Paracentesis and Mortality in U.S. HospitalsJosé L. González, MDWednesday, June 25th, 2014Journal Club

Intro: Retrospective Observational Design Does paracentesis decrease in-hospital mortality?

Reasons for this Study:

ASLD recommends Quality indicator Data linking paracentesis and outcomes is lacking

Epidemiology

Paracentesis is performed about 60% of the time Occurs in 25% of patients w/ clinically significant

ascites SBP is fatal in 30% of patients

Methods: Data Source: 2009 Nationwide Inpatient Sample (NIS) Data stratified by:

size ownership teaching status location

Sample:

>18 years of age Excluded transfers from OSH ICD-9 Codes:

Ascites SBP HES (if ascites is a secondary dx)

*All of the above pts had to have a 2º dx of cirrhosis

+/- Paracentesis procedure code

Variables considered:

Early vs Delayed :: <1 day vs >1day Age Sex Race / Ethnicity Weekday vs weekend Insurance provider Income Comorbidities

Hospital Factors Considered:

Size Ownership Private U.S. region Teaching status Rural vs. urban

Outcomes:

1º In-hospital mortality

2º Hospital length of stay Hospital charges

Statistics: Categorical variables: Pearson X2

Continuous variables: Student t test Re-examination of stats after excluding those who

died on the day of admission

Results

40 million DCs in 2009 17,741 met inclusion criteria 10,743 paracentesis were performed (61%)

Diagnosis N paracentesis performedHES 10,500

56%Ascites 2,977

SBP 4,233 77%

Results

Results:Para or no para

Increased likelihood to have had paracentesis Slightly younger Higher median income Dx of Sepsis & ARF Less likely to be in the South Teaching or urban hospital

56.4% in the South & 64.1% in the NE

Results:Para or no para

No difference: Sex, race, admitting circumstance, primary payer, # of

comorbidities, hospital size or ownership

Para independently associated w/ Self-pay ARF Teaching status of hospital

Less likely to be done on the weekends

Results:Primary Outcome

Those who received a para had a lower in-hosp mortality than those who did not (6.5% vs 8.5%, P = .03)

In-hosp mortality was lower in the Midwest Those who died:

Had more comorbidities More likely to have had sepsis More likely to have had RF

Results:Primary Outcome

Dx of HES or ascites: (6.8% vs 9.1% adjusted OR) 0.54: 95% CI, 0.38-0.76

Dx of SBP (5.8% vs 4.7% adjusted OR) 0.91: 95% CI, 0.38-2.19

Results:Primary Outcome

Delayed para <1 day vs >1 day More likely to

be Female be Admitted on weekend have Medicare Have more comorbidities To have ARF To be in a private, nonprofit hosp

And less likely to be in a teaching hospital 5.7% vs 8.1% p = 0.49, but not stat sig (0.78-2.02 CI)

Results:Secondary Outcome

Hospital Length of Stay and Hospital Charges Para = 6.6 days, $44,586 No para = 5.3days, $ 31,746

Conclusions Pts w/ cirrhosis and ascites, only 61% undergo para Paracentesis in these patients is associated w/

improved mortality Paracentesis in all pts studied is associated w/

increased LOS and hospital charges

Discussion

Only 61% of patients admitted for ascites or HES had a paracentesis

1996 survey data: IM graduating residents are comfortable w/ the procedure

Weekend admissions are associated w/ decrease para Detail in NIS info doesn’t tell us why, potential

reasons Low index of suspicion for SBP Tx empirically

Discussion

Mechanism for beneficial effect? Probably due to increased detection and tx of SBP

Para 6.8% HES or ascites

No Para 9.1%

Para 5.8%SBP

No para 4.7%

DiscussionSecondary Outcomes

Unit of obs = each admission, so readmission can’t be assessed

LOS and $ were increased in paracentesis group Undiagnosed SBP cases may have been DCd b4

recognition? How much did increased mortality contribute to

decreased LOS/$?

Study Limitations

Administrative data reliant on coding Canadian study, > 80% sensitivity for patacentesis

Data don’t distinguish between diagnostic and therapeutic paras

Subclinical ascites? Did severity of illness influence decision to perform

paras? Increased likelihood in sepsis and ARF Other studies show that worse liver dz is ass. w/

recommended ascites care Association but not causality

Sources Orman E, Hayashi P, Bataller R et al. Paracentesis and

Mortality in U.S. Hospitals. Clinical Gastroenterology and Hepatology 2014; 12:496-503.

Runyon, Bruce. Management of Adult Patients with Ascites Due to Cirrhosis: Update 2012. AASLD Practice Guideline, 2012.