Published: Nov 9, 2014
By Ed Susman , Contributing Writer, MedPage Today
Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
BOSTON -- Patients with decompensated liver cirrhosis who were transferred from hospitals to a transplant center faced worse outcomes, researchers suggested here.
In a series of 99 patients transported from outlying hospitals to a liver transplant center, 10 were eligible for transplant, but only three of them underwent liver transplantation during their admission while seven others died, reported Chad Cornish, MD, of the University of Rochester in N.Y., and colleagues.
Cornish's group found that the mean length of stay at the outside hospital was 6.8 days, and the time of the request to transfer the patients and delivery of the patient to the tertiary care center took a mean of 1.2 days, according to their poster presentation at the America Association for the Study of Liver Diseases annual meeting.
Transfer delays were caused by lack of bed space at the tertiary center or because the patient was too unstable to transfer. However, Cornish said none of the patients in the single-center study experienced a transfer delay because of health insurance issues.
"These patients have underlying liver disease and they may decompensated due to encephalopathy -- change in mental status, a gastrointestinal bleed, ascites that are no longer under control. Anyone who is cirrhotic is a sick patient to begin with; they have some other insult and their condition tailspins from there," Cornish said.
"Sometimes we can stabilize them," he continued, "but sometimes the patient has spiraled so far out of control, there is little that can be accomplished. A lot of patients that are transferred to [the transplant center] -- mainly in hopes that a liver transplant would be possible -- do not do well."
Cornish and colleagues wanted to determine how well these transferred patients fared when sent to the tertiary facility.
"Tertiary care liver transplant centers frequently receive requests from outlying hospital to transfer patients with decompensated cirrhosis for a higher level of care, including evaluation for liver transplantation," they explained. "There have been no published studies looking at clinical outcomes for patients with acute decompensated cirrhosis who are transferred to a liver transplant center or barriers to the interhospital transfer."
The study population consisted of patients (ages 18 and up) transferred from an outlying hospital to the university's Strong Memorial Hospital (SMH) for management of acute decompensated cirrhosis between January 2011 and July 2013. They were identified through the hospital's transfer request logs.
Among 30 cases of interhospital transfer delay, 30% were due to lack of bed availability while 13% cases of delay were due to the patient being too unstable to transfer, the authors wrote.
Nearly one-third of the patients died during their initial admission after a mean length of stay while two additional patients died after being transferred on a separate occasion. Mean peak outside hospital Model for End-Stage Liver Disease (MELD) score for patients who died at SMH was 31.3.
His group concluded that "very few patients with acute decompensated cirrhosis transferred from an outlying hospital were suitable for liver transplantation and an even smaller number of patients were transplanted. A substantial number of patients died following a prolonged hospitalization. Given the limited resources and cost associated with transferring patients to a tertiary care liver transplant center, patient selection for transfer is crucial in order to provide optimal care and allocate researches appropriately."
They called for additional studies to identify risk factors that can help prioritize patient transfers.
In commenting of the presentation, Mohsen Hasanin, MD, from the University Alabama in Birmingham, told MedPage Today that "when we see patients from outside the hospital, they are pretty much gone. These patients need to be transferred earlier. By the time they are transferred from primary care or from the outpatient setting by gastroenterologists or hepatologists, they have very bad as outcomes as transplant."
Cornish and co-authors disclosed no relevant relationships with industry.
Hasanin disclosed no relevant relationships with industry.