Optimum Sequence of Liver Serology in an Inpatient Setting
Abstract
Aims: To investigate the most cost effective and highest diagnostic yield of sequential vs. ‘shotgun’ approach when evaluating the cause of elevated liver biochemistries in the inpatient setting as it relates to Wilson’s Disease (WD) and Alpha-1 Antitrypsin Disease (AATD).
Materials and Methods: Inpatients without chronic liver disease were evaluated for acute elevated liver biochemistries and stratified into two cohorts: sequential and ‘shotgun’. Sequential had only an acute viral hepatitis panel ordered initially while ‘shotgun’ included the viral hepatitis panel and ceruloplasmin and/or alpha-1 antitrypsin level/phenotype. Diagnostic yield, length of stay, hospital acquired infections, and overall cost were evaluated. Secondary analysis evaluated how often each approach was used by different types of providers and hospital setting.
Results: 738 patients were evaluated, 23% using the ‘shotgun’ approach. Neither approach diagnosed WD or AATD. Patients in the sequential approach were discharged 1.06 days later (p=0.052), contributing to $2337 more per patient. There was no difference in the number of hospital acquired infections between approaches (p=0.36).
Conclusion: In the inpatient setting the yield of screening for WD or AATD in patients presenting with elevated liver biochemistries is low, however if these tests are ordered, it is more cost effective to use a ‘shotgun’ approach.
Keywords: Alpha 1 Antitrypsin; Ceruloplasmin; Wilson's Disease; Liver Biochemistries; Viral Hepatitis
Keywords
References
Arnold et. al. Should Patients with Abnormal Liver Function Tests in Primary Care be Tested for Chronic Viral Hepatitis: Cost Minimisation Analysis Based on a Comprehensively Tested Cohort. BMC Family Practice 2011, 12:9
Tapper EB, Rahni DO, Arnaout R, Lai M. The overuse of serum ceruloplasmin measurement. Am J Med. 2013;126(10):926.e1-5.
Chadwick A, Marks M. Low yield of unselected testing in patients with acutely abnormal liver function tests. JRSM Open. 2016;7(1):2054270415611309.
Cauza E, Maier-Dobersberger T, Polli C, Kaserer K, Kramer L, Ferenci P. Screening for Wilson’s disease in patients with liver diseases by serum ceruloplasmin. J Hepatol 1997;27:358-362.
American Thoracic Society, European Respiratory Society. American Thoracic Society/European Respiratory Society statement: standards for the diagnosis and management of individuals with alpha-1 antitrypsin deficiency. Am J Respir Crit Care Med 2003; 168:818.
Clark VC, Dhanasekaran R, Brantly M, Rouhani F, Schreck P, Nelson DR. Liver test results do not identify liver disease in adults with α(1)-antitrypsin deficiency. Clin Gastroenterol Hepatol. 2012;10(11):1278-83.
Daniel S, Ben-menachem T, Vasudevan G, Ma CK, Blumenkehl M. Prospective evaluation of unexplained chronic liver transaminase abnormalities in asymptomatic and symptomatic patients. Am J Gastroenterol. 1999;94(10):3010-4.
Skelly MM, James PD, Ryder SD. Findings on liver biopsy to investigate abnormal liver function tests in the absence of diagnostic serology. J Hepatol. 2001;35(2):195-9.
Centers for Medicare & Medicaid Services. Medicare Provider Utilization and Payment Data. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/medicare-provider-charge-data/index.html. August 8, 2017. Accessed November 15, 2017.
Fairbanks KD, Tavill AS. Liver disease in alpha 1-antitrypsin deficiency: a review. Am J Gastroenterol. 2008;103(8):2136-41.
Roberts EA, Schilsky ML. Diagnosis and treatment of Wilson disease: an update. Hepatology. 2008;47(6):2089-111.
Gow PJ, Smallwood RA, Angus PW, Smith AL, Wall AJ, Sewell RB. Diagnosis of Wilson’s disease: an experience over three decades. Gut 2000;46:415-419.
Feldman M, Friedman LS, Brandt LJ. Sleisenger and Fordtran's Gastrointestinal and Liver Disease- 2 Volume Set: Pathophysiology, Diagnosis, Management, 10e (Gastrointestinal & Liver Disease (Sleisinger/Fordtran)) 10th Edition; page 1247.
EASL Clinical Practice Guidelines: Wilson's disease. J Hepatol. 2012;56(3):671-85.
Bacon BR, Adams PC, Kowdley KV, Powell LW, Tavill AS. Diagnosis and management of hemochromatosis: 2011 practice guideline by the American Association for the Study of Liver Diseases. Hepatology. 2011;54(1):328-43.
Feldman M, Friedman LS, Brandt LJ. Sleisenger and Fordtran's Gastrointestinal and Liver Disease- 2 Volume Set: Pathophysiology, Diagnosis, Management, 10e (Gastrointestinal & Liver Disease (Sleisinger/Fordtran)) 10th Edition; page 1270.
Alpha-1 Antitrypsin Deficiency. NORD (National Organization for Rare Disorders). https://rarediseases.org/rare-diseases/alpha-1-antitrypsin-deficiency/. Accessed November 17, 2017.
Needham M, Stockley RA. Alpha 1-antitrypsin deficiency. 3: Clinical manifestations and natural history. Thorax. 2004;59(5):441-5.
Bals R. Alpha-1-antitrypsin deficiency. Best Pract Res Clin Gastroenterol. 2010;24(5):629-33.
Lee JH, Brantly M. Molecular mechanisms of alpha1-antitrypsin null alleles. Respir Med. 2000;94 Suppl C:S7-11.
Fairbanks KD, Tavill AS. Liver disease in alpha 1-antitrypsin deficiency: a review. Am J Gastroenterol. 2008;103(8):2136-41.
Bell H,SchrumpfE,FagerholMcK. Heterozygous MZ alpha 1-antitrypsin deficiency in adults with chronic liver disease. Scand J Gastroenterol 1990;25:788–92.
Rahmqvist M, Samuelsson A, Bastami S, Rutberg H. Direct health care costs and length of hospital stay related to health care-acquired infections in adult patients based on point prevalence measurements. Am J Infect Control. 2016;44(5):500-6.
Tapper EB, Saini SD, Sengupta N. Extensive testing or focused testing of patients with elevated liver enzymes. J Hepatol. 2017;66(2):313-319.
O'brien CB. The hospitalized patient with abnormal liver function tests. Clin Liver Dis. 2009;13(2):179-92.
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