COMMENTARIES Improving Quality of Health Care for Patients With Cirrhosis
T
he Institute of Medicine defines quality improvement (QI) as a “systematic effort and actions that lead to measurable improvement in health care services and the health status” of populations.1 As physicians and health care professionals, we all strive to better the quality of care provided to our patients. The need to improve quality has long been recognized as important in most European countries; it has become more pressing in the United States with the advent of payment reform models designed to reimburse care based on quality, safety, and cost. Indeed, QI efforts are now widespread in conditions as diverse as diabetes, cardiac diseases, cancer, and human immunodeficiency virus. The criteria for selecting conditions for QI include the presence of significant disease-related burden of mortality and morbidity, high-quality studies supporting effective interventions, and evidence that these therapies are inadequately or inconsistently applied. In this commentary, we discuss the rationale for QI efforts in cirrhosis, including the significant disease burden, fragmented health care delivery, and performance gaps in processes of care that affect this disease population. We also describe a multisite Cirrhosis Quality Collaborative (CQC) designed to initiate a systematic effort in improving quality of cirrhosis care.
Burden of Cirrhosis on the Health Care System and Individual Patients The human and economic burden of cirrhosis has increased substantially in the last 10 years, likely as a result of an aging chronic hepatitis C cohort and the rising prevalence of nonalcoholic fatty liver disease.2,3 Cirrhosis accounts for nearly 60,000 deaths in the United States each year.4 Liver disease is the second leading cause of digestive disease-related death (after colorectal cancer), and contributes the greatest Gastroenterology 2014;147:1204–1207
number of years of potential life lost.5,6 Similar data are reported from Western Europe, where cirrhosis is the fourth cause of disability adjusted life of years in males after ischemic heart disease, low back pain, and lung cancer.7 Despite improvements in technology and treatments, liver-related mortality has remained relatively unchanged over the last 3 decades. Cirrhosis is also a resource intensive and costly condition. In 2004, there were 759,000 hospital discharges and 2.4 million ambulatory care visits with liver disease as one of the listed diagnoses.6 Notably, more recent data from the Agencies for Healthcare Research in Quality have estimated an increasing number of emergency department visits with cirrhosis from 411,869 in 2006 to 548,092 in 2011.8 Similarly, the number of hospital discharges for complications of cirrhosis has increased from 436,901 in 2006 to 576,573 in 2011.8 Recent data show that nearly 70% of patients with cirrhosis who survive their initial hospitalization have 1 readmission, at an average cost exceeding $20,000 and V10,000 per readmission in United States and Europe, respectively.9,10 The burden of disease engendered by cirrhosis extends beyond its impact on traditional outcomes to include a negative impact on patient-reported measures such as health-related quality of life. Compared with the general population, patients with cirrhosis consistently report worse health status and greater functional disability.11 Recent work also suggests that individuals with cirrhosis have more comorbidities, use significantly more health care services, and need more than twice the number of informal caregiving hours per person than agematched controls without cirrhosis.12
Organization and Delivery of Healthcare for Populations With Cirrhosis A number of societal and delivery system barriers exist that prevent patients with cirrhosis from receiving
optimal care. For example, these patients are more likely than the general population to be poor and uninsured. Among US patients, approximately one quarter of the insured patients are covered by Medicaid, which lapses easily and has a limited provider network owing to low reimbursement rates.13,14 These inequities exist alongside racial disparities in the management and outcomes of cirrhosis patients.15 The proportion of uninsured individuals may decline as a result of provisions within the Affordable Care Act in the United States, which allows patients with a preexisting condition to be covered. However, access and other barriers to medical care will likely remain for many patients with cirrhosis, particularly in the 24 states that have not expanded Medicaid coverage to date.16 Even among those with good quality health insurance, access to specialty care is often difficult. According to European Union of Medical Specialists and European Board of Transplant Medicine, there are 35 certified transplant hepatologists in Europe. There are close to 490 boardcertified transplant hepatologists in the United States, and perhaps another 500 who are not board certified but focus primarily on liver disease.17 Most of these hepatologists (both in Europe and the United States) tend to be clustered at liver transplant centers. As a result, most of the care for patients with liver diseases is entrusted primarily to other providers, such as primary care physicians, gastroenterologists, or specialists in internal medicine who focus on the management of the liver diseases. For example, in an analysis of the US Nationwide Inpatient Sample, 82% of hospitalizations occurred at nontransplant hospitals (unpublished data). Among 276 hospitalized patients with cirrhosis in the Health and Retirement Study, only 45% had an encounter with a gastroenterologist during their hospitalization or in the ensuing year after discharge.18 Therefore, the provider “network” for populations with cirrhosis consists not only of hepatologists, but also gastroenterologists, specialists in internal medicine, and primary care physicians
COMMENTARIES practicing in academic institutions, hospitals or offices that are typically not linked together as part of larger organizations. This means that QI efforts need to engage and involve those practices, and not just focus on tertiary centers. Physicians who do not specialize in liver disease cannot be expected to keep up with the rapid advances in hepatology, and thus patients may not receive proven treatments. For example, patients with cirrhosis and ascites in the Veterans Affairs system were 33% more likely to receive recommended treatments such as antibiotics for secondary prophylaxis against spontaneous bacterial peritonitis (SBP) if they were followed by a gastroenterologist than if they only saw a primary care physician.19 Access to gastroenterology services has also been linked with greater likelihoods of undergoing surveillance for hepatocellular carcinoma as well as timely referral for liver transplantation.20 In Italy, a new hepatologist-run coordinated care model was more cost-effective than the routine primary care–based outpatient care model.10 In the future, novel delivery mechanisms such as project Extension for Community Healthcare Outcomes (ECHO) may improve access to specialty care. In addition, more research is needed into ways to improve care coordination between tertiary centers, community gastroenterologists, and primary care physicians.
