Who Treats Patients with Diabetes and Compensated Cirrhosis

Abstract

BackgroundIncreasingly, patients with multiple chronic conditions are being managed in patient-centered medical homes (PCMH) that coordinate primary and specialty care. However, little is known about the types of providers treating complex patients with diabetes and compensated cirrhosis.ObjectiveWe examined the mix of physician specialties who see patients dually-diagnosed with diabetes and compensated cirrhosis.DesignRetrospective cross-sectional study using 2000–2013 MarketScan® Commercial Claims and Encounters and Medicare Supplemental Databases.PatientsWe identified 22,516 adults (≥ 18 years) dually-diagnosed with diabetes and compensated cirrhosis. Patients with decompensated cirrhosis, HIV/AIDS, or liver transplantation prior to dual diagnosis were excluded.Main MeasuresPhysician mix categories: patients were assigned to one of four physician mix categories: primary care physicians (PCP) with no gastroenterologists (GI) or endocrinologists (ENDO); GI/ENDO with no PCP; PCP and GI/ENDO; and neither PCP nor GI/ENDO. Health care utilization: annual physician visits and health care expenditures were assessed by four physician mix categories.Key ResultsThroughout the 14 years of study, 92% of patients visited PCPs (54% with GI/ENDO and 39% with no GI/ENDO). The percentage who visited PCPs without GI/ENDO decreased 22% (from 63% to 49%), while patients who also visited GI/ENDO increased 71% (from 25% to 42%).ConclusionsThis is the first large nationally representative study to document the types of physicians seen by patients dually-diagnosed with diabetes and cirrhosis. A large proportion of these complex patients only visited PCPs, but there was a trend toward greater specialty care. The trend toward co-management by both PCPs and GI/ENDOs suggests that PCMH initiatives will be important for these complex patients. Documenting patterns of primary and specialty care is the first step toward improved care coordination.

Opioid prescriptions are associated with hepatic encephalopathy in a national cohort of patients with compensated cirrhosis

“…For instance, it may be that opioid‐induced altered mental status is being misdiagnosed as HE. However, the annual incidence of HE and other decompensation events are comparable to what has been published in the literature, providing external validity to our results . In addition, any event prompting a billing code for HE or the initiation of lactulose/rifaximin is likely to be clinically important.…”

“…Relatedly, there is the potential for confounding introduced as a result of increased opioid use among patients with more severe liver disease or other unmeasured confounders common to patients with pain. However, the use of landmark analysis, the lack of association between positive/negative exposure controls on HE events and the similar rates of non-HE 15,[35][36][37][38] In addition, any event prompting a billing code for HE or the initiation of lactulose/rifaximin is likely to be clinically important. Furthermore, the separation of exposure and outcome assessment through the landmark analysis limits the inclusion of episodes of altered mental status occurring immediately after opioid initiation, patients who were treated with lactulose for opioid-induced constipation or put on lactulose or rifaximin as HE prophylaxis after being started on opioids.…”

Trends in HIV Preexposure Prophylaxis Prescribing in the United States, 2012-2018

“…We categorized physician types into infectious disease, primary care physicians, and others. Primary care physicians included internal medicine, family practice, and other primary care physicians, which included medical physician, multispecialty physician group, geriatric medicine, and obstetrics and gynecology . Starting in 2015, when unique physician identifiers were available, we categorized physicians into HIV care and non–HIV care physicians, defined as those who provided care to patients infected with HIV or not based on HIV diagnosis codes from inpatient and outpatient claims.…”

Newer second-line glucose-lowering drugs versus thiazolidinediones on cirrhosis risk among older US adult patients with type 2 diabetes

“…Our primary coding definition required ICD-9 codes to be placed in the hospital setting only, while our secondary definition included the same codes but allowed them to be placed in either inpatient or outpatient settings. Since most cases of compensated cirrhosis receive care in the primary care setting, 42 our secondary definition had greater sensitivity for detecting cirrhosis and likely captured more individuals with both stable and decompensated disease, vs. only hospitalized patients with more severe disease or clinical decompensation (i.e., primary definition). Event rates for cirrhosis were expectedly higher with our secondary definition, and comparisons were better powered.…”