The Future of Quality Improvement for Cirrhosis

Real-World Trends and Future Projections of the Prevalence of Cirrhosis and Hepatic Encephalopathy Among Commercially and Medicare-Insured Adults in the United States

INTRODUCTION

Describing cirrhosis and hepatic encephalopathy (HE) burden over time can inform clinical management and resource allocation. Using healthcare claims data, this observational study examined recent trends in the prevalence of cirrhosis and HE and associated healthcare resource utilization among commercially and Medicare-insured adults in the United States.

METHODS

Data from the MarketScan Commercial Claims and Encounters Database and 100% Medicare Research Identifiable Files were analyzed (2007-2020). Annual prevalence of cirrhosis, HE, overt HE (OHE) hospitalizations, and rifaximin ± lactulose use, and costs per hospitalization per year were calculated. Average year-over-year changes in prevalence of cirrhosis, and HE were estimated. Trends were extrapolated to 2030 using ordinary least-squares regression.

RESULTS

From 2007 to 2020, the prevalence of cirrhosis increased by an average of 4.6% year-over-year in the Commercial population and 8.1% in the Medicare population; the prevalence of HE increased by 4.3% and 2.5%, respectively. Rates of OHE hospitalizations decreased from 27.5% to 5.5% (Commercial) and from 26.2% to 9.5% (Medicare), and rates of liver transplantation increased. Average payer costs (Commercial) and provider charges (Medicare) per OHE hospitalization increased (from $40,881 to $77,699 and from $45,913 to $74,894, respectively). Use of rifaximin ± lactulose showed an increasing trend during the observation period, whereas lactulose use declined steadily.

DISCUSSION

The healthcare burden of cirrhosis and HE in the United States is increasing. Trends are projected to continue unless action is taken, such as improving medication access and developing policies addressing the contributing factors.

Cirrhosis in primary practice: many patients remain potentially undiagnosed and are not receiving liver cancer surveillance

BACKGROUND AND AIM

Most patients with cirrhosis have compensated disease and are cared for in primary care; however, the exact epidemiology within Australia remains largely unknown. The aim of this study was to assess cirrhosis care in an Australian primary care setting by evaluating rates of cirrhosis diagnosis, appropriate hepatocellular carcinoma (HCC) surveillance and specialist communication.

METHODS

Electronic medical records in consenting general practices were reviewed using the "Liver Toolkit" to identify patients with an existing cirrhosis diagnosis. Individual cases were reviewed to identify outcomes of interest.

RESULTS

One hundred seventy-one patients with confirmed cirrhosis across nine general practices were identified (74% male, mean age: 61.2 years). There was significant variation in the rate of cirrhosis diagnosis between practices (range 31.7-637.9 per 100 000 patients, P < 0.0001). Patients with cirrhosis had predominately compensated disease (75% Child-Pugh A) and common etiologies of cirrhosis were alcohol (49%), hepatitis C (47%), and metabolic dysfunction-associated steatotic liver disease (29%). Forty-two patients (25%) had received appropriate HCC surveillance. Predictors of inadequate HCC surveillance were time from last specialist correspondence (odds ratio [OR] = 1.06 per month increase, 95% confidence interval [CI]: 1.02-1.10, P = 0.002) and hepatitis B (OR = 0.24, 95% CI: 0.06-0.98, P = 0.047). Specialist correspondence with primary care was older than 2 years or absent in 37% of cases.

CONCLUSIONS

There was a 20-fold difference in the rate of cirrhosis diagnosis between general practices within Sydney, suggesting a large proportion of patients remain undiagnosed. Three quarters of patients with diagnosed cirrhosis are not receiving appropriate HCC surveillance.

Albumin for Spontaneous Bacterial Peritonitis: Care Variation, Disparities, and Outcomes

INTRODUCTION

Intravenous albumin reduces mortality in spontaneous bacterial peritonitis (SBP). We sought to characterize albumin use for SBP over time and investigate patient-level and hospital-level factors associated with use.

METHODS

A retrospective cohort study in the Veterans Health Administration between 2008 and 2021 evaluated trends and patient-level, practice-level, and facility-level factors associated with use among patients with cirrhosis hospitalized for SBP confirmed with ascitic fluid criteria.