Quality Gaps in the Health Care of Patients With Cirrhosis It is well known that appropriate medical care for cirrhosis can delay complications, improve quality of life, and possibly extend survival. Indeed, there is evidence demonstrating that appropriate care processes using level I evidence can lead to desirable outcomes patients with cirrhosis. For example, results of controlled trials demonstrate the efficacy of antibiotic prophylaxis in patients with gastrointestinal bleeding and those with prior SBP,21 and show that nonselective b-blockers or variceal ligation reduce the risk of variceal bleeding and mortality.22 Similarly,
enrollment in a hepatocellular cancer surveillance program may be associated with increased detection of early stage cancer, increased utilization of potentially curative therapy, and improved survival.23 However, the full extent to which populations of patients with cirrhosis receive guideline recommended care is unknown; existing studies indicate significant shortfalls. In a cohort of 774 patients with cirrhosis seen at 3 Veterans Affairs Medical Centers between 2000 and 2007, nearly all patients with documented SBP received antibiotics for treatment of SBP.19 However, only 30% of these patients received recommended antibiotics for secondary prophylaxis after their discharge from the hospital.19 Similarly, only 24.3% (95% CI, 20.2%–28.3%) of patients had an upper endoscopy during the first year after cirrhosis diagnosis and 60% (95% CI, 50.2%–70.7%) of patients with varices received either b-blockers or endoscopic band ligation for primary prophylaxis of variceal bleeding.24 Singh et al25 found that follow-up endoscopy for secondary prophylaxis for variceal bleeding was arranged for only 65% of patients after the initial bleeding episode. Overall,
T
he Institute of Medicine defines quality improvement (QI) as a “systematic effort and actions that lead to measurable improvement in health care services and the health status” of populations.1 As physicians and health care professionals, we all strive to better the quality of care provided to our patients. The need to improve quality has long been recognized as important in most European countries; it has become more pressing in the United States with the advent of payment reform models designed to reimburse care based on quality, safety, and cost. Indeed, QI efforts are now widespread in conditions as diverse as diabetes, cardiac diseases, cancer, and human immunodeficiency virus. The criteria for selecting conditions for QI include the presence of significant disease-related burden of mortality and morbidity, high-quality studies supporting effective interventions, and evidence that these therapies are inadequately or inconsistently applied. In this commentary, we discuss the rationale for QI efforts in cirrhosis, including the significant disease burden, fragmented health care delivery, and performance gaps in processes of care that affect this disease population. We also describe a multisite Cirrhosis Quality Collaborative (CQC) designed to initiate a systematic effort in improving quality of cirrhosis care.
