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Introduction Acute pancreatitis (AP) occurs among patients with pancreas-sufficient cystic fibrosis (PS-CF) but is reportedly less common among patients with pancreas-insufficient cystic fibrosis (PI-CF). The incidence of AP may be influenced by cystic fibrosis transmembrane conductance regulator (CFTR) modulator use. We hypothesized that CFTR modulators would reduce AP hospitalizations, with the greatest benefit in PS-CF. Methods MarketScan (2012-2018) was queried for AP hospitalizations and CFTR modulator use among patients with CF. Multivariable Poisson models that enabled crossover between CFTR modulator treatment groups were used to analyze the rate of AP hospitalizations on and off therapy. Pancreas insufficiency was defined by the use of pancreas enzyme replacement therapy. Results A total of 10,417 patients with CF were identified, including 1,795 who received a CFTR modulator. AP was more common in PS-CF than PI-CF (2.9% vs 0.9%, P = 0.007). Overall, the observed rate ratio of AP during CFTR modulator use was 0.33 (95% confidence interval [CI] 0.10, 1.11, P = 0.07) for PS-CF and 0.38 (95% CI 0.16, 0.89, P = 0.03) for PI-CF, indicating a 67% and 62% relative reduction in AP hospitalizations, respectively. In a subset analysis of 1,795 patients who all had some CFTR modulator use, the rate ratio of AP during CFTR modulator use was 0.36 (95% CI 0.13, 1.01, P = 0.05) for PS-CF and 0.53 (95% CI 0.18, 1.58, P = 0.26) for PI-CF. Discussion CFTR modulator use is associated with a reduction in AP hospitalizations among patients with CF. These observational data support the prospective study of CFTR modulators to reduce AP hospitalizations among patients with CF.

Introduction The prevalence and significance of acute liver injury in patients with COVID-19 are poorly characterized. Methods Patients with confirmed COVID-19 who were hospitalized in geographically diverse medical centers in North America were included. Demographics, symptoms, laboratory data results, and outcomes were recorded. Linear and logistic regression identified factors associated with liver injury, in-hospital mortality, and length of stay (LOS). Results Among 1555 patients in the cohort, most (74%) had an elevated alanine aminotransferase (ALT) during hospitalization, which was very severe (> 20 × upper limit of normal [ULN]) in 3%. Severe acute liver injury (ALI) was uncommon, occurring in 0.1% on admission and 2% during hospitalization. No patient developed acute liver failure (ALF). Higher ALT was associated with leukocytosis (per mL3) (β 10.0, 95% confidence interval (CI) 6.7–12.6, p 20 × ULN (unadjusted OR 6.0, 95%CI 3.1–11.5, p 3 × ULN (unadjusted OR 4.4, 95%CI 2.5–7.7, p

BACKGROUND Symptomatic biliary and gallbladder disorders are common in adults with cystic fibrosis (CF) and the prevalence may rise with increasing CF transmembrane conductance regulator modulator use. Cholecystectomy may be considered, but the outcomes of cholecystectomy are not well described among modern patients with CF. AIM To determine the risk profile of inpatient cholecystectomy in patients with CF. METHODS The Nationwide Inpatient Sample was queried from 2002 until 2014 to investigate outcomes of cholecystectomy among hospitalized adults with CF compared to controls without CF. A propensity weighted sample was selected that closely matched patient demographics, patient's individual comorbidities, and hospital characteristics. The propensity weighted sample was used to compare outcomes among patients who underwent laparoscopic cholecystectomy. Hospital outcomes of open and laparoscopic cholecystectomy were compared among adults with CF. RESULTS A total of 1239 inpatient cholecystectomies were performed in patients with CF, of which 78.6% were performed laparoscopically. Mortality was < 0.81%, similar to those without CF (P = 0.719). In the propensity weighted analysis of laparoscopic cholecystectomy, there was no difference in mortality, or pulmonary or surgical complications between patients with CF and controls. After adjusting for significant covariates among patients with CF, open cholecystectomy was independently associated with a 4.8 d longer length of stay (P = 0.018) and an $18449 increase in hospital costs (P = 0.005) compared to laparoscopic cholecystectomy. CONCLUSION Patients with CF have a very low mortality after cholecystectomy that is similar to the general population. Among patients with CF, laparoscopic approach reduces resource utilization and minimizes post-operative complications.

