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Amador A, Salord S, Xiol X, Garcia-Guix M, Cachero A, Rota R, Hernandez Aretxabaleta N, Baliellas C, Castellote J. Improvement of quality of care provided to outpatients with hepatic cirrhosis after an educational intervention. Eur J Gastroenterol Hepatol 2024; 36:941-944. [PMID: 38625820 DOI: 10.1097/meg.0000000000002778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2024]
Abstract
OBJECTIVE A set of indicators has been reported to measure the quality of care for cirrhotic patients, and previously published studies report variable adherence rates to these indicators. This study aimed to assess the quality of care provided to cirrhotic outpatients before and after an educational intervention by determining its impact on adherence to quality indicators. METHODS We conducted a quasi-experimental, cross-sectional study including 324 cirrhotic patients seen in 2017 and 2019 at a tertiary teaching hospital in Spain. Quality indicators were assessed in five domains: documentation of cirrhosis etiology, disease severity assessment, hepatocellular carcinoma (HCC) screening, variceal bleeding prophylaxis, and vaccination. After identifying areas for improvement, an educational intervention was implemented. A second evaluation was performed after the intervention to assess changes in adherence rates. RESULTS Before the intervention, adherence rates were excellent (>90%) for indicators related to variceal bleeding prophylaxis and documentation of cirrhosis etiology, acceptable (60-80%) for HCC screening and disease severity assessment, and poor (<50%) for vaccinations. After the educational intervention, there was a statistically significant improvement in adherence rates for eight indicators related to HCC screening (70-90%), disease severity assessment (90%), variceal bleeding prophylaxis (>90%), and vaccinations (60-90%). CONCLUSION Our study demonstrates a significant improvement in the quality of care provided to cirrhotic outpatients after an educational intervention. The findings highlight the importance of targeted educational interventions to enhance adherence to quality indicators in the management of cirrhosis.
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Affiliation(s)
- Alberto Amador
- Hepatology Unit, Gastroenterology Department, Hospital Universitari de Bellvitge, Institut Català de la Salut, Hepatobiliary and Pancreatic Diseases Research Group, IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
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Yakovchenko V, Lamorte C, Chinman MJ, Goodrich DE, Gibson S, Park A, Bajaj JS, McCurdy H, Morgan TR, Rogal SS. Comparing the CFIR-ERIC matching tool recommendations to real-world strategy effectiveness data: a mixed-methods study in the Veterans Health Administration. Implement Sci 2023; 18:49. [PMID: 37828539 PMCID: PMC10571268 DOI: 10.1186/s13012-023-01307-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 09/25/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Practical and feasible methods for matching implementation strategies to diagnosed barriers of evidence-based interventions in real-world contexts are lacking. This evaluation compared actual implementation strategies applied with those recommended by an expert opinion-based tool to improve guideline-concordant cirrhosis care in a Veterans Health Administration national learning collaborative effort. METHODS This convergent parallel mixed-methods study aimed to (1) identify pre-implementation Consolidated Framework for Implementation Research (CFIR) barriers to cirrhosis care through focus groups with frontline providers, (2) generate 20 recommended strategies using focus group identified barriers entered into the CFIR-Expert Recommendations for Implementing Change (ERIC) Implementation Strategy Matching Tool, (3) survey providers over two consecutive years on the actual use of 73 ERIC strategies and determine strategy effectiveness, (4) compare actual versus recommended strategy use, and (5) compare actual versus expected barriers by reverse applying the CFIR-ERIC Matching Tool. RESULTS Eighteen semi-structured focus groups were conducted with 197 providers representing 95 VA sites to identify barriers to quality improvement, including cirrhosis care complexity, clarity of national goals, and local leadership support. The CFIR-ERIC Matching Tool recommended strategies such as assessing for readiness and needs, promoting adaptability, building local groups, preparing champions, and working with opinion leaders and early adopters. Subsequent strategy surveys found that sites used the top 20 "recommended" strategies no more frequently than other strategies. However, 14 (70%) of the top recommended strategies were significantly positively associated with cirrhosis care compared to 48% of actual strategies. Reverse CFIR-ERIC matching found that the strategies most used in the first year corresponded to the following barriers: opinion leaders, access to knowledge and information, and resources. The strategies most frequently employed in the second year addressed barriers such as champions, cosmopolitanism, readiness for implementation, relative priority, and patient needs and resources. Strategies used in both years were those that addressed adaptability, trialability, and compatibility. CONCLUSIONS This study is among the first to empirically evaluate the relationship between CFIR-ERIC Matching Tool recommended strategies and actual strategy selection and effectiveness in the real world. We found closer connections between recommended strategies and strategy effectiveness compared to strategy frequency, suggesting validity of barrier identification, and application of the expert-informed tool.
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Affiliation(s)
- Vera Yakovchenko
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive C (151C), Building 30, Pittsburgh, PA, 15240-1001, USA
| | - Carolyn Lamorte
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive C (151C), Building 30, Pittsburgh, PA, 15240-1001, USA
| | - Matthew J Chinman
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive C (151C), Building 30, Pittsburgh, PA, 15240-1001, USA
- Mental Health Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- RAND Corporation, Pittsburgh, PA, USA
| | - David E Goodrich
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive C (151C), Building 30, Pittsburgh, PA, 15240-1001, USA
| | - Sandra Gibson
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive C (151C), Building 30, Pittsburgh, PA, 15240-1001, USA
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA
| | - Angela Park
- Department of Veterans Affairs, Office of Healthcare Transformation, Washington, DC, USA
| | - Jasmohan S Bajaj
- Division of Gastroenterology and Hepatology, Central Virginia VA Health Care System, Richmond, VA, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Timothy R Morgan
- Gastroenterology Section, VA Long Beach Healthcare System, Long Beach, CA, USA
- Department of Medicine, University of California Irvine, Orange, CA, USA
| | - Shari S Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive C (151C), Building 30, Pittsburgh, PA, 15240-1001, USA.
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
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Dutta N, Kc M, Wang Q, Lim N. Impact of Gastroenterology Consultation on the Clinical Outcomes of Patients Admitted With Hepatic Encephalopathy. Cureus 2023; 15:e41610. [PMID: 37565113 PMCID: PMC10409643 DOI: 10.7759/cureus.41610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 08/12/2023] Open
Abstract
Introduction Hepatic encephalopathy (HE) is a common complication of cirrhosis and a common reason for hospital admission. We aimed to determine whether expert consultation from gastroenterology (GI) leads to better clinical outcomes for inpatients with HE. Methods A retrospective review was performed of all adult patients (age ≥ 18) admitted with HE to a tertiary care hospital between January 2013 and April 2018. Patients who received a GI consult were compared to patients who did not receive a GI consult (No consult group). The primary outcome was hospital length of stay (LOS); secondary outcomes were rates of 30-day hospital readmission and 90-day mortality. Multivariate analysis was conducted to adjust for known confounders. Results Four hundred and twenty-five patients (814 encounters) were included in the study; of these, 236 patients had received a GI consultation for HE. Patients in the GI consult group were younger (mean age 55 vs 58 years, p= 0.02) and had higher Model For End-Stage Liver Disease-sodium (MELD-Na) score (mean MELD-Na 23.5 vs 17.5, p<0.01) compared to patients who did not receive GI consultation. The precipitants of HE were significantly different between the groups: there was more spontaneous bacterial peritonitis (SBP) and GI bleeding (GIB) in the GI consult group and more lactulose non-adherence in the no consult group. There was no difference in the etiology of liver disease between the two groups. Median LOS for the GI consult group was six days vs three days in the no consult group (p<0.01); the incidence rate ratio was 1.79 (95%CI 1.59-2.02, p<0.01) on multivariate analysis. There was no difference in 30-day readmission or 90-day mortality between the two groups. Conclusion GI consultation for patients with HE admitted to a hospital medicine service may be associated with longer LOS. In selected patients admitted with HE, GI consultation may not be necessary to achieve good clinical outcomes.
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Affiliation(s)
- Nirjhar Dutta
- Division of Hospital Medicine, University of Minnesota, Minneapolis, USA
| | - Mandip Kc
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, USA
| | - Qi Wang
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, USA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, USA
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Gan M, Zong L, Yu X, Xu J. The effect of prophylactic antibiotics in acute upper gastrointestinal bleeding patients in the emergency department. World J Emerg Med 2023; 14:442-447. [PMID: 37969213 PMCID: PMC10632749 DOI: 10.5847/wjem.j.1920-8642.2023.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 05/12/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Currently, prophylactic antibiotics are recommended only for cirrhotic patients with acute upper gastrointestinal bleeding (AUGIB); however, the benefit for other AUGIB patients remains undetermined. We aimed to compare the clinical outcomes between patients with AUGIB with and without prophylactic antibiotics to identify the population that requires this therapy. METHODS Patients with AUGIB admitted between 1st January 2019 and 31st December 2021 in the Emergency Department of Peking Union Medical College Hospital were enrolled. Patients were divided into the antibiotic and non-antibiotic groups. The primary outcome was in-hospital mortality, and the secondary outcome was the onset of new infection. The risk factors for mortality and infection were analyzed, and stratification analysis of prophylactic antibiotics was performed. Continuous data were analyzed using the t-test or nonparametric rank sum test, and categorical data were analyzed using the Chi-square test or Fisher's exact test. Indicators with significant differences between the groups were included for logistic regression analysis. A P-value <0.05 was considered statistically significant. RESULTS A total of 392 individuals were included, among them, 281 patients received prophylactic antibiotics, and 111 patients did not receive prophylactic antibiotics. The mortality rates were significantly lower in the antibiotic group than in the non-antibiotics group (6.41% vs. 17.12%, P=0.001). The risk factors for infection were varicose veins (P=0.045) and endotracheal intubation (P=0.005) in the prophylactic antibiotic group, and endoscopic treatment (P=0.010) in the non-prophylactic antibiotic group. Stratified analyses showed that patients with age ≥ 65 years, endotracheal intubation, endoscopic treatment, and AUGIB of variceal etiologies benefited from prophylactic antibiotics. CONCLUSION AUGIB patients may benefit from prophylactic antibiotics to decrease mortality, especially those aged ≥ 65 years and those with endotracheal intubation, endoscopic treatment, and variceal etiologies.
