Access to Subspecialty Care And Survival Among Patients With Liver Disease

Mellinger, Jessica L.; Moser, Stephanie; Welsh, Deborah E.; Yosef, Matheos; Van, Tony; McCurdy, Heather; Rakoski, Mina O.; Moseley, Richard H.; Glass, Lisa; Waljee, Akbar K.; Volk, Michael L.; Sales, Anne E.; Su, Grace L.

doi:10.1038/ajg.2016.96

Cited by 27 publications

(42 citation statements)

References 32 publications

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“…Patients with a well‐characterized liver diagnosis such as hepatitis B, hepatitis C, cirrhosis, and cirrhosis complications were more likely to have had a SCAN‐ECHO visit. This is consistent with prior patterns seen, in which patients who had these diagnoses were more likely to have a specialty consultation leading to a visit . Similarly, patients with indicators suggestive of more severe liver disease such as elevated ALT and bilirubin were more likely to have had a SCAN‐ECHO visit than no visit.…”

Section: Resultssupporting

confidence: 87%

“…Despite wide uptake of the SCAN‐ECHO program in the VHA, data are limited regarding the clinical impact of VA SCAN‐ECHO, particularly on patient outcomes such as mortality . We previously showed that an in‐person specialist consultation visit is associated with improved survival in liver disease patients . This study sought to extend those findings by examining whether a virtual specialty SCAN‐ECHO consultation visit had a similar positive effect on survival of patients with liver disease.…”

mentioning

confidence: 92%

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Virtual Consultations Through the Veterans Administration SCAN‐ECHO Project Improves Survival for Veterans With Liver Disease

Glass

Tapper

et al. 2018

Hepatology

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Access to specialty care has been associated with improved survival in patients with liver disease but universal access is not always feasible. Methods of care delivery using virtual modalities including the SCAN-ECHO (Specialty Access Network-Extension of Community Healthcare Outcome) program were implemented by the Veterans Health Administration (VHA) to address this need but limited data are available on patient outcomes. We sought to evaluate the efficacy of a SCAN-ECHO visit within the context of a regional cohort of patients with liver disease in the VHA (n = 62,237) following implementation in the Ann Arbor SCAN-ECHO Liver Clinic from June 1, 2011, to March 31, 2015. The effect of a SCAN-ECHO visit on all-cause mortality was compared with patients with no liver clinic visit. To adjust for the differences among patients who had a SCAN-ECHO visit versus those with no visit, propensity score matching was performed on condition factors that affect the likelihood of a SCAN-ECHO visit: demographics, geographic location, liver disease diagnosis, severity, and comorbidities. During the study period, 513 patients who had a liver SCAN-ECHO visit were found within the cohort. Patients who had completed a virtual SCAN-ECHO visit were more likely younger, rural, with more significant liver disease, and evidence for cirrhosis. Propensity-adjusted mortality rates using the Cox Proportional Hazard Model showed that a SCAN-ECHO visit was associated with a hazard ratio of 0.54 (95% confidence interval 0.36-0.81, P = 0.003) compared with no visit. Conclusion: Improved survival in patients using SCAN-ECHO suggests that this approach may be an effective method to improve access for selected patients with liver disease, particularly in rural and underserved populations where access to specialty care is limited.

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Section: Resultssupporting

confidence: 87%

mentioning

confidence: 92%

Virtual Consultations Through the Veterans Administration SCAN‐ECHO Project Improves Survival for Veterans With Liver Disease

Glass

Tapper

et al. 2018

Hepatology

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“…Although APP involvement was associated with higher quality care compared with no APP, the quality of care provided by APPs without gastroenterologists/hepatologists was inferior to that provided by gastroenterologists/hepatologists alone in all categories except 30‐day readmissions. Our findings confirm a prior study from the VA, in which gastroenterology/hepatology consultation was associated with improved outcomes in patients with cirrhosis . However, access to gastroenterologists/hepatologists is limited; among Medicare and VA enrollees, 55% and 67% of patients with cirrhosis, respectively, are never evaluated by a gastroenterologist/hepatologist .…”

Section: Discussionsupporting

confidence: 83%

“…A major barrier to optimal care for cirrhosis is limited access to subspecialty care. Most patients with cirrhosis are not co‐managed by a gastroenterology‐trained or hepatology‐trained specialist . Previous studies have demonstrated that advanced practice providers (APPs) provide care that is equivalent in quality to medical doctors (MDs) in both primary care and specialty care when their practice is focused on one condition .…”

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confidence: 99%

The Quality and Outcomes of Care Provided to Patients with Cirrhosis by Advanced Practice Providers

et al. 2019

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Cirrhosis is morbid and increasingly prevalent, yet the U.S. health care system lacks enough physicians and specialists to adequately manage patients with cirrhosis. Although advanced practice providers (APPs) can expand access to cirrhosis‐related care, their impact on the quality of care remains unknown. We sought to determine the effect on care quality and outcomes for patients managed by APPs using a retrospective analysis of a nationally representative American commercial claims database (Optum), which included 389,257 unique adults with cirrhosis. We evaluated a complication of process measures (i.e., rates of hepatocellular carcinoma [HCC] screening, endoscopic varices screening, and use of rifaximin after hospitalization for hepatic encephalopathy) and outcomes (30‐day readmissions and survival). Compared with patients without APP care, patients with APP care had higher rates of HCC screening (adjusted odds ratio [OR] 1.23, 95% confidence interval 1.19, 1.27), varices screening (OR 1.20 [1.13, 1.27]), use of rifaximin after a discharge for hepatic encephalopathy (OR 2.09 [1.80, 2.43]), and reduced risk of 30‐day readmission (OR 0.68 [0.66, 0.70]). Gastroenterology/hepatology consultation was also associated with improved quality metric performance compared with primary care; however, shared visits between gastroenterologists/hepatologists and APPs were associated with the best performance and lower 30‐day readmissions compared with subspecialty consultation without an APP (OR 0.91 [0.87, 0.95]. Multivariate analysis adjusting for comorbidities, liver disease severity, and other factors including gastroenterology/hepatology consultation showed that patients seen by APPs were more likely to receive consistent HCC and varices screening over time, less likely to experience 30‐day readmissions, and had lower mortality (adjusted hazard ratio 0.57, 95% confidence interval 0.55, 0.60). Conclusion: APPs, particularly when working with gastroenterologists/hepatologists, are associated with improved quality of care and outcomes for patients with cirrhosis.

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“…The VA Ann Arbor was one of the first to implement SCAN‐ECHO for chronic liver disease. Having already shown that in‐person specialist consultation visits were associated with improved survival in patients with liver disease, Su et al set out to extend those findings by examining whether a virtual specialty consultation had a similar benefit on survival. Their findings are published in this month’s H epatology …”

mentioning

confidence: 99%

Project ECHO: The Specialist Will See You Now

2018

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Access to Subspecialty Care And Survival Among Patients With Liver Disease

Abstract: Access to ambulatory GI care was associated with improved 5-year survival for patients with liver disease. Innovative care coordination techniques may prove beneficial in extending access to care to liver disease patients.

Cited by 27 publications

References 32 publications

Virtual Consultations Through the Veterans Administration SCAN‐ECHO Project Improves Survival for Veterans With Liver Disease

Virtual Consultations Through the Veterans Administration SCAN‐ECHO Project Improves Survival for Veterans With Liver Disease

The Quality and Outcomes of Care Provided to Patients with Cirrhosis by Advanced Practice Providers

Project ECHO: The Specialist Will See You Now

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