 days, the median number of readmissions was 2 (range 0-40), with an overall rate of 3 hospitalizations/person-years. Patients with more frequent readmissions had higher risk of subsequent mortality, despite adjustment for confounders including the Model for End-stage Liver Disease (MELD) score. Predictors of time to first readmission included MELD score, serum sodium, and number of medications on discharge; predictors of hospitalization rate included these variables as well as the number of cirrhosis complications and being on the transplant list at discharge. Among 165 readmissions within 30 days, 22% were possibly preventable. Hospital readmissions among patients with decompensated cirrhosis are common, costly, moderately predictable, in some cases, possibly preventable, and independently associated with mortality. These findings support the development of disease management interventions to prevent rehospitalization.
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            Physician response to surveys A review of the literature

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              Patients with cirrhosis and denied liver transplants rarely receive adequate palliative care or appropriate management.

              Patients with cirrhosis who are receiving palliative care and are not eligible for liver transplantation (LT) are often hospitalized multiple times, with lack of expectations or understanding of death and dying. We evaluated how frequently these patients received appropriate and palliative care.
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                Author and article information

                Journal
                Journal of Palliative Medicine
                Journal of Palliative Medicine
                Mary Ann Liebert Inc
                1096-6218
                1557-7740
                August 2016
                August 2016
                : 19
                : 8
                : 836-841
                Article
                10.1089/jpm.2016.0002
                5335746
                27092870
                90f66ac3-c548-4976-9187-91089c3ba013
                © 2016
                History

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