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Affiliation(s)
- Miao Gan
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Liang Zong
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Xuezhong Yu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Jun Xu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
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Yakovchenko V, Morgan TR, Miech EJ, Neely B, Lamorte C, Gibson S, Beste LA, McCurdy H, Scott D, Gonzalez R, Park A, Powell BJ, Bajaj JS, Dominitz JA, Chartier M, Ross D, Chinman MJ, Rogal SS. Core implementation strategies for improving cirrhosis care in the Veterans Health Administration. Hepatology 2022; 76:404-417. [PMID: 35124820 PMCID: PMC9288973 DOI: 10.1002/hep.32395] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/11/2022] [Accepted: 01/14/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS The Veterans Health Administration (VHA) provides care for more than 80,000 veterans with cirrhosis. This longitudinal, multimethod evaluation of a cirrhosis care quality improvement program aimed to (1) identify implementation strategies associated with evidence-based, guideline-concordant cirrhosis care over time, and (2) use qualitative interviews to operationalize strategies for a manualized intervention. APPROACH AND RESULTS VHA providers were surveyed annually about the use of 73 implementation strategies to improve cirrhosis care in fiscal years 2018 (FY18) and 2019 (FY19). Implementation strategies linked to guideline-concordant cirrhosis care were identified using bivariate statistics and comparative configurational methods. Semistructured interviews were conducted with 12 facilities in the highest quartile of cirrhosis care to specify the successful implementation strategies and their mechanisms of change. A total of 106 VHA facilities (82%) responded at least once over the 2-year period (FY18, n = 63; FY19, n = 100). Facilities reported using a median of 12 (interquartile range [IQR] 20) implementation strategies in FY18 and 10 (IQR 19) in FY19. Of the 73 strategies, 35 (48%) were positively correlated with provision of evidence-based cirrhosis care. Configurational analysis identified multiple strategy pathways directly linked to more guideline-concordant cirrhosis care. Across both methods, a subset of eight strategies was determined to be core to cirrhosis care improvement and specified using qualitative interviews. CONCLUSIONS In a national cirrhosis care improvement initiative, a multimethod approach identified a core subset of successful implementation strategy combinations. This process of empirically identifying and specifying implementation strategies may be applicable to other implementation challenges in hepatology.
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Affiliation(s)
- Vera Yakovchenko
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
| | - Timothy R. Morgan
- Gastroenterology Section, VA Long Beach Healthcare System, Long Beach, CA,Division of Gastroenterology, Department of Medicine, University of California, Irvine, CA
| | - Edward J. Miech
- Department of Veterans Affairs, Roudebush VA Medical Center, HSR&D Center for Health Information & Communication, VA PRIS-M QUERI, Indianapolis, IN,Regenstrief Institute, Indianapolis, IN
| | - Brittney Neely
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Carolyn Lamorte
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Sandra Gibson
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA,Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Lauren A. Beste
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA,General Medicine Service, VA Puget Sound Health Care System, Seattle, WA
| | | | - Dawn Scott
- Department of Medicine, Central Texas Veterans Healthcare System, Temple, TX
| | - Rachel Gonzalez
- Department of Veterans Affairs, Sierra Pacific Veterans Integrated Service Network, Pharmacy Benefits Management, Mather, CA
| | - Angela Park
- Office of Healthcare Transformation, Department of Veterans Affairs, Washington, DC
| | - Byron J. Powell
- Brown School, Washington University in St. Louis, St. Louis, MO
| | - Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, Richmond, VA,Division of Gastroenterology, Central Virginia Veterans Affairs Healthcare System, Richmond, VA
| | - Jason A. Dominitz
- Gastroenterology Section, Veterans Affairs Puget Sound Health Care System, Seattle, WA,Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Maggie Chartier
- HIV, Hepatitis, and Related Conditions Programs, Office of Specialty Care Services, Veterans Health Administration, Washington, DC
| | - David Ross
- HIV, Hepatitis, and Related Conditions Programs, Office of Specialty Care Services, Veterans Health Administration, Washington, DC
| | - Matthew J. Chinman
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA,RAND Corporation, Pittsburgh, PA
| | - Shari S. Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA,Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, PA,Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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Volk ML, Clarke C, Asrani SK, Khaderi S, Bansal MB, Tapper EB, Ho C, Chung RT, Lake J, Lim N, Fortune BE, Kim R, Dronamraju D, Kanwal F. Cirrhosis Quality Collaborative. Clin Gastroenterol Hepatol 2022; 20:970-972. [PMID: 35123089 DOI: 10.1016/j.cgh.2022.01.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Michael L Volk
- Division of Gastroenterology and Transplant Institute, Loma Linda University Health, Loma Linda, California.
| | | | | | - Saira Khaderi
- Sections of Gastroenterology and Hepatology and Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Meena B Bansal
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | - Chanda Ho
- Division of Hepatology, Department of Transplant, California Pacific Medical Center, San Francisco, California
| | - Raymond T Chung
- Liver Center, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - John Lake
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Brett E Fortune
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California
| | - Deepti Dronamraju
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California
| | - Fasiha Kanwal
- Baylor College of Medicine and VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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Acute variceal bleeding and out-of-hours endoscopy: Evaluation of an emergency care setting according to Baveno VI guidelines adherence. Dig Liver Dis 2021; 53:1320-1326. [PMID: 34348881 DOI: 10.1016/j.dld.2021.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The extent to which patients with acute variceal bleeding (AVB) receive recommended care is largely unknown. AIM to evaluate the adherence of the 4 major Baveno VI recommendations [vasoactive agents, prophylactic antibiotic, esophagogastroduodenoscopy (EGD) within 12 hours, endoscopic variceal ligation (EVL)] as a marker of quality of an emergency model. METHODS Retrospective evaluation of AVB admissions to a tertiary centre in which endoscopy was available 24hours-a-day, with a regional out-of-hours service at night (the furthest hospital is 200Km away). Patients were divided in directly admitted or transferred from other centres. RESULTS 210 AVB patients were included; 101 (48.1%) were directly admitted. The majority of patients were submitted to vasoactive agents (85.7%) and prophylactic antibiotics (79%) before EGD. In 178 patients (84.8%) endoscopy was performed within 12h and EVL was the procedure of choice in 116 (74.8%) (only oesophageal varices). No significant differences were observed between directly admitted and transferred patients in adherence rates. Overall rebleeding rate was 8.6%, in-hospital mortality 11.4% and 6-week mortality 20%. CONCLUSION Adherence to quality metrics was high which might have played a vital role for reported outcomes. These results suggest that this model of care, provides accessibility and equity in access to urgent endoscopy.
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Gonzalez JJ, DiBattista J, Gomez V, Gonzalez E, Zhang Q, Vaughn VM, Tapper EB. Impact of Inpatient Attending Specialty and Gastroenterology Consultation on Quality of Care of Patients Hospitalized with Decompensated Cirrhosis. Am J Med 2021; 134:1270-1277.e2. [PMID: 34144013 PMCID: PMC10838397 DOI: 10.1016/j.amjmed.2021.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Data suggest hospitalists are less adherent to quality indicators for decompensated cirrhosis, and gastroenterology consultation may improve adherence. We sought to evaluate the impact of inpatient attending specialty and gastroenterology consultation on quality of care for decompensated cirrhosis. METHODS This was a retrospective cohort study of patients with decompensated cirrhosis admitted to gastroenterology or hospitalist service at the University of Michigan between 2016-2020. The primary outcome was adherence to nationally recommended inpatient quality indicators for ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, and gastrointestinal bleeding. Performance was calculated per patient admission as the proportion of quality indicators met vs quality indicators for which the patient was eligible. Quality indicator scores were compared between services using t-tests. We also evaluated the effect of gastroenterology consultation on quality indicator scores for patients admitted to hospitalist service. Clinical outcomes were compared using multivariable models adjusted for patient characteristics. RESULTS Two hundred eighty-eight admissions were included (155 to gastroenterology service; 133 to hospitalist service). Quality indicator score for all admissions was 69.9% (standard deviation [SD] ± 24.2%). Quality indicator scores were similar between gastroenterology (69.9%, SD ± 23.6%) and hospitalist (69.8%, SD ± 25.1%) services (P = .913). There was no difference in quality indicator subscores for each complication between services. Hospitalists placed a gastroenterology consultation in 53.4% of admissions, and it was associated with higher albumin administration for patients with spontaneous bacterial peritonitis (57.1% vs 25%, P = .044). Patients admitted to gastroenterology service had higher readmissions within 30 days (adjusted odds ratio = 1.95) and shorter length of hospitalization (adjusted rate ratio = 0.85). CONCLUSIONS Hospitalists provided comparable quality of care to gastroenterologists for inpatients with decompensated cirrhosis.
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Affiliation(s)
- Juan J Gonzalez
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.
| | - Jacob DiBattista
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | | | - Emelie Gonzalez
- Facultad de Medicina Dr. Jose Edmundo Vasquez, Universidad Dr. Jose Matias Delgado, La Libertad, El Salvador
| | - Qisu Zhang
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah Medical School, Salt Lake City
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
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Kc M, Olson APJ, Wang Q, Lim N. Unexpected clinical outcomes following the implementation of a standardised order set for hepatic encephalopathy. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000621. [PMID: 33866310 PMCID: PMC8055129 DOI: 10.1136/bmjgast-2021-000621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/14/2021] [Accepted: 03/27/2021] [Indexed: 11/08/2022] Open
Abstract
Objective We evaluated the effect on clinical outcomes of implementing a standardised inpatient order set for patients admitted with hepatic encephalopathy (HE). Methods A retrospective review of patients with cirrhosis admitted with HE. Hospital admissions for HE for which the electronic health record (EHR) order set was used were compared with admissions where the order set was not used. Primary outcome was length of hospital stay (LOS). Secondary outcomes were 30-day readmissions, in-hospital complications, in-hospital and 90-day mortality. Results There were 341 patients with 980 admissions over the study period: 263 patients with 736 admissions where the order set was implemented, and 78 patients with 244 admissions where the order set was not implemented. Median LOS was 4 days (IQR 3–8) in the order set group compared with 3 days (IQR 2–7) (p<0.001); incidence rate ratio 1.37 (95% CI 1.20 to 1.57), p<0.001. 30-day readmissions rate was 56% in the order set group compared with 40%, p=0.01; OR for readmission was 1.88 (95% CI 1.04 to 3.43), p=0.04. Hypokalaemia occurred in 46% of admissions with order set use compared with 36%, when the order set was not used; p=0.003, OR 1.72 (95% CI 1.22 to 2.43), p=0.002. No significant differences were seen for in-hospital mortality and 90-day mortality. Conclusion Implementation of an inpatient EHR order set for use in patients with HE was associated with unexpected clinical outcomes including increased LOS and readmissions. The convenience and advantages of standardisation of patient care should be balanced with a degree of individualisation, particularly in the care of medically complex patients. Furthermore, standardised processes should be evaluated frequently after implementation to assess for unintended consequences.