We sought to evaluate hospital outcomes of cirrhosis patients with nonvariceal upper gastrointestinal bleeding (NVUGIB).NVUGIB is common in patients with cirrhosis. However, national outcome studies of these patients are lacking.We utilized the 2014 Nationwide Readmission Database to evaluate NVUGIB in patients with cirrhosis, further stratified as no cirrhosis (NC), compensated cirrhosis (CC), or decompensated cirrhosis (DC). Validated International Classification of Diseases, Ninth Revision, Clinical Modification codes captured diagnoses and interventions. Outcomes included 30-day readmission rates, index admission mortality rates, health care utilization, and predictors of readmission and mortality using multivariable regression analysis.Overall, 13,701 patients with cirrhosis were admitted with NVUGIB. The 30-day readmission rate was 20.8%. Patients with CC were more likely to undergo an esophagogastroduodenoscopy (EGD) within 1 calendar day of admission (74.1%) than patients with DC (67.9%) or NC (69.4%). Patients with DC had longer hospitalizations (4.1 d) and higher costs of care ($11,834). The index admission mortality rate was higher in patients with DC (6.2%) than in patients with CC (1.7%, P0.001) or NC (1.4%, P0.001). Predictors of 30-day readmission included performing an EGD1 calendar day from admission (OR: 1.21; 95% CI, 1.00 to 1.46) and DC (OR: 1.78; 95% CI, 1.54 to 2.06). DC was a predictor of index admission mortality (OR: 3.68; 95% CI, 2.67 to 5.05).NVUGIB among patients with DC is associated with higher readmission rates, mortality rates, and health care utilization compared with patients with CC and NC. Early EGD is a modifiable variable associated with reduced readmission rates. Early identification of high-risk patients and adherence to guidelines may improve clinical outcomes.

The coronavirus disease 2019 pandemic led to changes in individuals' behaviors and healthcare delivery. We examined the impact of these changes on the rates and clinical course of acute pancreatitis (AP).Hospitalizations for AP from March 1 through August 31 in 2019 (baseline group) and the same period in 2020 (pandemic group) were retrospectively reviewed. Univariate and multivariate analyses were used for demographics and outcomes.Two hundred eighty subjects (315 admissions) were identified in 2019 and 237 subjects (264 admissions) in 2020. Subjects in the pandemic group were more likely to have systemic inflammatory response syndrome (40% vs 25%, P0.01), pancreatic necrosis (14% vs 10%, P = 0.03), and persistent organ failure (17% vs 9%, P = 0.01) compared with prepandemic. There was no difference in etiology of AP. A multivariable model indicates that increased comorbidities, prior pancreatitis, pancreatic necrosis, and prescription of opiates at discharge were associated with 30-day readmissions during the pandemic.Fewer patients were admitted for AP during the pandemic, suggesting that patients with milder symptoms avoided hospital interaction. Practices followed during the pandemic, especially avoidance of hospitalization and improved efficiency of hospital management, may reduce the burden of pancreatitis care in the future.

