Mumtaz Score for Readmission in Cirrhosis

Why did you develop the Mumtaz Score? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?

In our daily clinical practice, we see patients with decompensated cirrhosis (DC). Patients with DC are usually identified based on the presence of ascites, hepatic encephalopathy, variceal bleeding, or spontaneous bacterial peritonitis, etc. Approximately ⅓ of these patients are readmitted within 30 days. Early readmissions in patients with DC lead to an enormous burden on health care utilization. Moreover, patients who are readmitted are at increased risk of calendar year mortality.

There are risk score models available for patients with other chronic diseases such as congestive heart failure, asthma, etc. However, no validated risk score model is available for patients with DC. Lack of a validated risk model for patients with DC led me to develop the Mumtaz Score.

Given the economic burden of hospital readmissions, the Patient Protection and Affordable Care Act instituted the Readmission Reduction Program, which required the Centers for Medicare & Medicaid Services (CMS) to reduce payment for hospitals with higher readmission rates. In order to avoid early readmission, it is very important to learn about the risk of readmission and its predictors in patients with DC. The Mumtaz Score has been developed for physicians managing patients with DC to assess the risk of readmission at the time of discharge. It highlights the need for targeted interventions in order to decrease rates of readmission within this population.

What pearls, pitfalls and/or tips do you have for users of the Mumtaz Score? Do you know of cases when it has been applied, interpreted, or used inappropriately?

The Mumtaz Readmission Risk Score has been developed on one of the largest US national readmission databases (2013) and validated on a subsequent year database (2014). A sample of more than 100,000 patients each was used for development and validation of this risk score. Simple variables including demographics, type of insurance, clinical features, interventions and discharge dispositions are used. Therefore, it is generalizable to a large population.

Patients with high risk of post-discharge death such as those on mechanical ventilation, those receiving a palliative consult, and those admitted for common surgical interventions (cholecystectomy, appendectomy, hernia repair) were excluded. We also excluded patients who were admitted electively for any reason, or who had received a liver transplant before or during the index admission. Therefore, the Mumtaz Score is not applicable to these conditions.

What recommendations do you have for doctors once they have applied the Mumtaz Score? Are there any adjustments or updates you would make to the score based on new data or practice changes?

The Mumtaz Score has to be used at the time of discharge of decompensated cirrhosis patients from the index admission. All the variables included are extracted from the index admission. There are certain conditions that needs to be excluded before using the Mumtaz Score for prediction of readmission in patients with DC. Patients with high risk of post-discharge death, such as those on mechanical ventilation, those receiving a palliative consult, and those admitted for common surgical interventions (cholecystectomy, appendectomy, hernia repair) should be excluded from risk prediction. Patients who were admitted electively for any reason, or who had received a liver transplant before or during the index admission, should also be excluded.

How do you use the Mumtaz Score in your own clinical practice? Can you give an example of a scenario in which you use it?

The Mumtaz Score is based on patient demographics, insurance status, clinical features and interventions at the time of index admission. It can be used on inpatients with DC at the time of discharge disposition. An example of a clinical scenario that illustrates the readmission risk score calculation is as follows: A 35-year-old patient (7 points) with decompensated cirrhosis on Medicaid insurance (5 points), with alcoholic liver cirrhosis (0 points), ≥3 Elixhauser comorbidity index (2 points) with ascites (5 points), receiving paracentesis (4 points), and having a routine discharge (0 points) will have a total score of 23. This patient will have an estimated 36% risk (high risk) of readmission in 30 days.

Based on patient’s risk of readmission (low, medium or high), we try our level best to work on the modifiable readmission predictors.  

I have a chance to use the Mumtaz Score during my inpatient service at Ohio State University and found it useful in predicting the early readmission. If you use it based on the inclusion and exclusion criteria, then its ability to predict early readmission is good.

Any other research in the pipeline that you’re particularly excited about?

Yes, we are in the process of developing a protocol to prospectively validate the Mumtaz Score for early readmission in patients with DC. There is no study on prospectively validation of a risk score in patients with DC. In addition to existing variables we are planning to add new variables in our prospective study. Addition of new variables, such as MELD score, child score, liver frailty score, etc. will further improve the predictive ability of our risk score. We are also planning to study various interventions to avoid readmission in patients with DC.  

Khalid Mumtaz, MBBS, is a hepatologist and gastroenterologist at the Ohio State University Wexner Medical Center. He is also an associate professor of medicine at the Ohio State University. Dr. Mumtaz's primary research is focused on hepatitis, cirrhosis, and fatty liver disease.