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Affiliation(s)
- Mandip Kc
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Andrew P J Olson
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA.,Department of Pediatrics, Division of Pediatric Hospital Medicine, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Qi Wang
- Clinical and Translational Science Institute, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Nicholas Lim
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
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Kanwal F, Taylor TJ, Kramer JR, Cao Y, Smith D, Gifford AL, El-Serag HB, Naik AD, Asch SM. Development, Validation, and Evaluation of a Simple Machine Learning Model to Predict Cirrhosis Mortality. JAMA Netw Open 2020; 3:e2023780. [PMID: 33141161 PMCID: PMC7610191 DOI: 10.1001/jamanetworkopen.2020.23780] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/01/2020] [Indexed: 12/12/2022] Open
Abstract
Importance Machine-learning algorithms offer better predictive accuracy than traditional prognostic models but are too complex and opaque for clinical use. Objective To compare different machine learning methods in predicting overall mortality in cirrhosis and to use machine learning to select easily scored clinical variables for a novel cirrhosis prognostic model. Design, Setting, and Participants This prognostic study used a retrospective cohort of adult patients with cirrhosis or its complications seen in 130 hospitals and affiliated ambulatory clinics in the integrated, national Veterans Affairs health care system from October 1, 2011, to September 30, 2015. Patients were followed up through December 31, 2018. Data were analyzed from October 1, 2017, to May 31, 2020. Exposures Potential predictors included demographic characteristics; liver disease etiology, severity, and complications; use of health care resources; comorbid conditions; and comprehensive laboratory and medication data. Patients were randomly selected for model development (66.7%) and validation (33.3%). Three different statistical and machine learning methods were evaluated: gradient descent boosting, logistic regression with least absolute shrinkage and selection operator (LASSO) regularization, and logistic regression with LASSO constrained to select no more than 10 predictors (partial pathway model). Predictor inclusion and model performance were evaluated in a 5-fold cross-validation. Last, the predictors identified in the most parsimonious (the partial path) model were refit using maximum-likelihood estimation (Cirrhosis Mortality Model [CiMM]), and its predictive performance was compared with that of the widely used Model for End Stage Liver Disease with sodium (MELD-Na) score. Main Outcomes and Measures All-cause mortality. Results Of the 107 939 patients with cirrhosis (mean [SD] age, 62.7 [9.6] years; 96.6% male; 66.3% white, 18.4% African American), the annual mortality rate ranged from 8.8% to 15.3%. In total, 32.7% of patients died within 3 years, and 46.2% died within 5 years after the index date. Models predicting 1-year mortality had good discrimination for the gradient descent boosting (area under the receiver operating characteristics curve [AUC], 0.81; 95% CI, 0.80-0.82), logistic regression with LASSO regularization (AUC, 0.78; 95% CI, 0.77-0.79), and the partial path logistic model (AUC, 0.78; 95% CI, 0.76-0.78). All models showed good calibration. The final CiMM model with machine learning-derived clinical variables offered significantly better discrimination than the MELD-Na score, with AUCs of 0.78 (95% CI, 0.77-0.79) vs 0.67 (95% CI, 0.66-0.68) for 1-year mortality, respectively (DeLong z = 17.00; P < .001). Conclusions and Relevance In this study, simple machine learning techniques performed as well as the more advanced ensemble gradient boosting. Using the clinical variables identified from simple machine learning in a cirrhosis mortality model produced a new score more transparent than machine learning and more predictive than the MELD-Na score.
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Affiliation(s)
- Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Veterans Affairs (VA) Health Services Research and Development Service Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas
- Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Thomas J. Taylor
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Jennifer R. Kramer
- Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Veterans Affairs (VA) Health Services Research and Development Service Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas
- Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Yumei Cao
- Veterans Affairs (VA) Health Services Research and Development Service Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas
- Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Donna Smith
- Veterans Affairs (VA) Health Services Research and Development Service Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas
- Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Allen L. Gifford
- Department of Medicine, VA Boston Healthcare System, Boston University, Boston, Massachusetts
- Department of Health Law, Policy, and Management, VA Boston Healthcare System, Boston University, Boston, Massachusetts
| | - Hashem B. El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Veterans Affairs (VA) Health Services Research and Development Service Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas
- Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Aanand D. Naik
- Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Veterans Affairs (VA) Health Services Research and Development Service Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas
- Michael E. DeBakey VA Medical Center, Houston, Texas
- Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Steven M. Asch
- Veterans Affairs (VA) Health Services Research and Development Service Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California
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11
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Rogal SS, Yakovchenko V, Morgan T, Bajaj JS, Gonzalez R, Park A, Beste L, Miech EJ, Lamorte C, Neely B, Gibson S, Malone PS, Chartier M, Taddei T, Garcia-Tsao G, Powell BJ, Dominitz JA, Ross D, Chinman MJ. Getting to implementation: a protocol for a Hybrid III stepped wedge cluster randomized evaluation of using data-driven implementation strategies to improve cirrhosis care for Veterans. Implement Sci 2020; 15:92. [PMID: 33087156 PMCID: PMC7579930 DOI: 10.1186/s13012-020-01050-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 10/05/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Cirrhosis is a rapidly increasing cause of global mortality. To improve cirrhosis care, the Veterans Health Administration (VHA) developed the Hepatic Innovation Team (HIT) Collaborative to support VA Medical Centers (VAMCs) to deliver evidence-based cirrhosis care. This randomized HIT program evaluation aims to develop and assess a novel approach for choosing and applying implementation strategies to improve the quality of cirrhosis care. METHODS Evaluation aims are to (1) empirically determine which combinations of implementation strategies are associated with successful implementation of evidence-based practices (EBPs) for Veterans with cirrhosis, (2) manualize these "data-driven" implementation strategies, and (3) assess the effectiveness of data-driven implementation strategies in increasing cirrhosis EBP uptake. Aim 1 will include an online survey of all VAMCs' use of 73 implementations strategies to improve cirrhosis care, as defined by the Expert Recommendations for Implementing Change taxonomy. Traditional statistical as well as configurational comparative methods will both be employed to determine which combinations of implementation strategies are associated with site-level adherence to EBPs for cirrhosis. In aim 2, semi-structured interviews with high-performing VAMCs will be conducted to operationalize successful implementation strategies for cirrhosis care. These data will be used to inform the creation of a step-by-step guide to tailoring and applying the implementation strategies identified in aim 1. In aim 3, this manualized implementation intervention will be assessed using a hybrid type III stepped-wedge cluster randomized design. This evaluation will be conducted in 12 VAMCs, with four VAMCs crossing from control to intervention every 6 months, in order to assess the effectiveness of using data-driven implementation strategies to improve guideline-concordant cirrhosis care. DISCUSSION Successful completion of this innovative evaluation will establish the feasibility of using early evaluation data to inform a manualized, user-friendly implementation intervention for VAMCs with opportunities to improve care. This evaluation will provide implementation support tools that can be applied to enhance the implementation of other evidence-based practices. TRIAL REGISTRATION This project was registered at ClinicalTrials.Gov ( NCT04178096 ) on 4/29/20.
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Affiliation(s)
- Shari S Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R), University Drive C, Pittsburgh, PA, 15240, USA. .,Departments of Medicine and Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Vera Yakovchenko
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, USA
| | - Timothy Morgan
- Gastroenterology Section, VA Long Beach Healthcare System, Long Beach, CA, USA.,Division of Gastroenterology, Department of Medicine, University of California, Irvine, CA, USA
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, Richmond, VA, USA.,Division of Gastroenterology, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Rachel Gonzalez
- Department of Veterans Affairs, Sierra Pacific Veterans Integrated Service Network, Pharmacy Benefits Management, Mather, CA, USA
| | - Angela Park
- Office of Healthcare Transformation, Veterans Engineering Resource Center, Washington, DC, USA
| | - Lauren Beste
- Division of General Internal Medicine, Department of Medicine, VA Puget Sound Healthcare System, Seattle, WA, USA.,Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Edward J Miech
- Department of Veterans Affairs, Roudebush VA Medical Center, HSR&D Center for Health Information & Communication, VA PRIS-M QUERI, Indianapolis, IN, USA
| | - Carolyn Lamorte
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R), University Drive C, Pittsburgh, PA, 15240, USA
| | - Brittney Neely
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R), University Drive C, Pittsburgh, PA, 15240, USA
| | - Sandra Gibson
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R), University Drive C, Pittsburgh, PA, 15240, USA
| | | | - Maggie Chartier
- HIV, Hepatitis and Related Conditions Programs, Office of Specialty Care Services, Veterans Health Administration, Washington, DC, USA
| | - Tamar Taddei
- VA Connecticut Healthcare System, West Haven, CT, USA.,Department of Medicine, Yale University, West Haven, CT, USA
| | - Guadalupe Garcia-Tsao
- VA Connecticut Healthcare System, West Haven, CT, USA.,Department of Medicine, Yale University, West Haven, CT, USA
| | - Byron J Powell
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Jason A Dominitz
- Gastroenterology Section, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - David Ross
- HIV, Hepatitis and Related Conditions Programs, Office of Specialty Care Services, Veterans Health Administration, Washington, DC, USA
| | - Matthew J Chinman
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R), University Drive C, Pittsburgh, PA, 15240, USA.,RAND Corporation, Pittsburgh, PA, USA
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12
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Xiol Quingles X, Salord Vila S, Amador Navarrete A, Baliellas Comellas C, Cachero Ros A, Rota Roca R, Pérez Campuzano V, Castellote Alonso J. Quality of care provided to outpatients with hepatic cirrhosis in a teaching hospital. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:826-831. [PMID: 33054285 DOI: 10.17235/reed.2020.6811/2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION a set of indicators to measure the quality of care of cirrhotic patients has been established and previously published studies report an adherence rate to clinical guide indications of 40-80 %. OBJECTIVE to assess the adherence to quality indicators in a tertiary teaching hospital. METHODS a retrospective observational study was performed of all cirrhotic outpatients seen during one semester in 2017. The charts were studied of 324 patients and quality indicators related to five domains were collected. An overall adherence to 14 quality indicators was recorded and analyzed based on the attending physician's experience. RESULTS the results were excellent (more than 90 % adherence) for quality indicators related to prophylaxis of variceal bleeding and documentation of cirrhosis etiology, acceptable (60-90 % adherence) for hepatocellular carcinoma screening and disease severity assessment, and poor (less than 50 %) for vaccinations. Residents had significantly better results than experienced physicians in etiology, disease severity assessment and two indicators of prophylaxis of bleeding. Experienced physicians only presented a better adherence to hepatocellular carcinoma screening. CONCLUSIONS despite excellent results for some quality indicators, most required improvement, especially vaccinations. The quality of care achieved by residents is equal to and even better than that of experienced physicians. Measuring quality of care is essential to analyze and improve the health care of cirrhotic outpatients and may be a useful tool for supervising specialists in training.