BACKGROUND AND AIM Esophageal variceal bleeding is a dangerous complication of end-stage liver disease. There is limited information evaluating the hypothesis that medical procedures, specifically electroconvulsive therapy (ECT), may lead to variceal bleeding. The current study aims to determine the risk of variceal bleeding among subjects with cirrhosis who undergo ECT compared with other short medical procedures. METHODS The Nationwide Inpatient Sample (2002-2013) and Nationwide Readmissions Database (2010-2014) were queried using International Classification of Disease, Ninth Revision, codes to evaluate all patients 18 years or older with cirrhosis who underwent ECT, bronchoscopy, or cystoscopy, or who experienced in-hospital seizures. Rates of variceal bleeding and hospital outcomes were compared. Multivariable analysis for readmission rate was performed. RESULTS From the Nationwide Inpatient Sample, a total of 5,442,306 patients with cirrhosis were studied, including 840 (0.02%) patients who underwent ECT. Patients who underwent ECT were more likely to have compensated cirrhosis (P < 0.001). Among patients without ECT, 6.8% had variceal bleeding during admission compared with 0% who underwent ECT. From the Nationwide Readmissions Database, 1,383,853 patients were included, including 357 patients (0.03%) who underwent ECT during index admission. Electroconvulsive therapy did not increase the risk of 30- or 90-day readmission for variceal bleeding or mortality compared with other short medical procedures. CONCLUSIONS Electroconvulsive therapy does not increase the risk of variceal bleeding in subjects with compensated and decompensated cirrhosis. Preoperative optimization of these patients should take the risk of bleeding into account based on current guidelines for variceal surveillance.

Cystic fibrosis transmembrane conductance regulator (CFTR) modulators significantly improve pulmonary function in patients with cystic fibrosis (CF) but the effect on hepatobiliary outcomes remains unknown. We hypothesized that CF patients on CFTR modulators would have a decreased incidence of cirrhosis compared to patients not on CFTR modulators or on ursodiol.To investigate the effect of CFTR modulators on the development of cirrhosis in patients with CF.A retrospective analysis was performed using Truven MarketScan from January 2012 through December 2017 including all patients with a diagnosis of CF. Patients were excluded if they underwent a liver transplantation or if they had other etiologies of liver disease including viral hepatitis or alcohol use. Subjects were grouped by use of CFTR modulators, ursodiol, dual therapy, or no therapy. The primary outcome was development of cirrhosis. Kaplan-Meier curves estimated the incidence of cirrhosis and log-rank tests compared incidence curves between treatment groups.A total of 7201 patients were included, of which 955 (12.6%) used a CFTR modulator, 529 (7.0%) used ursodiol, 105 (1.4%) used combination therapy, and 5612 (74.3%) used neither therapy. The incidence of cirrhosis was 0.1% at 1 year and 0.7% at 4 years in untreated patients, 5.9% and 10.1% in the Ursodiol group, and 1.0% and 1.0% in patients who received both therapies. No patient treated with CFTR modulators alone developed cirrhosis. Patients on CFTR modulators alone had lower cirrhosis incidence than untreated patients (CFTR modulators are associated with a reduction in the incidence of cirrhosis compared to other therapies in patients with CF.

Background Esophageal varices are a result of progressive liver disease and portal hypertension. Treatment can be performed with band ligation versus non-selective beta blockers depending on the size of varices, ability to tolerate medications and history of variceal bleeding. Band ligation is an effective intervention with rare but serious complications including bleeding, ulcers and rarely obstruction. Few cases of esophageal obstruction and necrosis caused by banding have been reported, each with varied management from conservative treatment to band removal. Case summary An 89 years old woman with a past medical history of nonalcoholic steatohepatitis cirrhosis presented to the hospital with an inability to swallow one day after screening esophagogastroduodenoscopy where band ligation of esophageal varices was performed for primary prophylaxis. The patient was not able to tolerate her oral secretions. Initial blood work revealed a Model of End Organ Liver Disease score of 7. She was treated with sublingual nitroglycerin for esophageal spasm, a known complication after esophageal banding. When she failed to improve, esophagogastroduodenoscopy was performed and revealed the mucosa surrounding the banded varix was necrosed and blocking the lumen of the esophagus. The band was purposefully dislodged, revealing distal ulceration and stricturing. Within 72 h after band removal, she was tolerating an oral diet. Endoscopy performed 2 wk later revealed an intrinsic stenosis, measuring 8 mm in diameter by 1 cm in length, which was dilated. Conclusion Esophageal obstruction is a complication of variceal banding that should be considered in patients with inability to tolerate oral diet after banding.

