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Paracentesis and Mortality in U.S. Hospitals

Paracentesis and Mortality in U.S. Hospitals. José L. González, MD Wednesday, June 25 th , 2014 Journal Club. Retrospective Observational Design Does paracentesis decrease in-hospital mortality?. Intro:. ASLD recommends Quality indicator Data linking paracentesis and outcomes is lacking.

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Paracentesis and Mortality in U.S. Hospitals

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  1. Paracentesis and Mortality in U.S. Hospitals José L. González, MD Wednesday, June 25th, 2014 Journal Club

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

  3. ASLD recommends • Quality indicator • Data linking paracentesis and outcomes is lacking Reasons for this Study:

  4. Paracentesis is performed about 60% of the time • Occurs in 25% of patients w/ clinically significant ascites • SBP is fatal in 30% of patients Epidemiology

  5. Data Source: 2009 Nationwide Inpatient Sample (NIS) • Data stratified by: • size • ownership • teaching status • location Methods:

  6. >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 Sample:

  7. Early vs Delayed :: <1 day vs >1day • Age • Sex • Race / Ethnicity • Weekday vs weekend • Insurance provider • Income • Comorbidities Variables considered:

  8. Size • Ownership • Private • U.S. region • Teaching status • Rural vs. urban Hospital Factors Considered:

  9. 1º • In-hospital mortality • 2º • Hospital length of stay • Hospital charges Outcomes:

  10. Categorical variables: Pearson X2 • Continuous variables: Student t test • Re-examination of stats after excluding those who died on the day of admission Statistics:

  11. 40 million DCs in 2009 • 17,741 met inclusion criteria • 10,743 paracentesis were performed (61%) Diagnosis N paracentesis performed HES 10,500 56% Ascites 2,977 SBP 4,233 77% Results

  12. Results

  13. 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

  14. 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:Para or no para

  15. 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

  16. 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

  17. 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:Primary Outcome

  18. Hospital Length of Stay and Hospital Charges • Para = 6.6 days, $44,586 • No para = 5.3days, $ 31,746 Results:Secondary Outcome

  19. 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 Conclusions

  20. 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

  21. 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% Discussion

  22. 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/$? DiscussionSecondary Outcomes

  23. 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 Study Limitations

  24. 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. Sources

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