Identifying Quality Gaps in Preventive Care for Outpatients With Cirrhosis Within a Large, Academic Health Care System

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. (Hepatology Communications 2020;0:1-10). C irrhosis is a common condition associated with significant morbidity and mortality. (1,2) It is the twelfth leading cause of death in the United States (3) and carries a burden of disease that is projected to increase over the next decade due to a rising incidence of alcohol-associated liver disease and nonalcoholic steatohepatitis (NASH). (4,5) Cirrhosis is also associated with significantly decreased quality

The road to pandemic recovery: Tracking COVID-19’s impact on cirrhosis care and outcomes among 111,558 Veterans

“…After an early downward trajectory, HCC surveillance nadired and started to recover. Baseline HCC surveillance rates were 38%, higher than a previously published VA and non-VA rates of 18%–24%, reflecting active efforts to improve HCC-6 before the pandemic 25–28. The recovery of HCC-6 in VA may be in part related to this active, concerted, population-based approach to HCC surveillance 29.…”

The Future of Quality Improvement for Cirrhosis

“…Some centers have a funded infrastructure for QI, employing quality officers who coordinate process measurement. (11,12) There is substantial work to define the denominator-the population who should receive the process measure. Appropriate candidates are defined with reference to diagnosis codes and refined on the basis of exclusion criteria (eg, age, disqualifying diagnoses, factors obtained from clinical notes).…”

Alcohol use disorder treatment and outcomes among hospitalized adults with alcoholic hepatitis

“…( Hepner et al., 2019 ) ( Rogal et al., 2020 ). By comparison, pass rates for managing other aspects of all-cause cirrhosis for inpatients and outpatients are overall higher ( Gonzalez et al., 2021 ; Kardashian et al., 2020 ), AUD care should thus be a critical priority for future improvement efforts and will rely on overcoming specific barriers. For providers, these include a lack of time, little training ( Im et al., 2020 ) and poor access to subspecialty care, while patients may face financial issues, insurance issues, and perceived societal stigma of an addiction diagnosis.…”