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

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

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

4. 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

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

6. 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

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

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

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

10. Statistics:  Categorical variables: Pearson X 2  Continuous variables: Student t test  Re-examination of stats after excluding those who died on the day of admission

11. Results  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%

12. Results

13. 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

14. 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

15. 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

16. 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

17. Results: Primary Outcome  Delayed para 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)

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

19. 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

20. 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

21. 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%

22. Discussion Secondary 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/$?

23. 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

24. 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.