RESULTS

Among 3,871 veterans with SBP, 803 (20.7%) did not receive albumin, 1,119 (28.9%) received albumin but not per guidelines, and 1,949 (50.3%) received albumin per guidelines; use increased from 66% in 2008 to 88% in 2022. Veterans who identified as Black compared with White were less likely to receive guideline-recommended albumin (Odds ratio [OR] 0.76, 95% confidence interval [CI] 0.59-0.98) in all analyses. Guideline-recommended albumin was more likely to be administered to veterans with Child-Turcotte-Pugh class B (OR 1.39, 95% CI 1.17-1.64) and C (OR 2.21, 95% CI 1.61-3.04) compared with Child-Turcotte-Pugh A; and acute kidney injury Stage 1 (OR 1.48, 95% CI 1.22-1.79), Stage 2 (OR 2.17, 95% CI 1.62-2.91), and Stage 3 (OR 1.68, 95% CI 1.18-2.40) compared with no acute kidney injury. gastroenterology/hepatology consultation (OR 1.60, 95% CI 1.29-1.99), nephrology consultation (OR 1.60, 95% CI 1.23-2.07), and having both gastroenterology/hepatology and nephrology consultations (OR 2.17, 95% CI 1.60-2.96) were associated with higher albumin administration. In exploratory analyses accounting for interactions between model for end-stage liver disease sodium and albumin, guideline-recommended albumin was associated with lower in-hospital mortality (HR 0.90, 95% CI 0.85-0.96).

DISCUSSION

Future studies should investigate optimizing albumin use for SBP to reduce the variability and mitigate healthcare disparities.

High Hospitalization Rates and Risk Factors Among Frail Patients With Cirrhosis: A 10-year Population-based Cohort Study

BACKGROUND & AIMS

Cirrhosis-related inpatient hospitalizations have increased dramatically over the past decade. We used a longitudinal dataset capturing a large metropolitan area in the United States from 2011 to 2021 to evaluate contemporary hospitalization rates and risk factors among frail patients with cirrhosis.

METHODS

We conducted a retrospective, longitudinal cohort study using the Chicago Area Patient-Centered Outcomes Research Network (CAPriCORN) database, an electronic health record repository that aggregates de-duplicated data across 7 health care systems in the Chicago metropolitan area, from 2011 to 2021. The primary outcome of our study was the rate of hospitalization encounters. Frailty was defined by the Hospital Frailty Risk Score. Hospitalization rates were reported per 100 patients per year, and a multivariable logistic regression analysis identified predictors of annual hospitalization probability.

RESULTS

During the study period, of 36,971 patients, 16,265 patients (44%) were hospitalized (compensated, 18.4%; decompensated, 81.6%). Hospitalization rates were highest in patients with decompensated cirrhosis, reaching nearly 77.3 hospitalizations/100 patients per year. Hospitalization rates among patients with compensated cirrhosis were also high (14.2 vs 77.3 hospitalization/100 patients per year), with odds of annual hospitalization 3 times (odds ratio, 3.1; 95% confidence interval, 2.9-3.4) as high among compensated patients with intermediate frailty and 5 times (odds ratio, 5.2; 95% confidence interval, 4.5-6.0) as high among those with severe frailty (compared with compensated patients with low frailty).

CONCLUSION

Compensated and decompensated cirrhosis patients with intermediate to severe frailty face a substantially increased odds of annual hospitalizations compared with those with low frailty. Future work should focus on targeted interventions to incorporate routine frailty screenings into cirrhosis care and to ultimately minimize high hospitalization rates.

Bisphosphonate effectiveness in patients with cirrhosis: An emulated clinical trial

BACKGROUND

Falls and fractures are common and morbid for patients with cirrhosis. Bisphosphonates are recommended for the prevention of fractures for people with osteoporosis cirrhosis; however, data supporting effectiveness in cirrhosis are lacking.

AIM

We sought to emulate a clinical trial of bisphosphonates in cirrhosis.

METHODS

We used national Medicare data (2008-2020) to examine the 5-year risk of fractures in patients who did or did not receive bisphosphonates with a new-user design among people diagnosed with cirrhosis and osteoporosis. We balanced treated and untreated with inverse probability of treatment weighting, evaluated intention-to-treat and as-treated effects, and examined both control exposures (statin use) and outcomes (decompensation) to test causal relationships.

RESULTS

There were 253 and 20,888 new users and non-users of bisphosphonates, respectively. The median age was 74 years. The most common bisphosphonate used was alendronate (73.6%). Bisphosphonates significantly reduced fractures overall (27.5% vs. 33.0%, p = 0.0004) in the intention-to-treat analysis, particularly for people <65 years (sHR 0.56) old, men (sHR 0.64) and those with non-alcohol related liver disease (sHR 0.85). Though there were fewer arm (20.7% vs. 26.4%, p < 0.0001) and femur (28.9% vs. 31.2%, p = 0.005), there were more spinal (25.8% vs. 19.0%), rib (40.0% vs. 32.2%) and skull (10.1% vs. 8.7%) fractures. In the as-treated analysis, cumulative bisphosphonate exposure significantly reduced fractures, sHR 0.95 95% CI (0.91, 0.98). Treatment was inconsistent; bisphosphonate users spent 29.9% person-years of follow-up on the drug.