Background and Aim The effect of an influenza infection on patients with cirrhosis remains unclear. This study aimed to compare the rate of influenza hospitalizations, influenza associated complications, and healthcare outcomes in patients with and without cirrhosis. Methods Utilizing the Nationwide Inpatient Sample between 2005 and 2013, hospitalized patients with a diagnosis of influenza were identified. Patients with cirrhosis were classified as compensated or decompensated based on the Baveno criteria. Multivariable analyses were performed to evaluate complications of influenza, inpatient mortality and healthcare utilization including length of stay and cost of admission. Results In total, 236,513 patients with a diagnosis of influenza were admitted during the study period, including 1,553 (0.66%) with cirrhosis. Of those with cirrhosis, 1,176 (75.7%) were compensated and 377 (24.3%) were decompensated. On multivariable analysis, influenza patients with cirrhosis had a higher total cost of admission [$1,030; CI: $710-$1,351] compared to the general population. Influenza patients with decompensated cirrhosis had a longer length of stay [1.92 days; CI:1.63-2.21], higher total cost of admission [$5,005; CI: $4,459-$5,551] and increased rates of influenza complications [OR: 2.56; CI:1.32-4.93] compared to patients with compensated cirrhosis. Conclusions Patients with cirrhosis have increased healthcare utilization when admitted with influenza compared to the general population. Providers must advocate for patients with cirrhosis to obtain the influenza vaccine.

BACKGROUND Accurate detection of gastric antral vascular ectasia (GAVE) is critical for proper management of cirrhosis-related gastrointestinal bleeding. However, endoscopic diagnosis of GAVE can be challenging when GAVE overlaps with severe portal hypertensive gastropathy (PHG). AIM To determine the added diagnostic value of virtual chromoendoscopy to high definition white light for real-time endoscopic diagnosis of GAVE and PHG. METHODS We developed an I-scan virtual chromoendoscopy criteria for diagnosis of GAVE and PHG. We tested our criteria in a cross-sectional cohort of cirrhotic adults with GAVE and PHG when high-definition white light endoscopy (HDWLE) diagnosis was in doubt. We then compared the accuracy of I-scan vs HDWLE alone to histology. RESULTS Twenty-three patients were included in this study (65.2% Caucasians and 60.9% males). Chronic hepatitis C was the predominant cause of cirrhosis (43.5%) and seven adults (30.4%) had confirmed GAVE on histology. I-scan had higher sensitivity (100% vs 85.7%) and specificity (75% vs 62.5%) in diagnosing GAVE compared to HDWLE. This translates into a higher, albeit not statistically significant, accuracy of I-scan in detecting GAVE compared to HDWLE alone (82% vs 70%). I-scan was less likely to lead to an accurate diagnosis of GAVE in patients on dialysis (P < 0.05) and in patients with elevated creatinine (P < 0.05). I-scan had similar accuracy to HDWLE in detecting PHG. CONCLUSION This pilot work supports that virtual chromoendoscopy may obviate the need for biopsies when the presence of GAVE is in doubt. Larger studies are needed to assess the impact of virtual chromoendoscopy on success of endoscopic therapy for GAVE.

Introduction and objectives The success of direct-acting antivirals (DAA) has transformed the management of hepatitis C virus (HCV) infection and has led to the expansion of the deceased donor organ pool for liver transplantation. Material and methods We present a single center retrospective review of liver transplantations performed on HCV-seronegative recipients from HCV-seropositive organs from 11/2017 to 05/2020. HCV nucleic acid testing (NAT) was performed on HCV-seropositive donors to assess active HCV infection. Results 42 HCV-seronegative recipients underwent a liver transplant from a HCV-seropositive donor, including 21 NAT negative (20 liver, 1 simultaneous liver kidney transplant) and 21 NAT positive liver transplants. Two (9.5%) HCV antibody positive/NAT negative recipients developed HCV viremia and achieved sustained virologic response with DAA therapy. The remaining patients with available data (19 patients) remained polymerase chain reaction (PCR) negative at 6 months. 20 (95%) of HCV antibody positive/NAT positive recipients had a confirmed HCV viremia. 100% of patients with available data (15 patients) achieved SVR. Observed events include 1 mortality and graft loss and equivalent rates of post-transplant complications between NAT positive and NAT negative recipients. Conclusions HCV-seropositive organs can be safely transplanted into HCV-seronegative patients with minimal complications post-transplant.

