I read with interest the article by Jepsen and colleagues1 in a recent issue of Hepatology. In the United States, cirrhosis and portal hypertension are also considered diseases of major public health importance. However, details regarding national time trends associated with hospitalization and discharge status for cirrhosis and portal hypertension are not widely reported. Data from the National Inpatient Sample (NIS) for the period of 1999-2008 were recently examined for this population. The Healthcare Cost and Utilization Project Internet tool2 was used to extract information from the NIS on discharges, length of stay, and discharge patterns. Patients with cirrhosis and complications of portal hypertension were identified with the appropriate codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (571.0, 571.1, 571.2, 571.3, 571.40-571.49, 571.5, 571.6, 571.8, 571.9, 456.0, 456.20-456.21, 572.0, 576.0, 572.2, and 572.4); these codes include conditions such as variceal bleeding, ascites, hepatic encephalopathy, and hepatorenal syndrome.
According to this analysis, 1,450,759 hospitalizations were recorded over the 10-year period (Table 1), and there were 18% more admissions in 2008 versus 1999. Notably, the average length of stay did not significantly change during this period (from 6.8 days in 1999 to 6.4 days in 2008). Remarkably, the overall in-hospital mortality rate decreased by 30% (from roughly 10% to 7%). However, increases in the use of skilled rehabilitation/nursing facilities and home health care from 12% and 7.7%, respectively, in 1999 to 14% and 11.4%, respectively, in 2008 were observed. Individuals 65 years old or older represented 25% of all admissions for cirrhosis and portal hypertension in 2008.
|Length of stay (days)||6.8||6.6||6.6||6.6||6.5||6.2||6.4||6.2||6.2||6.4|
|Mortality rate (%)||10.31||9.95||10.01||9.10||9.00||8.56||8.23||7.68||6.78||6.93|
|Routine D/C (%)||63.97||64.40||63.46||63.96||63.50||61.97||61.76||61.81||62.57||61.52|
|Rehab/skilled nursing facility (%)||11.96||11.80||12.55||12.68||12.58||13.57||13.33||13.82||13.85||14.07|
|Home health (%)||7.74||7.22||7.99||8.30||8.89||10.07||10.48||10.47||10.62||11.45|
Accounting for known limitations within the NIS,3 I find that these results underscore the rising disease burden and economic impact of cirrhosis and portal hypertension in the United States. The exclusion of patients with cirrhosis and hepatocellular carcinoma to highlight nonmalignant complications implies that the burden of disease is even higher. The combination of more hospitalizations and reduced in-hospital mortality rates suggests that evidence-based care may be translating into clinical benefits. In contrast, the pattern of hospitalizing older patients requiring discharge to nursing-based care also raises the specter of frequent yet unplanned hospital readmission. The severity of illness or variations in the quality of care are likely to influence readmission in this respect. Further studies are needed to identify the reasons for increased hospital use because emerging alternatives such as telemonitoring4 for high-risk patients could have significant implications for managing this disease nationally.