Burden of Cirrhosis on the Health Care System and Individual Patients The human and economic burden of cirrhosis has increased substantially in the last 10 years, likely as a result of an aging chronic hepatitis C cohort and the rising prevalence of nonalcoholic fatty liver disease.2,3 Cirrhosis accounts for nearly 60,000 deaths in the United States each year.4 Liver disease is the second leading cause of digestive disease-related death (after colorectal cancer), and contributes the greatest Gastroenterology 2014;147:1204–1207
number of years of potential life lost.5,6 Similar data are reported from Western Europe, where cirrhosis is the fourth cause of disability adjusted life of years in males after ischemic heart disease, low back pain, and lung cancer.7 Despite improvements in technology and treatments, liver-related mortality has remained relatively unchanged over the last 3 decades. Cirrhosis is also a resource intensive and costly condition. In 2004, there were 759,000 hospital discharges and 2.4 million ambulatory care visits with liver disease as one of the listed diagnoses.6 Notably, more recent data from the Agencies for Healthcare Research in Quality have estimated an increasing number of emergency department visits with cirrhosis from 411,869 in 2006 to 548,092 in 2011.8 Similarly, the number of hospital discharges for complications of cirrhosis has increased from 436,901 in 2006 to 576,573 in 2011.8 Recent data show that nearly 70% of patients with cirrhosis who survive their initial hospitalization have 1 readmission, at an average cost exceeding $20,000 and V10,000 per readmission in United States and Europe, respectively.9,10 The burden of disease engendered by cirrhosis extends beyond its impact on traditional outcomes to include a negative impact on patient-reported measures such as health-related quality of life. Compared with the general population, patients with cirrhosis consistently report worse health status and greater functional disability.11 Recent work also suggests that individuals with cirrhosis have more comorbidities, use significantly more health care services, and need more than twice the number of informal caregiving hours per person than agematched controls without cirrhosis.12
Organization and Delivery of Healthcare for Populations With Cirrhosis A number of societal and delivery system barriers exist that prevent patients with cirrhosis from receiving
optimal care. For example, these patients are more likely than the general population to be poor and uninsured. Among US patients, approximately one quarter of the insured patients are covered by Medicaid, which lapses easily and has a limited provider network owing to low reimbursement rates.13,14 These inequities exist alongside racial disparities in the management and outcomes of cirrhosis patients.15 The proportion of uninsured individuals may decline as a result of provisions within the Affordable Care Act in the United States, which allows patients with a preexisting condition to be covered. However, access and other barriers to medical care will likely remain for many patients with cirrhosis, particularly in the 24 states that have not expanded Medicaid coverage to date.16 Even among those with good quality health insurance, access to specialty care is often difficult. According to European Union of Medical Specialists and European Board of Transplant Medicine, there are 35 certified transplant hepatologists in Europe. There are close to 490 boardcertified transplant hepatologists in the United States, and perhaps another 500 who are not board certified but focus primarily on liver disease.17 Most of these hepatologists (both in Europe and the United States) tend to be clustered at liver transplant centers. As a result, most of the care for patients with liver diseases is entrusted primarily to other providers, such as primary care physicians, gastroenterologists, or specialists in internal medicine who focus on the management of the liver diseases. For example, in an analysis of the US Nationwide Inpatient Sample, 82% of hospitalizations occurred at nontransplant hospitals (unpublished data). Among 276 hospitalized patients with cirrhosis in the Health and Retirement Study, only 45% had an encounter with a gastroenterologist during their hospitalization or in the ensuing year after discharge.18 Therefore, the provider “network” for populations with cirrhosis consists not only of hepatologists, but also gastroenterologists, specialists in internal medicine, and primary care physicians
COMMENTARIES practicing in academic institutions, hospitals or offices that are typically not linked together as part of larger organizations. This means that QI efforts need to engage and involve those practices, and not just focus on tertiary centers. Physicians who do not specialize in liver disease cannot be expected to keep up with the rapid advances in hepatology, and thus patients may not receive proven treatments. For example, patients with cirrhosis and ascites in the Veterans Affairs system were 33% more likely to receive recommended treatments such as antibiotics for secondary prophylaxis against spontaneous bacterial peritonitis (SBP) if they were followed by a gastroenterologist than if they only saw a primary care physician.19 Access to gastroenterology services has also been linked with greater likelihoods of undergoing surveillance for hepatocellular carcinoma as well as timely referral for liver transplantation.20 In Italy, a new hepatologist-run coordinated care model was more cost-effective than the routine primary care–based outpatient care model.10 In the future, novel delivery mechanisms such as project Extension for Community Healthcare Outcomes (ECHO) may improve access to specialty care. In addition, more research is needed into ways to improve care coordination between tertiary centers, community gastroenterologists, and primary care physicians.
Quality Gaps in the Health Care of Patients With Cirrhosis It is well known that appropriate medical care for cirrhosis can delay complications, improve quality of life, and possibly extend survival. Indeed, there is evidence demonstrating that appropriate care processes using level I evidence can lead to desirable outcomes patients with cirrhosis. For example, results of controlled trials demonstrate the efficacy of antibiotic prophylaxis in patients with gastrointestinal bleeding and those with prior SBP,21 and show that nonselective b-blockers or variceal ligation reduce the risk of variceal bleeding and mortality.22 Similarly,
enrollment in a hepatocellular cancer surveillance program may be associated with increased detection of early stage cancer, increased utilization of potentially curative therapy, and improved survival.23 However, the full extent to which populations of patients with cirrhosis receive guideline recommended care is unknown; existing studies indicate significant shortfalls. In a cohort of 774 patients with cirrhosis seen at 3 Veterans Affairs Medical Centers between 2000 and 2007, nearly all patients with documented SBP received antibiotics for treatment of SBP.19 However, only 30% of these patients received recommended antibiotics for secondary prophylaxis after their discharge from the hospital.19 Similarly, only 24.3% (95% CI, 20.2%–28.3%) of patients had an upper endoscopy during the first year after cirrhosis diagnosis and 60% (95% CI, 50.2%–70.7%) of patients with varices received either b-blockers or endoscopic band ligation for primary prophylaxis of variceal bleeding.24 Singh et al25 found that follow-up endoscopy for secondary prophylaxis for variceal bleeding was arranged for only 65% of patients after the initial bleeding episode. Overall,
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