INTRODUCTION Given the increased rates of pregnancy in liver transplant recipients, evaluating the safety of pregnancy is crucial. We aim to evaluate pregnancy-related complications and outcomes in liver transplant recipients. METHODS A retrospective nationwide review comparing pregnancy outcomes in liver transplant recipients vs the general population was performed between 2005 and 2013. Propensity-matched and multivariable regression analyses were performed to study pregnancy- and delivery-related complications in addition to patient and hospital outcomes. RESULTS A total of 38,449,030 pregnancy-related admissions were evaluated in this study including 1,469 (0.004%) admissions in liver transplant recipients. Liver transplant recipients were more likely to undergo a caesarean delivery (60% vs 36%) and have a pregnancy-related complication (56% vs 27%) including miscarriage, intrauterine growth restriction, portpartum hemorrhage, hypertension, preeclampsia, and thromboembolism (P < 0.001) compared with the general population. Propensity-weighted analysis revealed higher rates of pregnancy complications (odds ratio 2.11, 95% confidence interval [CI] 1.63-2.73), cost ($3,023, 95% CI $850-$5,197), and longer length of stay (1.52 days, 95% CI 0.62-2.41) in transplant recipients. Liver transplant recipients experienced zero inpatient mortalities compared with 0.01% of the general population. Transplant recipients with at least 1 complication had a longer length of stay (2.45 days, 95% CI 1.44-3.45) and higher cost of admission ($5,205, 95% CI $2,848-$7,561) compared with transplant recipients without a complication. DISCUSSION Pregnancy after liver transplant is associated with higher rates of complications and worse outcomes without an increased risk of mortality.

AIM To determine if racial disparities continue to exist in the treatment of hepatocellular carcinoma (HCC). METHODS A retrospective database analysis using the Nationwide Inpatient Sample was performed including patients with a primary diagnosis of HCC. Univariate and multivariate analyses were utilized to determine racial disparities in liver decompensation, treatment, inpatient mortality, and metastatic disease. RESULTS A total of 62604 patients with HCC were included consisting of 32428 Caucasian, 9726 African-American, 8988 Hispanic, and 11462 patients of other races. Caucasian patients were more likely to undergo curative therapies of liver transplant (OR: 2.66, 95%CI: 1.92-3.68), resection (OR: 1.82, 95%CI: 1.48-2.23), and ablation (OR: 1.77, 95%CI: 1.36-2.30) than African-American patients. Hispanic patients were more likely to undergo transplant (OR: 2.18, 95%CI: 1.40-3.39) and ablation (OR: 1.46, 95%CI: 1.05-2.03) than African-American patients. Patients of other races were more likely to receive a liver transplant (OR: 2.41, 95%CI: 1.62-3.61), resection (OR: 1.79 95%CI: 1.39-2.32), and ablation (OR: 2.03, 95%CI: 1.47-2.80) than African-American patients. There are no differences in the rates of transarterial chemoembolization between races. CONCLUSION Racial disparities in HCC treatment exist despite emphasis to support equality in healthcare. African-American patients are less likely to undergo curative treatments for HCC.

BACKGROUND AND AIM Geographic differences have existed in the management of hepatocellular carcinoma (HCC), and efforts to reduce regional disparities have been initiated. The aim of this study is to use the Nationwide Inpatient Sample to determine if regional disparities in the treatment of HCC continue to exist. METHOD A retrospective database analysis using the Nationwide Inpatient Sample was performed that included patients with a primary diagnosis of HCC. Logistic regression models were utilized to determine geographic disparities in liver decompensation, treatment, inpatient mortality, and metastatic disease. RESULTS This study's locational reach of 62 604 patients included 22 769 patients from the South (36%), 14 554 in the Northeast (23%), 14 041 in the West (22%), and 11 240 in the Midwest (18%). Patients who received treatment in the West were more likely to have inpatient mortality (OR 1.28, 95% CI 1.03, 1.53) than patients who received treatment in the Midwest. No significant differences were observed between rates of resection, ablation, and transarterial chemoembolization when comparing by region. Rates of liver transplantation were lower in the West compared with the Midwest (OR 0.51, 95% CI 0.29, 0.87). There was no significant difference between other regions. CONCLUSION Geographic disparities in the treatment of HCC are improving.

