Introduction The benefit of early specialist outpatient follow-up (FU) in patients admitted with decompensated chronic liver disease (DCLD) is unclear, although evidence from the United States suggests reduced overall mortality1. Applicability to United Kingdom practice is unknown, where in-patient care may be managed by general physicians, gastroenterologists or dedicated hepatologists.
We introduced a discharge clinic (DC) for early (within 14 days) specialist FU of all DCLD admissions, and compared clinic outcomes of those who did and did not attend (DNA).
Method A retrospective cohort study was conducted of all patients offered DC review following DCLD admission at our service from May 2014-June 2015. Survival, readmission, future clinic attendance and timely variceal/hepatocelluar carcinoma (HCC) surveillance and dietetic review were compared between attenders and DNA.
Results 77 patients were included; 70.2% had alcohol related disease. Commonest causes for admission were ascites (34.4%) and jaundice (15.1%). 57 (74%) of survivors attended DC.
Attenders had significantly increased mean survival compared to DNA (552 vs 428 days; p=0.0397), and were also more likely to attend subsequent clinical FU (mean attendances 2.65 vs 1.25; p=0.0006). There was a trend towards reduced readmission rate in attenders which did not reach significance (2.12 vs 2.55 admissions; p=0.5828).
In attenders, Child-Pugh (CP) score improved from admission to DC (9-8; p=0.0023), and from admission to 6 months later (p=0.0197). Model for end-stage liver disease (MELD) score improved from admission to DC (15-12; p=0.023) and from admission to 4 months later (p=0.016); this benefit was still observed at 15 months (p=0.0115). DNA showed no significant improvement between admission and 6 month CP (p=0.0991) or 4 month MELD score (p=0.3959).
Many patients did not have varices/HCC surveillance arranged pre-discharge, which was instead booked at DC. Although rates of variceal surveillance did not significantly vary between attenders and DNA (93% vs 80%; p=0.1942), DNA were significantly less likely to enter HCC surveillance (80% vs 100%; p=0.0036). Finally, attenders were more likely to have had dietetic review or assessment (87.7% vs 65%; p=<0.0001).
Conclusion DC attendance was associated with superior survival and reduced CP/MELD scores over time, and improved rates of varices/HCC surveillance and dietetic input. This suggests there may an important role for early specialist FU of DCLD in improving clinical outcomes.
. Kanwalet al. Hepatology. 2016Aug;64(2):569–81.
Disclosure of Interest None Declared
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