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Affiliation(s)
- Xavier Xiol Quingles
- Aparato Digestivo, Hospital Universitari de Bellvitge. IDIBELL. Univerisitat de Barcelona, España
| | | | | | | | - Alba Cachero Ros
- Aparato Digestivo, Hospital Universitari de Bellvitge-IDIBELL, España
| | - Rosa Rota Roca
- Aparato Digestivo, Hospital Universitari de Bellvitge-IDIBELL, España
| | | | - José Castellote Alonso
- Aparato Digestivo, Hospital Universitari de Bellvitge-IDIBELL.Universitat de Barcelona , España
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13
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Kardashian A, Patel AA, Aby ES, Cusumano VT, Soroudi C, Winters AC, Wu E, Beah P, Delshad S, Kim N, Yang L, May FP. Identifying Quality Gaps in Preventive Care for Outpatients With Cirrhosis Within a Large, Academic Health Care System. Hepatol Commun 2020; 4:1802-1811. [PMID: 33305151 PMCID: PMC7706302 DOI: 10.1002/hep4.1594] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/28/2020] [Accepted: 07/30/2020] [Indexed: 12/12/2022] Open
Abstract
We sought to identify specific gaps in preventive care provided to outpatients with cirrhosis and to determine factors associated with high quality of care (QOC), to guide quality improvement efforts. Outpatients with cirrhosis who received care at a large, academic tertiary health care system in the United States were included. Twelve quality indicators (QIs), including preventive care processes for ascites, esophageal varices, hepatic encephalopathy, hepatocellular carcinoma (HCC), and general cirrhosis care, were measured. QI pass rates were calculated as the proportion of patients eligible for a QI who received that QI during the study period. We performed logistic regression to determine predictors of high QOC (≥ 75% of eligible QIs) and receipt of HCC surveillance. Of the 439 patients, the median age was 63 years, 59% were male, and 19% were Hispanic. The median Model for End-Stage Liver Disease-Sodium score was 11, 64% were compensated, and 32% had hepatitis C virus. QI pass rates varied by individual QIs, but were overall low. For example, 24% received appropriate HCC surveillance, 32% received an index endoscopy for varices screening, and 21% received secondary prophylaxis for spontaneous bacterial peritonitis. In multivariable analyses, Asian race (odds ratio [OR]: 3.7, 95% confidence interval [CI]: 1.3-10.2) was associated with higher QOC, and both Asian race (OR: 3.3, 95% CI: 1.2-9.0) and decompensated status (OR: 2.1, 95% CI: 1.1-4.2) were associated with receipt of HCC surveillance. A greater number of specialty care visits was not associated with higher QOC. Conclusion: Receipt of outpatient preventive cirrhosis QIs was variable and overall low in a diverse cohort of patients with cirrhosis. Variation in care by race/ethnicity and illness trajectory should prompt further inquiry into identifying modifiable factors to standardize care delivery and to improve QOC.
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Affiliation(s)
- Ani Kardashian
- Vatche and Tamar Manoukian Division of Digestive Diseases Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA.,Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA
| | - Arpan A Patel
- Vatche and Tamar Manoukian Division of Digestive Diseases Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA.,Veterans Affairs Greater Los Angeles Healthcare System Los Angeles CA
| | - Elizabeth S Aby
- Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA
| | - Vivy T Cusumano
- Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA
| | - Camille Soroudi
- Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA
| | - Adam C Winters
- Vatche and Tamar Manoukian Division of Digestive Diseases Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA.,Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA
| | - Eric Wu
- Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA
| | - Peter Beah
- Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA
| | - Sean Delshad
- Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA
| | - Nathan Kim
- Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA
| | - Liu Yang
- Vatche and Tamar Manoukian Division of Digestive Diseases Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA
| | - Folasade P May
- Vatche and Tamar Manoukian Division of Digestive Diseases Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA.,Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA.,Veterans Affairs Greater Los Angeles Healthcare System Los Angeles CA.,Jonsson Comprehensive Cancer Center UCLA Los Angeles CA
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14
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Spiewak T, Taefi A, Patel S, Li CS, Chak E. Racial disparities of Black Americans hospitalized for decompensated liver cirrhosis. BMC Gastroenterol 2020; 20:245. [PMID: 32727386 PMCID: PMC7391571 DOI: 10.1186/s12876-020-01392-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 07/21/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Racial disparities have been reported in liver transplantation and chronic hepatitis C treatment outcomes. Determining causes of these disparities is important given the racially diverse American population and the economic burden associated with chronic liver disease. METHODS A retrospective study was performed among 463 patients diagnosed with cirrhosis admitted from (January 1, 2013 to January 1, 2018) to a tertiary care academic medical center. Patients were identified based on the International Classification of Diseases (ICD-10) for cirrhosis or its complications. Demographic information, laboratory data, medical comorbidities, insurance and adherence to cirrhosis quality care indicators were recorded to determine their relationship to readmission rates and other healthcare outcomes. RESULTS A total of 463 individual patients with cirrhosis were identified including Whites (n = 241), Hispanics (n = 106), Blacks (n = 50), Asian and Pacific Islander Americans (API, n = 27) and Other (n = 39). A significantly higher proportion of Blacks had Medicaid insurance compared to Whites (40% versus 20%, p = 0.0002) and Blacks had lower median income than Whites ($45,710 versus $54,844, p = 0.01). All groups received high quality cirrhosis care. Regarding healthcare outcomes, Black patients had the highest mean total hospital admissions (6.1 ± 6.3, p = 0.01) and the highest mean number of 30-day re-admissions (2.1 ± 3.7, p = 0.05) compared to all other racial groups. Multivariable proportional odds regression analysis showed that race was a statistically significant predictor of 90-day readmission (p = 0.03). CONCLUSIONS Black Americans hospitalized for complications of cirrhosis may experience significant disparities in healthcare outcomes compared to Whites despite high quality cirrhosis care. Socioeconomic factors may contribute to these disparities.
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Affiliation(s)
- Ted Spiewak
- Department of Internal Medicine, UC Davis Medical Center, Sacramento, California, USA
| | - Amir Taefi
- Department of Gastroenterology and Hepatology, UC Davis Medical Center, 4150 V Street, PSSB 3500, Sacramento, CA, 95817, USA
| | - Shruti Patel
- Department of Internal Medicine, UC Davis Medical Center, Sacramento, California, USA
| | - Chin-Shang Li
- School of Nursing, The State University of New York at Buffalo, Buffalo, New York, USA
| | - Eric Chak
- Department of Gastroenterology and Hepatology, UC Davis Medical Center, 4150 V Street, PSSB 3500, Sacramento, CA, 95817, USA.
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15
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Wu CK, Yang SC, Liang CM, Li YC, Yeh WS, Tai WC, Lee CH, Yang YH, Hsu CN, Tsai TH, Chuah SK. The role of antibiotics in upper gastrointestinal bleeding among cirrhotic patients without major complications after endoscopic hemostasis. J Gastroenterol Hepatol 2020; 35:777-787. [PMID: 31674688 DOI: 10.1111/jgh.14873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 09/09/2019] [Accepted: 09/14/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Antibiotic prophylaxis should be instituted for cirrhotic patients with upper gastrointestinal bleeding (UGIB), but the benefit on compensated patients remains undetermined. We aimed to compare the clinical outcomes between cirrhotic patients without major complications with UGIB with and without antibiotic prophylaxis. METHODS We conducted this population-based cohort study by using Taiwanese Longitudinal Health Insurance Database 2000 (LHID2000, between 1997 to 2013), aged 18 years or older with a hospital discharge diagnosis of cirrhosis (n = 64,506), UGIB (n = 7,784), and endoscopic therapy (n = 2,292). After strict exclusions, 1205 patients were enrolled and were divided into antibiotic exposure (n = 558) and non-exposure (n = 647) groups. The outcomes were rebleeding and mortality. RESULTS After completing the analysis adjusted by death, the rebleeding rates within 4 weeks were significantly lower in patients with antibiotic prophylaxis (3.05% versus 6.03%, P = 0.0142) and those with endoscopic therapy (0.72% vs 3.09%, P = 0.0033) but not significant after 3 months and onwards. Male patients aged > 55, high CCI score ≧ 4, and UGIB of variceal etiologies were benefited from rebleeding. The use of antibiotics did not significantly impact 6-week mortality (adjusted hazard ratio: 1.07, 95%CI: 0.41~2.75; P = 0.8943). Old age, multiple comorbidities, and UGIB of variceal etiologies were risk factors of all-cause mortality. CONCLUSIONS The current study suggested that cirrhotic patients without major complications who suffered from UGIB were benefited by the use of antibiotics to prevent rebleeding within 4 weeks after endoscopic treatment of UGIB especially for those with age > 55, high CCI score ≧ 4, and UGIB of variceal etiologies.
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Affiliation(s)
- Cheng-Kun Wu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shih-Cheng Yang
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Ming Liang
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Chi Li
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wen-Shuo Yeh
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wei-Chen Tai
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chen-Hsiang Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yao-Hsu Yang
- Department of Traditional Chinese Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan.,Health Information and Epidemiology Laboratory of Chang Gung Memorial Hospital, Chiayi, Taiwan.,School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Ning Hsu
- Department of Pharmacy, Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tzu-Hsien Tsai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Seng-Kee Chuah
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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16
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Naik AD, Arney J, Clark JA, Martin LA, Walling AM, Stevenson A, Smith D, Asch SM, Kanwal F. Integrated Model for Patient-Centered Advanced Liver Disease Care. Clin Gastroenterol Hepatol 2020; 18:1015-1024. [PMID: 31357029 PMCID: PMC9319576 DOI: 10.1016/j.cgh.2019.07.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/11/2019] [Accepted: 07/24/2019] [Indexed: 02/07/2023]
Abstract
Advanced liver disease (AdvLD) is a high-risk common condition with a progressive, highly morbid, and often fatal course. Despite effective treatments, there are substantial shortfalls in access to and use of evidence-based supportive and palliative care for AdvLD. Although patient-centered, chronic illness models that integrate early supportive and palliative care with curative treatments hold promise, there are several knowledge gaps that hinder development of an integrated model for AdvLD. We review these evidence gaps. We also describe a conceptual framework for a patient-centered approach that explicates key elements needed to improve integrated care. An integrated model of AdvLD would allow clinicians, patients, and caregivers to work collaboratively to identify treatments and other healthcare that best align with patients' priorities.