Background and Aims The United States spends more money per person on health care than any other country in the world. Patients with cirrhosis are at an increased risk of health-care utilization. The aim of this study is to evaluate differences in health-care utilization based on the region of treatment during the inpatient management of patients with cirrhosis. Method A retrospective database analysis using the Nationwide Inpatient Sample was performed, including adult patients with a primary diagnosis of cirrhosis determined by ICD-9 codes. Univariate and multivariate analyses were performed to analyze liver decompensation, mortality, length of stay, and total charges in different regions across the United States. Results A total of 75 280 patients with cirrhosis who received treatment in nine different regions across the United States were included. Rates of liver decompensation were significantly decreased in the Pacific region compared to the New England region (OR: 0.69, 95% CI: 0.51-0.94). Length of stay was significantly different between regions; however, the means only varied by half a day and were of minimal clinical significance. Inpatient mortality rates were not significantly different between regions. Total charges for inpatient management between regions were significantly different, with the Pacific region having the highest total hospital charges with a mean of $82 731. Conclusions Health-care utilization during the inpatient management of cirrhosis varies based on the region. The charges for treatment were the highest in the West despite no impact on mortality, minimal improvement in length of stay, and fewer features of decompensation on admission.

Key Clinical Message Significant elevations in alpha‐fetoprotein should raise suspicion for hepatocellular carcinoma as malignancies with metastasis to the liver can elevate the alpha‐fetoprotein level but typically

Crohn’s disease (CD) is a chronically relapsing condition that frequently requires hospitalization. In 2008, the Centers for Medicare and Medicaid Services selected ten conditions that were deemed healthcare-acquired conditions (HACs). Costs related to HACs are not reimbursed as they are considered to be preventable. To determine the prevalence and impact of HACs on hospital outcomes of hospitalized CD patients. This was a cross-sectional study using data from the Nationwide Inpatient Sample between 2007 and 2011 with an extended time frame between 2002 and 2013 to specifically evaluate the prevalence of HACs. CD-related hospitalizations and HACs were identified using International Classification of Diseases, Ninth revision, Clinical modification codes. The trend of HACs between 2002 and 2013 was assessed using a Cochran–Armitage test. Primary outcomes, including hospital mortality, length of stay, and hospital charges, were analyzed using univariate and multivariate analyses. The prevalence of HACs initially increased between 2002 and 2008, remained stable between 2008 and 2011, than significantly decreased from 2011 to 2013. CD patients with HACs had higher hospital mortality, prolonged LOS, and higher hospital charges compared to patients without HACs. The prevalence of HACs among hospitalized CD patients initially increased from 2002 to 2008; however, rates began to decrease between 2011 and 2013. In addition, HACs were associated with worse healthcare outcomes in hospitalized CD patients.

Acute myelogenous leukemia (AML) is the most prevalent acute leukemia and is defined by the presence of myeloid blasts in the blood or bone marrow. Rarely, AML can be present in the gastrointestinal tract. We present a patient with AML undergoing treatment with decitabine who presented with hematemesis. He underwent endoscopy which revealed two 5 mm duodenal ulcers that were biopsied, and pathology was consistent with AML. Endoscopy should be considered in patients with leukemia who present with nausea, vomiting, or signs of bleeding to evaluate for gastrointestinal involvement. Patients diagnosed with AML are treated with chemotherapy.

