Patterns of Care Utilization and Hepatocellular Carcinoma Surveillance: Tracking Care Across the Pandemic

Serper, Marina; Tapper, Elliot B.; Kaplan, David E.; Taddei, Tamar H.; Mahmud, Nadim

doi:10.14309/ajg.0000000000002011

Cited by 8 publications

(7 citation statements)

References 25 publications

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“…The causes of cirrhosis vary by context and many overlap. In a study of 68 673 patients from a national sample of patients in the Veterans Administration (2020-2021), the causes of cirrhosis were hepatitis C (24.0%), alcohol related (27.9%), hepatitis C and alcohol related (17.4%), NAFLD related (25.9%), and due to other conditions (3.7%) . Patients diagnosed with cirrhosis typically have a mean age of 59.5 to 62.4 years .…”

Section: Discussionmentioning

confidence: 99%

“…Cirrhosis is defined as the fibrotic replacement of liver tissue that can result from any chronic liver disease. Most prevalent cases of cirrhosis are caused by alcohol use disorder (approximately 45% of all cirrhosis cases), hepatitis C (41%), and nonalcoholic fatty liver disease (26%), with many patients having overlapping causes . However, hepatitis C is now curable with direct-acting antivirals and most newly diagnosed cirrhosis is due to nonalcoholic fatty liver disease (NAFLD) (accounting for 61.8% of incident cases) and alcohol use disorder (accounting for 20.0%) …”

Section: Introductionmentioning

confidence: 99%

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Diagnosis and Management of Cirrhosis and Its Complications

Tapper

Parikh

2023

JAMA

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104

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ImportanceCirrhosis affects approximately 2.2 million adults in the US. From 2010 to 2021, the annual age-adjusted mortality of cirrhosis increased from 14.9 per 100 000 to 21.9 per 100 000 people.ObservationsThe most common causes of cirrhosis in the US, which can overlap, include alcohol use disorder (approximately 45% of all cases of cirrhosis), nonalcoholic fatty liver disease (26%), and hepatitis C (41%). Patients with cirrhosis experience symptoms including muscle cramps (approximately 64% prevalence), pruritus (39%), poor-quality sleep (63%), and sexual dysfunction (53%). Cirrhosis can be diagnosed by liver biopsy but may also be diagnosed noninvasively. Elastography, a noninvasive assessment of liver stiffness measured in kilopascals, can typically confirm cirrhosis at levels of 15 kPa or greater. Approximately 40% of people with cirrhosis are diagnosed when they present with complications such as hepatic encephalopathy or ascites. The median survival time following onset of hepatic encephalopathy and ascites is 0.92 and 1.1 years, respectively. Among people with ascites, the annual incidence of spontaneous bacterial peritonitis is 11% and of hepatorenal syndrome is 8%; the latter is associated with a median survival of less than 2 weeks. Approximately 1% to 4% of patients with cirrhosis develop hepatocellular carcinoma each year, which is associated with a 5-year survival of approximately 20%. In a 3-year randomized clinical trial of 201 patients with portal hypertension, nonselective β-blockers (carvedilol or propranolol) reduced the risk of decompensation or death compared with placebo (16% vs 27%). Compared with sequential initiation, combination aldosterone antagonist and loop diuretics were more likely to resolve ascites (76% vs 56%) with lower rates of hyperkalemia (4% vs 18%). In meta-analyses of randomized trials, lactulose was associated with reduced mortality relative to placebo (8.5% vs 14%) in randomized trials involving 705 patients and reduced risk of recurrent overt hepatic encephalopathy (25.5% vs 46.8%) in randomized trials involving 1415 patients. In a randomized clinical trial of 300 patients, terlipressin improved the rate of reversal of hepatorenal syndrome from 39% to 18%. Trials addressing symptoms of cirrhosis have demonstrated efficacy for hydroxyzine in improving sleep dysfunction, pickle brine and taurine for reducing muscle cramps, and tadalafil for improving sexual dysfunction in men.Conclusions and RelevanceApproximately 2.2 million US adults have cirrhosis. Many symptoms, such as muscle cramps, poor-quality sleep, pruritus, and sexual dysfunction, are common and treatable. First-line therapies include carvedilol or propranolol to prevent variceal bleeding, lactulose for hepatic encephalopathy, combination aldosterone antagonists and loop diuretics for ascites, and terlipressin for hepatorenal syndrome.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Diagnosis and Management of Cirrhosis and Its Complications

