Title:
Healthcare utilization in chronic liver disease: the importance of pain and prescription opioid use.

Abstract:
The aim of this study was to assess factors associated with healthcare utilization in patients with chronic liver disease with a focus on pain, opioid use and psychiatric symptoms.
We retrospectively assessed a consecutive sample of 1286 visitors to a hepatology clinic with chronic liver disease. Baseline psychiatric symptoms, pain and opioid prescriptions were collected. Liver-related clinic visits, total clinic visits, phone calls and hospitalizations were assessed over a subsequent 6-month period. Multivariable logistic and negative binomial regression models were used to determine the medical and psychosocial factors associated with increased healthcare utilization.
Over a 6-month period, hospitalization was more common among patients with pain (13% vs. 7%, P < 0.0001) and opioid usage (18% vs. 6% P < 0.0001). Pain and opioid usage were independently and significantly associated with an increased hospitalizations and median number of clinic visits and phone calls (P < 0.0001). In multivariable modelling, hospitalization was significantly associated with opioid use (OR = 2.72, CI = 1.72, 4.29), Child's Class B (OR = 2.24, CI = 1.19, 4.14) and C (OR = 8.51, CI = 4.18, 17.27) cirrhosis, and cardiopulmonary disease (OR = 2.11, CI = 1.28, 3.41). Pain and opioid usage were independently and significantly associated with the numbers of phone calls and total outpatient visits, as were medical comorbidities and Child's Class. The significant predictors of increased outpatient liver-related visits were pain (IRR = 1.13, CI = 1.02, 1.26), interferon usage (IRR = 1.75, CI = 1.54, 1.98) and more advanced liver disease (IRR = 1.58, CI = 1.32, 1.88).
Pain and prescription opioid usage were significantly linked to increased healthcare utilization, suggesting the need to evaluate and incorporate evidence-based pain management strategies into routine care of patients with chronic liver disease.