Targets to improve quality of care for patients with hepatic encephalopathy: data from a multi-centre cohort
Targets to improve quality of care for patients with hepatic encephalopathy: data from a multi-centre cohort
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DOI：
10.1111/apt.15265
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发表时间：
2019-06-01
影响因子：
7.6
通讯作者：
Reddy, K. Rajender
中科院分区：
文献类型：
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作者：
Bajaj, Jasmohan S.;O'Leary, Jacqueline G.;Reddy, K. Rajender
肝性脑病（HE）可对住院和门诊肝硬化患者的预后产生不良影响。目的在多中心北美终末期肝病联盟（NACSELD）队列中确定提高HE管理护理质量的目标。方法分析NACSELD住院患者队列的（a）药物相关促发物，（B）吸入性肺炎的发生，（c）HE药物治疗变化和（d）90天HE复发/再入院。在未治疗、仅乳果糖、仅利福昔明或两者的患者之间进行比较。根据MELD评分调整90天HE再入院分析。结果共纳入2810例患者，其中未治疗1102例，乳果糖659例，利福昔明154例，两者均用859例。入院时HE和住院期间HE的发生率在仅接受乳果糖或双重治疗的患者中最高，与未接受治疗或仅接受利福昔明相比（P < 0.001）。药物是最普遍的催醒剂（32%; 21%乳果糖过度使用/使用不足，5%苯二氮卓类药物，4%阿片类药物，1%利福昔明使用不足，1%催眠药）。与其他促发剂相比，药物相关促发剂患者的预后更好。共有23%（n = 217）达到3/4级HE，其中16%发展为HE相关吸入性肺炎。2420例患者出院时未接受肝移植（790例未接受治疗，639例接受乳果糖，136例接受利福昔明，855例接受两种治疗）; 12.5%（n = 99）的未接受治疗患者出院时未接受HE治疗更新。在16%的患者中观察到90天的HE相关再入院（9%未治疗，9%仅利福昔明，18%仅乳果糖，21%双重，
Background Hepatic encephalopathy (HE) can adversely affect outcomes in both in-patients and out-patients with cirrhosis. Aim To define targets for improving quality of care in HE management in the multi-centre North American Consortium for End-Stage Liver Disease (NACSELD) cohort. Method NACSELD in-patient cohort was analysed for (a) medication-associated precipitants, (b) aspiration pneumonia development, (c) HE medication changes, and (d) 90-day HE recurrence/readmissions. Comparisons were made between patients on no-therapy, lactulose only, rifaximin only or both. Ninety-day HE-readmission analysis was adjusted for MELD score. Results Two thousand eight hundred and ten patients (1102 no-therapy, 659 lactulose, 154 rifaximin, 859 both) were included. HE on admission, and HE rates during hospitalisation were highest in those on lactulose only or dual therapy compared to no-therapy or rifaximin only (P < 0.001). Medications were the most prevalent precipitants (32%; 21% lactulose over/underuse, 5% benzodiazepines, 4% opioids, 1% rifaximin underuse, 1% hypnotics). Patients with medication-associated precipitants had a better prognosis compared to other precipitants. A total of 23% (n = 217) reached grade 3/4 HE, of which 16% developed HE-related aspiration pneumonia. Two thousand four hundred and twenty patients were discharged alive without liver transplant (790 no-therapy, 639 lactulose, 136 rifaximin, 855 both); 12.5% (n = 99) of no-therapy patients did not receive a discharge HE therapy renewal. Ninety-day HE-related readmissions were seen in 16% of patients (9% no-therapy, 9% rifaximin only, lactulose only 18%, dual 21%,