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Affiliation(s)
- Aanand D. Naik
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Medicine, Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Jennifer Arney
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Sociology, University of Houston-Clear Lake, Houston, Texas
| | - Jack A. Clark
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Lindsey A. Martin
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Department of Medicine, Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Anne M. Walling
- Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California,Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Autumn Stevenson
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Donna Smith
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Steven M. Asch
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Medical Center, Palo Alto, California,Division of Primary Care and Population Health, Stanford University, Palo Alto, California
| | - Fasiha Kanwal
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
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17
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A Quality Improvement Initiative Results in Improved Rates of Timely Postvariceal Bleeding Surveillance Endoscopy. Am J Gastroenterol 2020; 115:625-628. [PMID: 32141918 PMCID: PMC7127939 DOI: 10.14309/ajg.0000000000000577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES We performed a study to assess the effects of a quality improvement (QI) initiative on the rates of postvariceal bleeding surveillance upper endoscopy (EGD). METHODS We identified patients with cirrhosis hospitalized with variceal bleeding and assessed the rates of timely (≤4 weeks) EGD before and after a QI initiative. RESULTS Preintervention: 16% (5 of 32) of patients underwent timely surveillance EGD. We developed a standardized ordering template for gastroenterology fellows and reserved postvariceal EGD scheduling slots. Postintervention: 43% (12 of 28) of patients underwent timely surveillance EGD. DISCUSSION A QI intervention was associated with a 27% absolute increase in timely surveillance EGDs.
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Moon AM, Green PK, Rockey DC, Berry K, Ioannou GN. Hepatitis C eradication with direct-acting anti-virals reduces the risk of variceal bleeding. Aliment Pharmacol Ther 2020; 51:364-373. [PMID: 31773763 PMCID: PMC7416556 DOI: 10.1111/apt.15586] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/03/2019] [Accepted: 10/27/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The real-world, long-term benefits of sustained virologic response (SVR) on the risk of variceal bleeding remain unclear. AIM To assess the association between DAA-induced SVR and post-treatment variceal bleeding METHODS: We identified patients who initiated DAA-only anti-viral treatments in the United States Veterans Affairs healthcare system from 2013 to 2015. We followed patients until 1 January 2019 for the development of gastro-oesophageal variceal bleeding defined by diagnostic codes. We used multivariable Cox proportional hazards regression to assess the association between SVR and development of variceal bleeding, adjusting for potential confounders. RESULTS Among 33 582 DAA-treated patients, 549 (1.6%) developed variceal bleeding after treatment (mean follow-up 3.1 years). Compared to no SVR, SVR was associated with a significantly lower incidence of variceal bleeding among all patients (0.46 vs 1.26 per 100 patient-years, adjusted hazard ratio [AHR] 0.66, 95% CI 0.52-0.83), among patients with pre-treatment cirrhosis (1.55 vs 2.96 per 100 patient-years, AHR 0.73, 95% CI 0.57-0.93) and among patients without pre-treatment cirrhosis (0.07 vs 0.29 per 100 patient-years, AHR 0.33, 95% CI 0.17-0.65). The risk of variceal bleeding after treatment was lower in those who achieved SVR vs no SVR among patients who had non-bleeding varices (3.5 vs 4.9 per 100 patient-years) or bleeding varices (12.9 vs 16.4 per 100 patient-years) diagnosed before treatment, but these differences were not statistically significant in adjusted analyses. CONCLUSION DAA-induced SVR is independently associated with a lower risk of variceal bleeding during long-term follow-up in patients with and without pre-treatment cirrhosis. These findings demonstrate an important real-world benefit of DAA treatment.
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Affiliation(s)
- Andrew M. Moon
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Pamela K. Green
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Don C. Rockey
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - George N. Ioannou
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA.,Division of Gastroenterology, Department of Medicine Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
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19
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Serper M, Kaplan DE, Shults J, Reese PP, Beste LA, Taddei TH, Werner RM. Quality Measures, All-Cause Mortality, and Health Care Use in a National Cohort of Veterans With Cirrhosis. Hepatology 2019; 70:2062-2074. [PMID: 31107967 PMCID: PMC6864236 DOI: 10.1002/hep.30779] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 05/10/2019] [Indexed: 02/06/2023]
Abstract
Decompensated cirrhosis is associated with high morbidity and mortality. However, no standardized quality measures (QMs) have yet been adopted widely. The Veterans Affairs (VA) Advanced Liver Disease Technical Advisory Group recently developed a set of six internal QMs to guide quality improvement efforts in cirrhosis in the domains of access to care, hepatocellular carcinoma surveillance, variceal surveillance, quality of inpatient care for upper gastrointestinal bleeding, and cirrhosis-related rehospitalizations. We aimed to (1) quantify adherence to cirrhosis QMs and (2) determine whether adherence was associated with all-cause mortality and health care use within a large national cohort of veterans with cirrhosis. We performed a retrospective study using data from the Veterans Outcomes and Costs Asociated with Liver Disease cohort of 121,129 patients newly diagnosed with cirrhosis from January 1, 2008, to December 31, 2016, at 128 VA facilities. The mean follow-up time was 2.7 years (interquartile range, 1.1-5.1 years). Adherence to outpatient access to specialty care was 71%, variceal surveillance was 32%, and early postdischarge care was 54%. In adjusted analyses, outpatient access to specialty care (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.78-0.82), hepatocellular carcinoma surveillance (HR, 0.92; 95% CI, 0.90-0.95), variceal surveillance (HR, 0.93; 95% CI, 0.89-0.99), and early postdischarge care (HR, 0.57; 95% CI, 0.54-0.60) were associated with lower all-cause mortality. Readmissions after 30 days (HR, 1.53; 1.46-1.60) and 90 days (HR, 1.88; 95% CI, 1.54-1.70) were associated with higher all-cause mortality. Higher adherence to QMs was also associated with lower inpatient health care use. Conclusion: Five of the six proposed VA cirrhosis QMs were measurable using existing data sources, associated with mortality and health care use, and may be used to guide future quality improvement efforts in cirrhosis.
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Affiliation(s)
- Marina Serper
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - David E. Kaplan
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Justine Shults
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Peter P. Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Lauren A. Beste
- VA Puget Sound Health Care System, Health Services Research and Development, Seattle, WA
- VA Puget Sound Health Care System, General Medicine Service, Seattle, WA, USA
- Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Tamar H. Taddei
- VA Connecticut Healthcare System, West Haven, Connecticut CT
- Division of Gastroenterology, Yale University School of Medicine, New Haven, CT
| | - Rachel M. Werner
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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20
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Lim N, Sanchez O, Olson A. Impact on 30-d readmissions for cirrhotic patients with ascites after an educational intervention: A pilot study. World J Hepatol 2019; 11:701-709. [PMID: 31749900 PMCID: PMC6856018 DOI: 10.4254/wjh.v11.i10.701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 09/23/2019] [Accepted: 10/02/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A low proportion of patients admitted to hospital with cirrhosis receive quality care with timely paracentesis an important target for improvement. We hypothesized that a medical educational intervention, delivered to medical residents caring for patients with cirrhosis, would improve quality of care.
AIM To determine if an educational intervention can improve quality of care in cirrhotic patients admitted to hospital with ascites.
METHODS We performed a pilot prospective cohort study with time-based randomization over six months at a large teaching hospital. Residents rotating on hospital medicine teams received an educational intervention while residents rotating on hospital medicine teams on alternate months comprised the control group. The primary outcome was provision of quality care- defined as adherence to all quality-based indicators derived from evidence-based practice guidelines- in admissions for patients with cirrhosis and ascites. Patient clinical outcomes- including length of hospital stay (LOS); 30-d readmission; in-hospital mortality and overall mortality- and resident educational outcomes were also evaluated.
RESULTS Eighty-five admissions (60 unique patients) met inclusion criteria over the study period-46 admissions in the intervention group and 39 admissions in the control group. Thirty-seven admissions were female patients, and 44 admissions were for alcoholic liver disease. Mean model for end-stage liver disease (MELD)-Na score at admission was 25.8. Forty-seven (55.3%) admissions received quality care. There was no difference in the provision of quality care (56.41% vs 54.35%, P = 0.9) between the two groups. 30-d readmission was lower in the intervention group (35% vs 52.78%, P = 0.1) and after correction for age, gender and MELD-Na score [RR = 0.62 (0.39, 1.00), P = 0.05]. No significant differences were seen for LOS, complications, in-hospital mortality or overall mortality between the two groups. Resident medical knowledge and self-efficacy with paracentesis improved after the educational intervention.
CONCLUSION Medical education has the potential to improve clinical outcomes in patients admitted to hospital with cirrhosis and ascites.
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Affiliation(s)
- Nicholas Lim
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN 55455, United States
| | - Otto Sanchez
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN 55455, United States
| | - Andrew Olson
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN 55455, United States
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Stotts MJ, Grischkan JA, Khungar V. Improving cirrhosis care: The potential for telemedicine and mobile health technologies. World J Gastroenterol 2019; 25:3849-3856. [PMID: 31413523 PMCID: PMC6689809 DOI: 10.3748/wjg.v25.i29.3849] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 06/14/2019] [Accepted: 07/03/2019] [Indexed: 02/06/2023] Open
Abstract
Decompensated cirrhosis is a condition associated with significant morbidity and mortality. While there have been significant efforts to develop quality metrics that ensure high-value care of these patients, wide variations in clinical practice exist. In this opinion review, we discuss the quality gap in the care of patients with cirrhosis, including low levels of compliance with recommended cancer screening and other clinical outcome and patient-reported outcome measures. We posit that innovations in telemedicine and mobile health (mHealth) should play a key role in closing the quality gaps in liver disease management. We highlight interventions that have been performed to date in liver disease and heart failure-from successful teleconsultation interventions in the care of veterans with cirrhosis to the use of telemonitoring to reduce hospital readmissions and decrease mortality rates in heart failure. Telemedicine and mHealth can effectively address unmet needs in the care of patients with cirrhosis by increasing preventative care, expanding outreach to rural communities, and increasing high-value care. We aim to highlight the benefits of investing in innovative solutions in telemedicine and mHealth to improve care for patients with cirrhosis and create downstream cost savings.