Background and aim Cirrhosis-related complications are associated with high inpatient mortality, cost, and length of stay. There is a lack of multi-centered studies on interventions for hepatic hydrothorax and its impact on patient outcomes. The aim of this study was to determine the effect of performing thoracentesis for hepatic hydrothorax on hospital length of stay, mortality, cost, and 30-day readmission. Methods A retrospective analysis of the Nationwide Inpatient Sample between 2002 and 2013 and Nationwide Readmission Database during 2013 was performed including patients with a primary diagnosis of hydrothorax or pleural effusion and a secondary diagnosis of cirrhosis based on International Classification of Disease 9 codes. Univariate and multivariate analyses were performed to determine the effect of thoracentesis on patient outcomes during their hospital stay. Results Of the 37 443 patients included from the Nationwide Inpatient Sample, 26 889 (72%) patients underwent thoracentesis. Thoracentesis was associated with a longer length of stay (4.56 days, 95% confidence interval [CI]: 2.40-6.72) and higher total cost ($9449, 95% CI: 3706-15 191). There was no significant difference in inpatient mortality between patients who underwent thoracentesis compared with those who did not. Of the 2371 patients included from the Nationwide Readmission Database, 870 (33%) were readmitted within 30 days. Thoracentesis was not a predictor of readmission; however, transjugular intrahepatic portosystemic shunt (odds ratio: 4.89, 95% CI: 1.17-20.39) and length of stay (odds ratio: 1.02, 95% CI: 1.001-1.05) on index admission were predictors of readmission. Conclusion When considering treatment for hepatic hydrothorax, many factors should contribute to determining the best intervention. While performing thoracentesis may provide immediate relief to symptomatic patients, it should not be considered a long-term intervention given that it increases hospital cost, was associated with longer length of stays, and did not improve mortality.

AIM To determine the readmission rate, its reasons, predictors, and cost of 30-d readmission in patients with cirrhosis and ascites. METHODS A retrospective analysis of the nationwide readmission database (NRD) was performed during the calendar year 2013. All adults cirrhotics with a diagnosis of ascites, spontaneous bacterial peritonitis, or hepatic encephalopathy were identified by ICD-9 codes. Multivariate analysis was performed to assess predictors of 30-d readmission and cost of readmission. RESULTS Of the 59597 patients included in this study, 18319 (31%) were readmitted within 30 d. Majority (58%) of readmissions were for liver related reasons. Paracentesis was performed in 29832 (50%) patients on index admission. Independent predictors of 30-d readmission included age < 40 (OR: 1.39; CI: 1.19-1.64), age 40-64 (OR: 1.19; CI: 1.09-1.30), Medicaid (OR: 1.21; CI: 1.04-1.41) and Medicare coverage (OR: 1.13; CI: 1.02-1.26), > 3 Elixhauser comorbidity (OR: 1.13; CI: 1.05-1.22), nonalcoholic cirrhosis (OR: 1.16; CI: 1.10-1.23), paracentesis on index admission (OR: 1.28; CI: 1.21-1.36) and having hepatocellular carcinoma (OR: 1.21; CI: 1.05; 1.39). Cost of index admission was similar in patients readmitted and not readmitted (P-value: 0.34); however cost of care was significantly more on 30 d readmission ($30959 ± 762) as compared to index admission ($12403 ± 378), P-value: < 0.001. CONCLUSION Cirrhotic patients with ascites have a 33% chance of readmission within 30-d. Younger patients, with public insurance, nonalcoholic cirrhosis and increased comorbidity who underwent paracentesis are at increased risk of readmission. Risk factors for unplanned readmission should be targeted given these patients have higher healthcare utilization.

Background:The Appalachian region is medically underserved and characterized by high morbidity and mortality. We investigated disparities among patients listed for liver transplantation (LT) in wait-list outcomes, according to residence in the Appalachian region.Methods:Data on adult patients listed for LT were obtained from the United Network for Organ Sharing for July 2013 to December 2015. Wait-list outcomes were compared using cause-specific hazard models by region of residence (Appalachian vs non-Appalachian) among patients listed at centers serving Appalachia. Posttransplant patient and graft survival were also compared. The study included 1835 LT candidates from Appalachia and 5200 from non-Appalachian regions, of whom 1016 patients experienced wait-list mortality or were delisted; 3505 received liver transplants.Results:In multivariable analyses, patients from Appalachia were less likely to receive LT (hazard ratio [HR] = 0.86; 95% confidence interval [CI]: 0.79-0.93; P < .001), but Appalachian residence was not associated with wait-list mortality or delisting (HR = 1.03; 95% CI: 0.89-1.18; P = .696). Among liver transplant recipients, patient and graft survival did not differ by Appalachian versus non-Appalachian residence.Conclusion:Appalachian residence was associated with lower access to transplantation after listing for LT. This geographic disparity should be addressed in the current debate over reforming donor liver allocation and patient priority for LT.