CONCLUSION

In a nationally representative cohort of elderly patients with cirrhosis, bisphosphonates reduced fractures overall. Efforts to increase uptake and drug continuation are needed.

Implementing pragmatic clinical trials in hepatology

Patients with chronic liver disease would benefit from pragmatic trial designs. A pragmatic trial seeks to inform clinical decision-making by providing evidence for the adoption of an intervention into real-world clinical practice. A trial's pragmatism is based on the efficiency by which it identifies, recruits, and follows patients, the degree to which the interventions and design mirror the usual clinical care, and the importance of the outcomes to the patients. We review the promise, trade-offs, and purpose of pragmatic trials in hepatology.

Secondary Prevention of Esophageal Variceal Bleeding Is Often Imperfect: A National, Population-Based Cohort Study of 3592 Patients

BACKGROUND AND AIMS

Secondary prevention of esophageal variceal bleeding is important to improve prognosis, but uptake of guidelines is unknown in a real-world setting. Here, we determined the proportion of patients receiving appropriate nonselective beta-blocker treatment and repeat upper endoscopy after a first episode of esophageal variceal bleeding within a reasonable time frame.

METHODS

Population-based registers were used to identify all patients with a first episode of esophageal variceal bleeding in Sweden from 2006 to 2020. Crosslinkage between registers was performed to receive information on the cumulative incidence of patients with a dispensation of nonselective beta-blockers and repeat upper endoscopy within 120 days from baseline. Overall mortality was investigated using Cox regression.

RESULTS

In total, 3592 patients were identified, with a median age of 63 (interquartile range, 54-71) years. The cumulative incidence of a dispensation of nonselective beta-blockers and a repeat endoscopy within 120 days was 33%. A total of 77% received either of these treatments. Overall mortality was high, with 65% of patients dying after esophageal variceal bleeding during the full follow-up period (median 1.7 years). We observed an improved overall mortality during the later years of the study period (adjusted hazard ratio for the 2016-2020 period compared with the 2006-2010 period, 0.80; 95% confidence interval, 0.71-0.89). Patients with receipt of nonselective beta-blockers and repeat upper endoscopy had better overall survival compared with those without (adjusted hazard ratio, 0.80; 95% confidence interval, 0.72-0.90).

CONCLUSIONS

Secondary prevention of esophageal variceal bleeding has not been widely undertaken, with many patients not receiving guideline-supported interventions within a reasonable time frame. This highlights a need to raise awareness on appropriate prevention strategies to clinicians and patients.

Comparing the CFIR-ERIC matching tool recommendations to real-world strategy effectiveness data: a mixed-methods study in the Veterans Health Administration

BACKGROUND

Practical and feasible methods for matching implementation strategies to diagnosed barriers of evidence-based interventions in real-world contexts are lacking. This evaluation compared actual implementation strategies applied with those recommended by an expert opinion-based tool to improve guideline-concordant cirrhosis care in a Veterans Health Administration national learning collaborative effort.

METHODS

This convergent parallel mixed-methods study aimed to (1) identify pre-implementation Consolidated Framework for Implementation Research (CFIR) barriers to cirrhosis care through focus groups with frontline providers, (2) generate 20 recommended strategies using focus group identified barriers entered into the CFIR-Expert Recommendations for Implementing Change (ERIC) Implementation Strategy Matching Tool, (3) survey providers over two consecutive years on the actual use of 73 ERIC strategies and determine strategy effectiveness, (4) compare actual versus recommended strategy use, and (5) compare actual versus expected barriers by reverse applying the CFIR-ERIC Matching Tool.

RESULTS

Eighteen semi-structured focus groups were conducted with 197 providers representing 95 VA sites to identify barriers to quality improvement, including cirrhosis care complexity, clarity of national goals, and local leadership support. The CFIR-ERIC Matching Tool recommended strategies such as assessing for readiness and needs, promoting adaptability, building local groups, preparing champions, and working with opinion leaders and early adopters. Subsequent strategy surveys found that sites used the top 20 "recommended" strategies no more frequently than other strategies. However, 14 (70%) of the top recommended strategies were significantly positively associated with cirrhosis care compared to 48% of actual strategies. Reverse CFIR-ERIC matching found that the strategies most used in the first year corresponded to the following barriers: opinion leaders, access to knowledge and information, and resources. The strategies most frequently employed in the second year addressed barriers such as champions, cosmopolitanism, readiness for implementation, relative priority, and patient needs and resources. Strategies used in both years were those that addressed adaptability, trialability, and compatibility.

CONCLUSIONS

This study is among the first to empirically evaluate the relationship between CFIR-ERIC Matching Tool recommended strategies and actual strategy selection and effectiveness in the real world. We found closer connections between recommended strategies and strategy effectiveness compared to strategy frequency, suggesting validity of barrier identification, and application of the expert-informed tool.

