S1302 Effect of Bed Size of the Hospital on the Risk of Development of Acute on Chronic Liver Failure (ACLF) in Patients With Decompensated Cirrhosis

Abstract

Introduction: The healthcare cost and utilization project has classified hospitals as small, medium, and large bed size. This division is based on the hospital's region, location, and teaching status. To our knowledge, there have been no studies assessing the impact of bed size on the development of acute on chronic liver failure (ACLF) in patients with decompensated cirrhosis. We hypothesize that large bed size hospitals care for a sicker population and admitted patients have a higher incidence and risk of developing ACLF. Methods: We queried the National Inpatient Sample (NIS) database using ICD-10 codes. ACLF was defined as the presence of renal failure or hepatic encephalopathy and one other organ dysfunction or two non-renal organ failures in patients with cirrhosis and a decompensating event. Decompensating events were defined as presence of ascites, varices, hepatic encephalopathy, or infection. The relationship between hospital bed size and ACLF in patients with decompensated cirrhosis was examined using multivariate analysis. Results: A total of 1.78 million adult patients were admitted with a diagnosis of acute decompensation of cirrhosis. Of these, 945,440 (52.8%) were admitted to large bed size hospitals. Patients admitted to large bed size hospitals had a higher incidence of hepatic encephalopathy, ascites, and variceal bleeding. Patient demographics are presented in Table. Of the total patients admitted with a decompensating event, 830,365 patients (46.4%) met criteria for ACLF. A total of 453,095 patients (54.6%) who developed ACLF were admitted to large bed size hospitals. Our study found that patients admitted to large bed size hospitals have 20% higher odds of developing ACLF (aOR-1.20, 95% CI-1.17-1.23, p< 0.001). Large bed size hospitals were also associated with a higher risk of developing ACLF grades 2 and 3 (aOR-1.27, 95% CI-1.24-1.32, p< 0.001 and aOR-1.73, 95% CI-1.51-1.98, p< 0.001, respectively). Conclusion: Our study identifies hospital bed size as a significant predictor for development of ACLF in patients admitted with decompensated cirrhosis. Targeted education and implementation of best practices focused on large hospitals may help reduce the risk of ACLF. Table 1. - Characteristics of patients with decompensated cirrhosis stratified by bed size of the hospital Small bed size Medium bed size Large bed size Age category < 0.001 18-44 31,090 (9.47) 50,045 (9.73) 101,445 (10.73) 45-64 171,485 (52.23) 272,360 (52.93) 512,485 (54.21) >65 125,725 (38.3) 192,165 (37.34) 331,510 (35.06) Gender < 0.001 Males 189,850 (57.83) 300,920 (58.48) 556,670 (58.88) Females 138,450 (42.17) 213,650 (41.52) 388,770 (41.12) Race < 0.001 White 227,390 (69.26) 340,635 (66.2) 625,285 (66.14) Black 29,690 (9.04) 48,575 (9.44) 92,860 (9.82) Hispanic 50,625 (15.42) 91,275 (17.74) 162,900 (17.23) Asian/Pacific Islander 6,020 (1.83) 9,455 (1.84) 21,015 (2.22) Primary expected payer < 0.001 Medicare 162,880 (49.61) 247,930 (48.18) 441,145 (46.66) Medicaid 77,670 (23.66) 123,200 (23.94) 244,975 (25.91) Private 60,210 (18.34) 96,575 (18.77) 178,480 (18.88) Uninsured 16,945 (5.16) 29,410 (5.72) 50,160 (5.31) Median household income < 0.001 Lowest quartile 95,060 (28.96) 172,670 (33.56) 350,665 (37.09) Second quartile 90,575 (27.59) 135,295 (26.29) 250,605 (26.51) Third quartile 82,330 (25.08) 116,010 (22.55) 207,695 (21.97) Highest quartile 60,335 (18.38) 90,595 (17.61) 136,475 (14.44) Region of hospital < 0.001 Northeast 66,420 (20.23) 94,705 (18.4) 129,295 (13.68) Midwest 67,370 (20.52) 75,890 (14.75) 208,140 (22.02) South 130,055 (39.61) 238,385 (46.33) 365,320 (38.64) West 64,455 (19.63) 105,590 (20.52) 242,685 (25.67) Location < 0.001 Rural 16,570 (5.05) 24,690 (4.8) 86,345 (9.13) Urban 311,730 (94.95) 489,880 (95.2) 859,095 (90.87) Hospital teaching status < 0.001 Non-Teaching 71,525 (21.79) 150,630 (29.27) 292,045 (30.89) Teaching 256,775 (78.21) 363,940 (70.73) 653,395 (69.11) Etiology Alcoholic liver disease 156,510 (47.67) 244,380 (47.49) 446,455 (47.22) 0.3666 Hepatitis C 34,540 (10.52) 56,480 (10.98) 100,680 (10.65) 0.1372 Decompensations Hepatic encephalopathy 115,795 (35.27) 185,220 (36.00) 354,280 (37.47) < 0.001 Ascites 186,590 (56.84) 300,505 (58.4) 582,875 (61.65) < 0.001 Varices 24,005 (7.31) 42,230 (8.21) 75,715 (8.01) < 0.001 Bacterial infections 145,525 (44.33) 221,525 (43.05) 386,985 (40.93) < 0.001 ACLF 142,565 (43.43) 234,705 (45.61) 453,095 (47.92) < 0.001