Tapper

Parikh

2023

JAMA

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104

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“…This retrospective cohort study identified trends in the processes and outcomes of care for Veterans with cirrhosis over the COVID-19 pandemic from 2018 to 2022. This evaluation adds to other COVID-related studies of cirrhosis care [23,24] by including > 100,000 Veterans over a nearly 4-year period and assessing multiple outcomes using Joinpoint regression, a rigorous approach to evaluating trajectories. Joinpoint analyses captured inflection points or times when the trends changed course.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2023

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Background & Aims: This study aimed to evaluate quarterly trends in process and health outcomes among Veterans with cirrhosis and assess the factors associated with cirrhosis outcomes before and during the COVID-19 pandemic. Approach & Results: US Veterans with cirrhosis were identified using the Veterans Health Administration Corporate Data Warehouse. Quarterly measures were evaluated from September 30, 2018, through March 31, 2022, including twice yearly screening for hepatocellular carcinoma (HCC-6), new HCC, surveillance for or treatment of esophageal varices, variceal bleeding, all-cause hospitalization, and mortality. Joinpoint analyses were used to assess the changes in trends over time. Logistic regression models were used to identify the demographic and medical factors associated with each outcome over time. Among 111,558 Veterans with cirrhosis with a mean Model for End-stage Liver Disease-Sodium of 11±5, rates of HCC-6 sharply declined from a prepandemic peak of 41%, to a nadir of 28%, and rebounded to 36% by March 2022. All-cause mortality did not significantly change over the pandemic, but new HCC diagnosis, EVST, variceal bleeding, and all-cause hospitalization significantly declined over follow-up. Quarterly HCC diagnosis declined from 0.49% to 0.38%, EVST from 50% to 41%, variceal bleeding from 0.15% to 0.11%, and hospitalization from 9% to 5%. Rurality became newly, significantly associated with nonscreening over the pandemic (aOR for HCC−6=0.80, 95% CI 0.74 to 0.86; aOR for EVST=0.95, 95% CI 0.90 to 0.997). Conclusions: The pandemic continues to impact cirrhosis care. Identifying populations at the highest risk of care disruptions may help to address ongoing areas of need.

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“…VA-specific programs like the HITs of experts who educate frontline providers and the use of dashboards for population health management may also improve care delivery. 32 …”

Section: Discussionmentioning

confidence: 99%

“…The COVID-19 pandemic facilitated rapid shifts to telehealth for cirrhosis early in the public health emergency; 15 however, more recently, telehealth use has declined and its optimal integration into clinical care remains understudied. 16 …”

Section: Introductionmentioning

confidence: 99%

Multidisciplinary teams, efficient communication, procedure services, and telehealth improve cirrhosis care: A qualitative study

Serper

Agha

Garren

et al. 2023

Hepatology Communications

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Background: Cirrhosis care and outcomes are improved with access to subspecialty gastroenterology and hepatology care. In qualitative interviews, we investigated clinicians’ perceptions of factors that optimize or impede cirrhosis care. Methods: We conducted 24 telephone interviews with subspecialty clinicians at 7 Veterans Affairs medical centers with high- and low-complexity services. Purposive sampling stratified Veterans Affairs medical centers on timely post-hospitalization follow-up, a quality measure. We asked open-ended questions about facilitators and barriers of care coordination, access to appointments, procedures, transplantation, management of complications, keeping up to date with medical knowledge, and telehealth use. Results: Key themes that facilitated care were structural: multidisciplinary teams, clinical dashboards, mechanisms for appointment tracking and reminders, and local or virtual access to transplant and liver cancer specialists through the “specialty care access network extension for community health care outcomes” program. Coordination and efficient communication between transplant and non-transplant specialists and between transplant and primary care facilitated timely care. Same-day access to laboratory, procedural, and clinical services is an indicator of high-quality care. Barriers included lack of on-site procedural services, clinician turnover, patient social needs related to transportation, costs, and patient forgetfulness due to HE. Telehealth enabled lower complexity sites to obtain recommendations for complex patient cases. Barriers to telehealth included lack of credit (eg, VA billing equivalent), inadequate staff, lack of audiovisual technology support, and patient and staff discomfort with technology. Telehealth was optimal for return visits, cases where physical examination was nonessential, and where distance and transportation precluded in-person care. Rapid telehealth uptake during the COVID-19 pandemic was a positive disruptor and facilitated use. Conclusions: We identify multi-level factors related to structure, staffing, technology, and care organization to optimize cirrhosis care delivery.

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Patterns of Care Utilization and Hepatocellular Carcinoma Surveillance: Tracking Care Across the Pandemic

Cited by 8 publications

References 25 publications

Diagnosis and Management of Cirrhosis and Its Complications

Diagnosis and Management of Cirrhosis and Its Complications

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

Multidisciplinary teams, efficient communication, procedure services, and telehealth improve cirrhosis care: A qualitative study

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