A Prospective Multimodal Education Intervention for Providers Does Not Increase Hepatic Encephalopathy Treatment Rates

Patrick A Twohig; Thoetchai Bee Peeraphatdit; Kaeli Samson; Makayla Schissel; Lynette Smith; Allison Ashford; Laura Freese; Timothy McCashland

doi:10.1007/s10620-024-08445-2

A Prospective Multimodal Education Intervention for Providers Does Not Increase Hepatic Encephalopathy Treatment Rates

Dig Dis Sci. 2024 Apr 23. doi: 10.1007/s10620-024-08445-2. Online ahead of print.

Authors

Patrick A Twohig¹, Thoetchai Bee Peeraphatdit², Kaeli Samson³, Makayla Schissel³, Lynette Smith³, Allison Ashford⁴, Laura Freese⁴, Timothy McCashland³

Affiliations

¹ Division of Gastroenterology & Hepatology, University of Nebraska Medical Center, 982000 Medical Center Drive, Omaha, NE, 68198-2000, USA. patwohig@gmail.com.
² Division of Gastroenterology & Hepatology, University of Nebraska Medical Center, 982000 Medical Center Drive, Omaha, NE, 68198-2000, USA.
³ Department of Biostatistics, University of Nebraska Medical Center, 984375 Nebraska Medical Center, Omaha, NE, 68198, USA.
⁴ Departments of Internal Medicine & Hospital Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA.

PMID: 38652390
DOI: 10.1007/s10620-024-08445-2

Abstract

Background: Over 50% of hospitalizations from hepatic encephalopathy (HE) are preventable, but patients often do not receive medical treatment.

Aims: To use a multimodal education intervention (MMEI) to increase HE treatment rates and to evaluate (1) trends in HE treatment, (2) predictors of receiving treatment, and (3) the impact of treatment on hospitalization outcomes.

Methods: Prospective single-center cohort study of patients hospitalized with HE from April 1, 2020-September 30, 2022. The first 15 months were a control ("pre-MMEI"), the subsequent 15 months (MMEI) included three phases: (1) prior authorization resources, (2) electronic order set, and (3) in-person provider education. Treatment included receiving any drug (lactulose or rifaximin), or combination therapy. Treatment rates pre- vs. post-MMEI were compared using logistic regression.

Results: 471 patients were included. There were lower odds of receiving any drug post-MMEI (p = 0.03). There was no difference in receiving combination therapy pre- or post-MMEI (p = 0.32). Predictors of receiving any drug included alcohol-related or cryptogenic cirrhosis (p's < 0.001), and the presence of ascites (p = 0.005) and/or portal hypertension (p = 0.003). The only significant predictor of not receiving any drug treatment was having autoimmune cirrhosis (p < 0.001). Patients seen by internal medicine (p = 0.01) or who were intoxicated (p = 0.02) were less likely to receive rifaximin. Any treatment was associated with higher 30-day liver disease-specific readmission (p < 0.001).

Conclusion: This MMEI did not increase HE treatment rates, suggesting that alternative strategies are needed to identify and address barriers to treatment.

Keywords: Hepatic encephalopathy; Hospital readmission; Hospitalization; Inpatient mortality; Medical education; Quality improvement.