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Affiliation(s)
- Matthew Jonathon Stotts
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Justin Alexander Grischkan
- Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States
| | - Vandana Khungar
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
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22
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Kanwal F, Tapper EB, Ho C, Asrani SK, Ovchinsky N, Poterucha J, Flores A, Ankoma-Sey V, Luxon B, Volk M. Development of Quality Measures in Cirrhosis by the Practice Metrics Committee of the American Association for the Study of Liver Diseases. Hepatology 2019; 69:1787-1797. [PMID: 30586188 DOI: 10.1002/hep.30489] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 12/28/2022]
Abstract
Health care delivery is increasingly evaluated according to quality measures, yet such measures are underdeveloped for cirrhosis. The Practice Metrics Committee of the American Association for the Study of Liver Diseases was charged with developing explicit process-based and outcome-based measures for adults with cirrhosis. We identified candidate measures from comprehensive reviews of the literature and input from expert clinicians and patient focus groups. We conducted an 11-member expert clinician panel and used a modified Delphi method to systematically identify a set of quality measures in cirrhosis. Among 119 candidate measures, 46 were identified as important measures to define the quality of cirrhosis care, including 26 process measures, 7 clinical outcome measures, and 13 patient-reported outcome measures. The final process measures captured care processes for ascites (n = 5), varices/bleeding (n = 7), hepatic encephalopathy (n = 4), hepatocellular cancer (HCC) screening (n = 1), liver transplantation evaluation (n = 2), and other care (n = 7). Clinical outcome measures included survival, variceal bleeding and rebleeding, early-stage HCC, liver-related hospitalization, and rehospitalization within 7 and 30 days. Patient-reported outcome measures covered physical symptoms, physical function, mental health, general function, cognition, social life, and satisfaction with care. The final list of patient-reported outcomes was validated in 79 patients with cirrhosis from nine institutions in the United States. Conclusion: We developed an explicit set of evidence-based quality measures for adult patients with cirrhosis. These measures are a tool for providers and institutions to evaluate their care quality, drive quality improvement, and deliver high-value cirrhosis care. The quality measures are intended to be applicable in any clinical care setting in which care for patients with cirrhosis is provided.
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Affiliation(s)
- Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Chanda Ho
- Department of Transplantation, California Pacific Medical Center, San Francisco, CA
| | - Sumeet K Asrani
- Division of Hepatology, Baylor University Medical Center, Dallas, TX
| | - Nadia Ovchinsky
- Division of Pediatric Gastroenterology, Children's Hospital at Montefiore, Bronx, NY
| | - John Poterucha
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
| | - Avegail Flores
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
| | - Victor Ankoma-Sey
- Sherri & Alan Conover Center for Liver Disease & Transplantation, Department of Gastroenterology & Hepatology, Houston Methodist Hospital, Houston, TX
| | - Bruce Luxon
- Department of Medicine, Georgetown University, Washington, DC
| | - Michael Volk
- Division of Gastroenterology and Transplantation Institute, Loma Linda University, Loma Linda, CA
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23
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Tey KR, Mohan P, Liu X, Desai AP. Closing the Quality Chasm in Cirrhosis. Clin Liver Dis (Hoboken) 2018; 12:45-49. [PMID: 30988910 PMCID: PMC6385903 DOI: 10.1002/cld.725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 04/10/2018] [Accepted: 04/21/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
| | | | - Xibei Liu
- Department of MedicineUniversity of ArizonaTucsonAZ
| | - Archita P. Desai
- Division of Gastroenterology, Thomas D. Boyer Liver Research Institute, Department of MedicineUniversity of ArizonaTucsonAZ
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24
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Everett BT, Lidofsky SD. Adherence to surveillance endoscopy following hospitalization for index esophageal variceal hemorrhage. World J Gastrointest Surg 2018; 10:40-48. [PMID: 29707105 PMCID: PMC5920137 DOI: 10.4240/wjgs.v10.i4.40] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/09/2018] [Accepted: 04/11/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate patient adherence to surveillance endoscopy after index esophageal variceal hemorrhage and the extent to which adherence influences outcomes. METHODS We reviewed the records of patients with cirrhosis admitted to the medical intensive care unit between 2000 and 2014 for first time esophageal variceal hemorrhage treated with endoscopic variceal ligation who were subsequently discharged and scheduled for surveillance endoscopy at our medical center. Demographic and clinical data were obtained through the medical records, including etiology of cirrhosis, completion of variceal obliteration, attendance at surveillance endoscopy, zip code of primary residence, distance from home to hospital, insurance status, rehospitalization for variceal hemorrhage, beta-blocker at discharge, pharmacologically treated psychiatric disorder, and transplant free survival. RESULTS Of 99 consecutive survivors of esophageal variceal bleeding, the minority (33) completed variceal obliteration and fewer (12) adhered to annual surveillance. Completion of variceal obliteration was associated with fewer rehospitalizations for variceal rebleeding (27% vs 56%, P = 0.0099) and when rehospitalizations occurred, they occurred later in those who had completed obliteration (median 259 d vs 207 d, P = 0.0083). Incomplete adherence to endoscopic surveillance was associated with more rehospitalizations for variceal rebleeding compared to those fully adherent to annual endoscopic surveillance (51% vs 17%, P = 0.0328). Those adherent to annual surveillance were more likely to be insured privately or through Medicare compared to those who did not attend post-hospital discharge endoscopy (100% vs 63%, P = 0.0119). CONCLUSION Most patients do not complete variceal obliteration after index esophageal variceal hemorrhage and fewer adhere to endoscopic surveillance, particularly the uninsured and those insured with Medicaid.
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Affiliation(s)
- Brendan T Everett
- Gastroenterology and Hepatology Unit, University of Vermont Medical Center, Burlington, VT 05401, United States
| | - Steven D Lidofsky
- Gastroenterology and Hepatology Unit, University of Vermont Medical Center, Burlington, VT 05401, United States
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25
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Pateu E, Oberti F, Calès P. The noninvasive diagnosis of esophageal varices and its application in clinical practice. Clin Res Hepatol Gastroenterol 2018; 42:6-16. [PMID: 28870440 DOI: 10.1016/j.clinre.2017.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 07/31/2017] [Indexed: 02/04/2023]
Abstract
Here, we review recent improvements made to different noninvasive tests used for the diagnosis of esophageal varices (EV) in the light of the recent Baveno VI recommendation and with an emphasis on clinical application. Like for fibrosis tests, these noninvasive EV tests can be classified as direct markers when they provide a visualization of EV (including all imaging procedures like endoscopy or radiology) and as indirect markers when they do not (blood markers or elastometry). Clinical descriptors expressed as percentages, especially the spared endoscopy rate and the missed high-risk esophageal varices (HREV) rate, are more eloquent in this setting than classical statistical descriptors like accuracy. Single biomarkers are insufficient, generally due to a missed HREV rate exceeding the acceptable limit of 5% indicated in the Baveno VI consensus. Thus, biomarker combinations are currently garnering the most interest. The Baveno VI recommendation states that in alcoholic and viral cirrhoses, screening endoscopy can be safely set aside for patients with liver stiffness<20kPa and platelets>150G/L. The Baveno rule's mean missed HREV rate is<5% but its spared endoscopy rate is<20%. New combinations or stepwise algorithms show promise but must be validated. Going forward, the Baveno rule provides a simple noninvasive method to rule out HREV in clinical practice but the need for further research continues. The noninvasive diagnosis of HREV will be significantly improved by new, simple and affordable combinations.
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Affiliation(s)
- Etienne Pateu
- Hepato-Gastroenterology Department, University Hospital, 49933 Angers, France
| | - Frédéric Oberti
- Hepato-Gastroenterology Department, University Hospital, 49933 Angers, France; HIFIH Laboratory, University Angers, Bretagne-Loire University, 49045 Angers, France
| | - Paul Calès
- Hepato-Gastroenterology Department, University Hospital, 49933 Angers, France; HIFIH Laboratory, University Angers, Bretagne-Loire University, 49045 Angers, France.
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26
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Calès P, Sacher-Huvelin S, Valla D, Bureau C, Olivier A, Oberti F, Boursier J, Galmiche JP. Large oesophageal varice screening by a sequential algorithm using a cirrhosis blood test and optionally capsule endoscopy. Liver Int 2018. [PMID: 28622450 DOI: 10.1111/liv.13497] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Large oesophageal varice (LEV) screening is recommended in cirrhosis. We performed a prospective study to improve non-invasive LEV screening. DESIGN 287 patients with cirrhosis had upper gastrointestinal endoscopy (LEV reference), oesophageal capsule endoscopy (ECE), liver elastography and blood marker analyses. CirrhoMeter (cirrhosis blood test), the most accurate non-invasive LEV test, was segmented for cirrhosis (reference comparator) or LEV. VariScreen, a sequential and partially minimally invasive diagnostic algorithm, was developed by multivariate analysis. It uses CirrhoMeter first, then ECE if CirrhoMeter cannot rule LEV out or in, and finally endoscopy if CirrhoMeter+ECE combination remains uninformative. RESULTS Diagnostic effectiveness rates for LEV were: cirrhosis-segmented CirrhoMeter: 14.6%, LEV-segmented CirrhoMeter: 34.6%, ECE: 60.6% and VariScreen: 66.4% (P ≤ .001 for overall or pair comparison). The respective missed LEV rates were: 2.8%, 5.6%, 8.3% and 5.6% (P = .789). Spared endoscopy rates were, respectively: 15.6%, 36.0%, 70.6% and 69%, (P < .001 for overall or paired comparison except ECE vs VariScreen: P = .743). VariScreen spared 38% of ECE and reduced missed LEV by 87% compared to classical ECE performed in all patients. Excepting cirrhosis-segmented CirrhoMeter, these spared endoscopy rates were significantly higher than that of the Baveno VI recommendation (using platelets and Fibroscan): 18.4% (P < .001). Ascites and Child-Pugh class independently predicted endoscopy sparing by VariScreen: from 86.0% in compensated Child Pugh class A to 24.1% in Child-Pugh class C with ascites. CONCLUSION VariScreen algorithm significantly reduced the missed LEV rate with ECE by 87%, ECE use by 38% and endoscopy requirement by 69%, and even 86% in compensated cirrhosis.
