Quality Measures, All‐Cause Mortality, and Health Care Use in a National Cohort of Veterans With Cirrhosis

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.

Telemedicine in Liver Disease and Beyond: Can the COVID‐19 Crisis Lead to Action?

“…(4,5) Multiple studies in liver disease have shown that access to specialty care improves adherence to guideline-recommended care for liver disease and clinical outcomes such as readmissions and mortality. (6)(7)(8) Rooted in this prior research, the goal of our program was to improve access to care for advanced liver disease, which has a comparable morbidity and mortality to end-stage congestive heart failure and chronic obstructive pulmonary disease. (9) The tertiary care team partnered with a large, community-based gastroenterology (GI) practice of 23 health care providers located in Lancaster, Pennsylvania, about 60 miles from the downtown University hospital.…”

Care quality and outcomes among US veterans with chronic hepatitis B in the hepatitis C direct‐acting antiviral era

“…Patients were classified as having received liver imaging if they underwent at least one abdominal ultrasound or contrast‐enhanced computed tomography (CT) or magnetic resonance (MR) study for 2 years following the index HBsAg + result. We evaluated HCC surveillance in screening candidates: age ≥40 years OR any age with cirrhosis, 5,27 calculating the proportion of total follow‐up time during which patients were adherent to annual or biannual screening intervals with appropriate liver imaging (ultrasound, contrast‐enhanced CT or MRI) as per our previous work 28,29 . A grace period of 30 days was accounted for in adherence calculations 29 .…”

“…We evaluated HCC surveillance in screening candidates: age ≥40 years OR any age with cirrhosis, 5,27 calculating the proportion of total follow‐up time during which patients were adherent to annual or biannual screening intervals with appropriate liver imaging (ultrasound, contrast‐enhanced CT or MRI) as per our previous work 28,29 . A grace period of 30 days was accounted for in adherence calculations 29 . Outpatient pharmacy data were used to determine whether patients were prescribed antiviral therapy with oral nucleoside analogs such as interferon‐alpha, lamivudine, adefovir, telbivudine, entecavir or tenofovir.…”

A Telephone and Mail Outreach Program Successfully Increases Uptake of Hepatocellular Carcinoma Surveillance

“…( 14 ) Adherence to HCC surveillance for patients with cirrhosis in the VHA is estimated at only 42%. ( 15 ) The reasons for this low rate are unclear. Access to gastroenterology and hepatology in the VHA is associated with higher reported rates of surveillance, but rates are still low despite most centers now offering these specialists.…”