Background and Aims The United States spends more money per person on health care than any other country in the world. Patients with cirrhosis are at an increased risk of health‐care utilization. The aim of this study is to evaluate differences in health‐care utilization based on the region of treatment during the inpatient management of patients with cirrhosis. Method A retrospective database analysis using the Nationwide Inpatient Sample was performed, including adult patients with a primary diagnosis of cirrhosis determined by ICD‐9 codes. Univariate and multivariate analyses were performed to analyze liver decompensation, mortality, length of stay, and total charges in different regions across the United States. Results A total of 75 280 patients with cirrhosis who received treatment in nine different regions across the United States were included. Rates of liver decompensation were significantly decreased in the Pacific region compared to the New England region (OR: 0.69, 95% CI: 0.51–0.94). Length of stay was significantly different between regions; however, the means only varied by half a day and were of minimal clinical significance. Inpatient mortality rates were not significantly different between regions. Total charges for inpatient management between regions were significantly different, with the Pacific region having the highest total hospital charges with a mean of $82 731. Conclusions Health‐care utilization during the inpatient management of cirrhosis varies based on the region. The charges for treatment were the highest in the West despite no impact on mortality, minimal improvement in length of stay, and fewer features of decompensation on admission.

Geographic differences have existed in the management of hepatocellular carcinoma (HCC), and efforts to reduce regional disparities have been initiated. The aim of this study is to use the Nationwide Inpatient Sample to determine if regional disparities in the treatment of HCC continue to exist.A retrospective database analysis using the Nationwide Inpatient Sample was performed that included patients with a primary diagnosis of HCC. Logistic regression models were utilized to determine geographic disparities in liver decompensation, treatment, inpatient mortality, and metastatic disease.This study's locational reach of 62 604 patients included 22 769 patients from the South (36%), 14 554 in the Northeast (23%), 14 041 in the West (22%), and 11 240 in the Midwest (18%). Patients who received treatment in the West were more likely to have inpatient mortality (OR 1.28, 95% CI 1.03, 1.53) than patients who received treatment in the Midwest. No significant differences were observed between rates of resection, ablation, and transarterial chemoembolization when comparing by region. Rates of liver transplantation were lower in the West compared with the Midwest (OR 0.51, 95% CI 0.29, 0.87). There was no significant difference between other regions.Geographic disparities in the treatment of HCC are improving.

AIM To evaluate disparities in the treatment of hepatocellular carcinoma (HCC) based on gender. METHODS A retrospective database analysis using the Nationwide Inpatient Sample (NIS) was performed between 2010 and 2013. Adult patients with a primary diagnosis of hepatocellular carcinoma determined by International Classification of Disease 9 (ICD-9) codes were included. Univariate analysis and multivariate logistic regressions were performed to analyze differences in treatment, mortality, features of decompensation, and metastatic disease based on the patient’s gender. RESULTS The analysis included 62582 patients with 45908 men and 16674 women. Women were less likely to present with decompensated liver disease (OR = 0.84, P < 0.001) and had less risk of inpatient mortality when compared to men (OR = 0.75, P < 0.001). Women were more likely to receive inpatient resection (OR = 1.31, P < 0.001) or an ablation (OR = 1.22, P = 0.028) than men. There was no significant difference between men and women in regard to liver transplantation and transcatheter arterial chemoembolization (TACE). CONCLUSION Gender impacts treatment for hepatocellular carcinoma. Women are more likely to undergo an ablation or resection then men. Gender disparities in transplantation have resolved.