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Affiliation(s)
- Paul Calès
- Department of Liver-Gastroenterology, University Hospital, HIFIH Laboratory, UNIV Angers, Bretagne Loire University, Angers, France
| | - Sylvie Sacher-Huvelin
- CIC 1413, INSERM, CHU, Nantes, France.,Department of Gastroenterology, IMAD, CHU and UNIV Nantes, Bretagne Loire University, Nantes, France
| | - Dominique Valla
- Liver Unit, DHU UNITY, Beaujon Hospital, HUPNVS, APHP, INSERM UMR U1149, University Paris Diderot, Clichy, France
| | | | - Anne Olivier
- Department of Liver-Gastroenterology, University Hospital, HIFIH Laboratory, UNIV Angers, Bretagne Loire University, Angers, France
| | - Frédéric Oberti
- Department of Liver-Gastroenterology, University Hospital, HIFIH Laboratory, UNIV Angers, Bretagne Loire University, Angers, France
| | - Jérôme Boursier
- Department of Liver-Gastroenterology, University Hospital, HIFIH Laboratory, UNIV Angers, Bretagne Loire University, Angers, France
| | - Jean Paul Galmiche
- Department of Gastroenterology, IMAD, CHU and UNIV Nantes, Bretagne Loire University, Nantes, France
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27
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Overuse of Repeat Upper Endoscopy in the Veterans Health Administration: A Retrospective Analysis. Am J Gastroenterol 2017; 112:1678-1685. [PMID: 28695907 DOI: 10.1038/ajg.2017.192] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 05/02/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Americans undergo ∼7 million esophagogastroduodenoscopies (EGDs) annually, and one-third of Medicare beneficiaries undergo a repeat EGD within 3 years. As many as 43% of these repeat EGDs are inappropriate. We aimed to determine the rate of repeat inappropriate EGD within the Veterans Health Administration (VHA), and identify factors associated with repeat EGD. METHODS We conducted retrospective analyses of Veterans undergoing an index EGD at 159 VHA facilities between 1 January 2003 and 30 June 2007. We excluded Veterans without regular use of VHA for health care or 5 years of follow-up. Appropriateness of repeat EGDs was classified based on diagnostic and procedure codes into three categories: Likely Appropriate, Possible Overuse, and Probable Overuse. The proportion of repeat EGDs in each category was tabulated. Multilevel logistic regression was performed to estimate the impact of patient-level and site-level factors on the odds of repeat EGD. RESULTS Of the 235,855 included Veterans, 85,690 (36.3%) underwent a repeat EGD within 5 years. Of the repeat EGDs, 42,412 (49.5%) were Likely Appropriate, 35,503 (41.4%) represented Possible Overuse, and 7,756 (9.1%) represented Probable Overuse. Patients with more frequent encounters with primary care providers and access to facilities performing EGD and with greater complexity of services were more likely to receive repeat EGD, regardless of whether the repeat EGD was appropriate or overuse. Women were slightly more likely to undergo repeat EGD in Probable Overuse situations. CONCLUSIONS Overuse of repeat EGD is common in VHA despite the absence of financial incentives that promote overuse. Efforts are needed to better understand the motivations for overuse and barriers to appropriate use, and to promote appropriate use of repeat EGD.
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Robinson A, Tavakoli H, Liu B, Bhuket T, Cheung R, Wong RJ. African-Americans with Cirrhosis Are Less Likely to Receive Endoscopic Variceal Screening Within One Year of Cirrhosis Diagnosis. J Racial Ethn Health Disparities 2017; 5:860-866. [PMID: 29052175 DOI: 10.1007/s40615-017-0432-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/06/2017] [Accepted: 09/08/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Esophageal variceal hemorrhage is a complication of cirrhosis that carries high mortality, and can be reduced with timely endoscopic variceal screening and treatment. AIM We aim to evaluate overall rates of and disparities in receipt of endoscopic variceal screening among an ethnically diverse urban safety-net hospital. METHODS All consecutive adults with cirrhosis (7/1/2014 to 12/31/2015) were retrospectively evaluated to determine the rates of receiving esophageal variceal screening within 6 months and within 1 year after cirrhosis diagnosis. Race-/ethnicity-specific differences in rates of variceal screening were compared using chi-square testing and multivariate regression methods. RESULTS Among 157 patients (65% male, 33.8% Hispanic, 22.3% African-American, 44.6% alcoholic liver disease, 29.9% chronic HCV), 56.8% received variceal screening within 6 months and 65.8% received screening within 1 year. Compared to non-Hispanic whites with cirrhosis, African-Americans (52.2 vs. 76.2%, p < 0.05), Asians (57.1 vs. 76.2%, p < 0.05), and Hispanics (43.9 vs. 76.2%, p < 0.05) were all significantly less likely to receive endoscopic variceal screening within 6 months after cirrhosis diagnosis. On multivariate analysis, African-Americans with cirrhosis were 66% less likely to receive variceal screening compared to non-Hispanic whites (HR 0.34, 95% CI 0.15-0.77, p < 0.01). CONCLUSION Among adults with cirrhosis at a community-based safety-net hospital system, overall first-time variceal screening remains suboptimal. African-Americans were the least likely to receive timely variceal screening. These findings are particularly concerning given the significant barriers that ethnic minorities and safety-net populations already face in timely access to medical care.
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Affiliation(s)
- Ann Robinson
- Department of Internal Medicine, Alameda Health System-Highland Hospital, Oakland, CA, USA
| | - Hesam Tavakoli
- Department of Internal Medicine, Alameda Health System-Highland Hospital, Oakland, CA, USA
| | - Benny Liu
- Division of Gastroenterology and Hepatology, Alameda Health System-Highland Hospital Campus, 1411 East 31st Street, Highland Hospital-Highland Care Pavilion 5th Floor, Endoscopy Unit, Oakland, CA, 94602, USA
| | - Taft Bhuket
- Division of Gastroenterology and Hepatology, Alameda Health System-Highland Hospital Campus, 1411 East 31st Street, Highland Hospital-Highland Care Pavilion 5th Floor, Endoscopy Unit, Oakland, CA, 94602, USA
| | - Ramsey Cheung
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Alameda Health System-Highland Hospital Campus, 1411 East 31st Street, Highland Hospital-Highland Care Pavilion 5th Floor, Endoscopy Unit, Oakland, CA, 94602, USA.
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Increased Distance to a Liver Transplant Center Is Associated With Higher Mortality for Patients With Chronic Liver Failure. Clin Gastroenterol Hepatol 2017; 15:958-960. [PMID: 28246053 PMCID: PMC5440193 DOI: 10.1016/j.cgh.2017.02.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 02/16/2017] [Accepted: 02/21/2017] [Indexed: 02/07/2023]
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Shukla R, Kramer J, Cao Y, Ying J, Tansel A, Walder A, Advani S, El-Serag HB, Kanwal F. Risk and Predictors of Variceal Bleeding in Cirrhosis Patients Receiving Primary Prophylaxis With Non-Selective Beta-Blockers. Am J Gastroenterol 2016; 111:1778-1787. [PMID: 27670600 DOI: 10.1038/ajg.2016.440] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 08/22/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Prior studies have demonstrated the efficacy of non-selective beta-blockers (NSBB) in preventing first variceal bleeding in patients with cirrhosis. However, little is known about the overall effectiveness of NSBB in routine clinical care. METHODS We conducted a retrospective cohort study of cirrhotic patients without prior bleeding who initiated a NSBB (propranolol, nadolol) at any Veterans Administration facility between 2008 and 2013. The primary outcome was variceal bleeding within 12 months. We conducted Cox-proportional hazards analyses to identify demographic, clinical, and NSBB-related (type of NSBB, mean dose, dose change, and heart rate response) factors associated with variceal bleeding. RESULTS Of 5,775 patients, 678 (11.7%) developed variceal bleeding. Mean daily dose of NSBB was <40 mg in 58.8%, 18.1% had either upward or downward titration in NSBB dose, and 9.8% had hemodynamic response. Patients who were younger, with ascites, greater medical comorbidity, and higher MELD (Model for end-stage liver disease) scores had a higher risk of variceal bleeding. Patients on a higher daily dose (>60 vs. <40 mg, adjusted hazard ratio (HR) 0.64; 95% confidence interval (CI): 0.51-0.81), who had either upward or downward dose titration (adjusted HR 0.69; 95% CI: 0.52-0.90 and 0.64; 95% CI 0.45-0.90, respectively), and those who achieved hemodynamic response (adjusted HR 0.75; 95% CI=0.57-1.0) had lower risk. CONCLUSIONS Approximately 12% of patients bled while being on NSBB for primary prophylaxis. A higher NSBB dose and dose titration were protective; yet most patients did not have the NSBB dose titrated to the recommended levels. Our data highlight the need for careful monitoring of cirrhotic patients on NSBB.
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Affiliation(s)
- Richa Shukla
- Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Jennifer Kramer
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
| | - Yumei Cao
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
| | - Jun Ying
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
| | - Aylin Tansel
- Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Annette Walder
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
| | - Shailesh Advani
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
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31
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Moon AM, Dominitz JA, Ioannou GN, Lowy E, Beste LA. Use of Antibiotics Among Patients With Cirrhosis and Upper Gastrointestinal Bleeding Is Associated With Reduced Mortality. Clin Gastroenterol Hepatol 2016; 14:1629-1637.e1. [PMID: 27311621 DOI: 10.1016/j.cgh.2016.05.040] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/12/2016] [Accepted: 05/19/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Prophylactic antibiotics are recommended for all patients with cirrhosis hospitalized for upper gastrointestinal bleeding (UGIB). We evaluated the association between use of antibiotics, outcomes of re-admissions, and mortality in these patients. METHODS We performed a retrospective study of 6451 patients with cirrhosis (mean age, 60.6 y) in the Veterans Affairs health care system hospitalized for UGIB from January 1, 2005, through December 31, 2013 (8655 hospitalizations). We collected information on patients' baseline features, hospitalizations, etiology of UGIB, antibiotics given, hospital re-admission within 30 days of discharge, and mortality. We defined timely administration of antibiotics as receipt from 8 hours before admission through 48 hours afterward. RESULTS Timely administration of antibiotics occurred during 48.6% of admissions (n = 4210), increasing from 30.6% in 2005 to 58.1% in 2013. Independent predictors of antibiotic receipt included ascites, high model for end-stage liver disease score, esophageal variceal hemorrhage, and administration of octreotide or intravenous proton pump inhibitors. Variables associated with decreased odds of antibiotic provision included black race and nonalcoholic fatty liver disease. In multivariate analysis, timely administration of antibiotics was associated with a reduced 30-day mortality rate (adjusted odds ratio, 0.70; 95% confidence interval, 0.52-0.93; P = .012). CONCLUSIONS In a study of patients with cirrhosis and UGIB in the VA health care system, timely administration of antibiotics was associated with a 30% reduction in 30-day mortality. The proportion of patients with cirrhosis and UGIB receiving timely antibiotics nearly doubled from 2005 to 2013, but many patients-particularly those with less-advanced cirrhosis-did not receive this intervention. Targeted efforts are needed to promote the appropriate use of antibiotics among patients with cirrhosis and UGIB.
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Affiliation(s)
- Andrew M Moon
- Department of Medicine, University of Washington, Seattle, Washington
| | - Jason A Dominitz
- Department of Medicine, University of Washington, Seattle, Washington; VA Puget Sound Health Care System, Seattle, Washington
| | - George N Ioannou
- Department of Medicine, University of Washington, Seattle, Washington; VA Puget Sound Health Care System, Seattle, Washington
| | - Elliott Lowy
- VA Puget Sound Health Care System, Seattle, Washington; School of Public Health, University of Washington, Seattle, Washington
| | - Lauren A Beste
- Department of Medicine, University of Washington, Seattle, Washington; VA Puget Sound Health Care System, Seattle, Washington.
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Sclair SN, Carrasquillo O, Czul F, Trivella JP, Li H, Jeffers L, Martin P. Quality of Care Provided by Hepatologists to Patients with Cirrhosis at Three Parallel Health Systems. Dig Dis Sci 2016; 61:2857-2867. [PMID: 27289585 DOI: 10.1007/s10620-016-4221-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 05/29/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Evidence-based guidelines and quality indicators for cirrhosis care have been established. Whether there are variations in adherence to these cirrhosis standards at different specialty settings has not been investigated. AIMS To evaluate the quality of cirrhosis care delivered at diverse hepatology care sites. METHODS We conducted a retrospective study comparing the quality of care at three hepatology specialty clinics: a Faculty Practice, safety-net hospital, and Veterans Affairs (VA) Medical Center. Consecutive patients with cirrhosis (85 Faculty Practice, 81 safety-net, and 76 VA) between 2010 and 2011 were included. Median follow-up was 2.3 years. Outcome measures were the adherence to six cirrhosis-specific quality-of-care indicators. RESULTS Adherence to hepatitis A and B vaccinations was highest at the safety-net hospital, 81 and 74 %, compared to 46 and 30 % at the Faculty Practice (P < .001). Adherence to yearly hepatocellular carcinoma surveillance was highest at the safety-net site (79 %) versus the VA (50 %) and Faculty Practice (42 %), P = .001. In contrast, screening rates for esophageal varices were 75 % at the Faculty Practice and only 58 and 43 % at the VA and safety-net sites, respectively (P < .001). Liver transplant discussions were documented most consistently at the Faculty Practice (82 %) compared to the safety-net site (53 %) and VA (54 %), P < .001. CONCLUSIONS Disparities in cirrhosis quality measures existed by site. Strategies to overcome these disparities need to be developed to improve the delivery of quality cirrhosis care as we face a rise in cirrhosis-related complications over the next two decades.
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Affiliation(s)
- Seth N Sclair
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Olveen Carrasquillo
- Division of General Internal Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,Miami Clinical and Translational Sciences Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Frank Czul
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan P Trivella
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hua Li
- Miami Clinical and Translational Sciences Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Biostatistics Collaboration and Consulting Core, Department of Epidemiology and Public Health, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Lennox Jeffers
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,Hepatology Section, Medicine Service, Miami VA Medical Center, Miami, FL, USA
| | - Paul Martin
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
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Tapper EB. Building Effective Quality Improvement Programs for Liver Disease: A Systematic Review of Quality Improvement Initiatives. Clin Gastroenterol Hepatol 2016; 14:1256-1265.e3. [PMID: 27103114 DOI: 10.1016/j.cgh.2016.04.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/06/2016] [Accepted: 04/11/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Quality indicators are the measurable components of clinical standards. Data are limited about the design and impact of interventions to improve quality indicators for patients with chronic liver disease. METHODS A systematic review of PubMed, Web of Science, and conference proceedings was performed to find reports of quality improvement (QI) interventions. Data regarding the several indicators were collected. The search focused on vaccination against hepatitis A or hepatitis B virus, management of spontaneous bacterial peritonitis, screening for varices, management of acute variceal hemorrhage, hepatocellular carcinoma screening, and 30-day readmissions. RESULTS Fifteen studies reported on the results of QI interventions. Ten focused on specific quality indicators (1 specific to vaccination, 2 spontaneous bacterial peritonitis, 3 gastrointestinal bleeding, and 4 hepatocellular carcinoma screening); 5 focused on clinical outcomes. Most studies used a pre-post study design. Interventions included checklists, educational conferences, electronic decision supports, nurse coordinators, and systematic changes to facilitate specialist co-management. Successful interventions optimized clinical workflow, closed knowledge gaps among frontline providers, created forced functions in the electronic ordering system, added dedicated staff to manage specific indicators, and provided viable alternatives to hospitalization to reduce readmission. Unsuccessful interventions included case management, phone calls, and home visits to reduce readmissions, checklists, and educational programs. CONCLUSIONS Past experience with QI provides generalizable rules for successful future interventions aimed at improved quality indicator adherence and patient outcomes.
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Affiliation(s)
- Elliot B Tapper
- Liver Center, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
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Facility- and Patient-Level Factors Associated with Esophageal Variceal Screening in the USA. Dig Dis Sci 2016; 61:62-9. [PMID: 26363933 PMCID: PMC4809672 DOI: 10.1007/s10620-015-3865-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 09/03/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM The American Association for the Study of Liver Disease (AASLD) recommends screening for esophageal varices (EV) by esophagoduodenoscopy (EGD) in patients with cirrhosis to guide decisions regarding primary prophylaxis for EV hemorrhage. We aimed to identify patient and facility factors associated with EV screening in veterans with hepatitis C (HCV)-associated cirrhosis. METHODS This was a population-based cohort study. Veterans with HCV and newly diagnosed cirrhosis between 1/1/2004 and 12/31/2005 and followed until 12/31/2011 were included. The primary outcome was receipt of EGD within 1 year of cirrhosis diagnosis. Patient- and facility-level factors associated with EV screening were determined. RESULTS A total of 4230 patients with HCV cirrhosis were identified. During median follow-up of 6.1 years (IQR: 4.0-8.0), 21.5 % developed a decompensating event, and 38.3 % died. Fifty-four percent received an EGD, and 33.8 % had an EGD within guidelines. Median time from cirrhosis diagnosis to EGD was 72 days (IQR: 12-176). Factors independently associated with receipt of EV screening were a decompensation event (OR 1.16, CI 1.01-1.32) and gastroenterology/hepatology clinic access (OR 2.1, CI 1.73-2.46), whereas cardiovascular (OR 0.81, CI 0.69-0.95), mental health (OR 0.79, CI 0.68-0.91), and respiratory (OR 0.85, CI 0.72-0.99) comorbidities were associated with reduced likelihood of EV screening. CONCLUSION EV screening per AASLD guidelines occurs in only one-third of patients. This missed opportunity was strongly associated with access to gastroenterology/hepatology specialty care. Additionally, providers may be relying on clinical cues (i.e., decompensation) to prompt referral for endoscopy suggesting education to improve compliance with guidelines is needed.
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Lim N, Lidofsky SD. Impact of physician specialty on quality care for patients hospitalized with decompensated cirrhosis. PLoS One 2015; 10:e0123490. [PMID: 25837700 PMCID: PMC4383455 DOI: 10.1371/journal.pone.0123490] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 02/27/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Decompensated cirrhosis is a common precipitant for hospitalization, and there is limited information concerning factors that influence the delivery of quality care in cirrhotic inpatients. We sought to determine the relation between physician specialty and inpatient quality care for decompensated cirrhosis. DESIGN We reviewed 247 hospital admissions for decompensated cirrhosis, managed by hospitalists or intensivists, between 2009 and 2013. The primary outcome was quality care delivery, defined as adherence to all evidence-based specialty society practice guidelines pertaining to each specific complication of cirrhosis. Secondary outcomes included new complications, length-of-stay, and in-hospital death. RESULTS Overall, 147 admissions (59.5%) received quality care. Quality care was given more commonly by intensivists, compared with hospitalists (71.7% vs. 53.1%, P = .006), and specifically for gastrointestinal bleeding (72% vs. 45.8%, P = .03) and hepatic encephalopathy (100% vs. 63%, P = .005). Involvement of gastroenterology consultation was also more common in admissions in which quality care was administered (68.7% vs. 54.0%, P = .023). Timely diagnostic paracentesis was associated with reduced new complications in admissions for refractory ascites (9.5% vs. 46.6%, P = .02), and reduced length-of-stay in admissions for spontaneous bacterial peritonitis (5 days vs. 13 days, P = .02). CONCLUSIONS Adherence to quality indicators for decompensated cirrhosis is suboptimal among hospitalized patients. Although quality care adherence appears to be higher among cirrhotic patients managed by intensivists than by hospitalists, opportunities for improvement exist in both groups. Rational and cost-effective strategies should be sought to achieve this end.
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Affiliation(s)
- Nicholas Lim
- Division of Gastroenterology and Hepatology, University of Vermont College of Medicine, Burlington, Vermont, United States of America
- University of Vermont Medical Center, Burlington, Vermont, United States of America
| | - Steven D. Lidofsky
- Division of Gastroenterology and Hepatology, University of Vermont College of Medicine, Burlington, Vermont, United States of America
- University of Vermont Medical Center, Burlington, Vermont, United States of America
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36
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Kanwal F, Volk M, Singal A, Angeli P, Talwalkar J. Improving quality of health care for patients with cirrhosis. Gastroenterology 2014; 147:1204-7. [PMID: 25449026 DOI: 10.1053/j.gastro.2014.10.029] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | - Michael Volk
- University of Michigan Health System, Ann Arbor, Michigan
| | - Amit Singal
- University of Texas Southwestern Medical Center, Dallas, Texas
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Abstract
Gastroesophageal varices are present in almost half of patients with cirrhosis at the time of initial diagnosis. Variceal bleeding occurs in 25% to 35% of patients with cirrhosis. Effective and timely care can prevent variceal bleeding (primary prophylaxis). For example, clinical studies demonstrate that both beta-blockers and endoscopic variceal ligation are effective in preventing a first episode of variceal bleeding. The major challenge is to screen patients in a timely manner and institute a form of therapy that has the highest chance of success in terms of patient compliance and effectiveness.
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38
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Affiliation(s)
- Fasiha Kanwal
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; the Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; and the Section of Health Services Research, Department of MedicineBaylor College of MedicineHoustonTX
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