Quantifying days at home in patients with cirrhosis: A national cohort study

BACKGROUND AND AIMS

Days at home (DAH) is a patient-centric metric developed by the Medicare Payment Advisory Commission, capturing annual health care use, including and beyond hospitalizations and mortality. We quantified DAH and assessed factors associated with DAH differences among patients with cirrhosis.

APPROACH AND RESULTS

Using a national claims database (Optum) between 2014 and 2018, we calculated DAH (365 minus mortality, inpatient, observation, postacute, and emergency department days). Among 20,776,597 patients, 63,477 had cirrhosis (median age, 66, 52% males, and 63% non-Hispanic White). Age-adjusted mean DAH for cirrhosis was 335.1 days (95% CI: 335.0 to 335.2) vs 360.1 (95% CI: 360.1 to 360.1) without cirrhosis. In mixed-effects linear regression, adjusted for demographic and clinical characteristics, patients with decompensated cirrhosis spent 15.2 days (95% CI: 14.4 to 15.8) in postacute, emergency, and observation settings and 13.8 days (95% CI: 13.5 to 14.0) hospitalized. Hepatic encephalopathy (-29.2 d, 95% CI: -30.4 to -28.0), ascites (-34.6 d, 95% CI: -35.3 to -33.9), and combined ascites and hepatic encephalopathy (-63.8 d, 95% CI: -65.0 to -62.6) were associated with decreased DAH. Variceal bleeding was not associated with a change in DAH (-0.2 d, 95% CI: -1.6 to +1.1). Among hospitalized patients, during the 365 days after index hospitalization, patients with cirrhosis had fewer age-adjusted DAH (272.8 d, 95% CI: 271.5 to 274.1) than congestive heart failure (288.0 d, 95% CI: 287.7 to 288.3) and chronic obstructive pulmonary disease (296.6 d, 95% CI: 296.3 to 297.0).

CONCLUSIONS

In this national study, we found that patients with cirrhosis spend as many, if not more, cumulative days receiving postacute, emergency, and observational care, as hospitalized care. Ultimately, up to 2 months of DAH are lost annually with the onset of liver decompensation. DAH may be a useful metric for patients and health systems alike.

Actionable Solutions to Achieve Health Equity in Chronic Liver Disease

There are well-described racial and ethnic disparities in the burden of chronic liver diseases. Hispanic persons are at highest risk for developing nonalcoholic fatty liver disease, the fastest growing cause of liver disease. Hepatitis B disproportionately affects persons of Asian or African descent. The highest rates of hepatitis C occur in American Indian and Alaskan Native populations. In addition to disparities in disease burden, there are also marked racial and ethnic disparities in access to treatments, including liver transplantation. Disparities also exist by gender and geography, especially in alcohol-related liver disease. To achieve health equity, we must address the root causes that drive these inequities. Understanding the role that social determinants of health play in the disparate health outcomes that are currently observed is critically important. We must forge and/or strengthen collaborations between patients, community members, other key stakeholders, health care providers, health care institutions, professional societies, and legislative bodies. Herein, we provide a high-level review of current disparities in chronic liver disease and describe actionable strategies that have potential to bridge gaps, improve quality, and promote equity in liver care.

Medical malpractice claims in Hepatology: Rates, Reasons, and Results

BACKGROUND

Clinicians are motivated to provide safe, high-quality care to patients with chronic liver disease. This includes the desire to avoid litigation. Data are limited regarding the actual sources of medicolegal risk in chronic liver disease.

METHODS

We conducted a review of a national liability insurer (Candello) with an additional granular analysis of our institution's registry of liability claims. We included closed cases involving chronic liver disease-related encounters between 2012 and 2021. We determined rates of legal claims from a denominator of unique patients with cirrhosis or transplant care seen over the study period.

RESULTS

Local database: We retrieved 39 claims of which 15 involved patients with non-cirrhotic chronic liver disease, 13 involved cirrhosis (0.06% incidence), and 11 involved patients who underwent transplantation (0.6% incidence). Most claims involved periprocedural complications. Others included adverse reactions to prophylactic plasma transfusion, medication-induced HE, and falls/fractures.

NATIONAL DATABASE

We found 94 claims related to liver disease out of 102,575 (0.09%) total claims. Overall, 56% involved diagnosis-related issues (failure/delay in ordering a diagnostic test, failure to appreciate and reconcile a symptom/sign or result, or the misinterpretation of a diagnostic study). Miscommunication between providers and between providers and patients was implicated in 22% of cases. Patient behavior-related factors (nonadherence with scheduled appointments, treatments, or diagnostic testing) factored in 20% of cases. Selection or the management of therapy played a role in 7% of cases. Very rarely were cases associated with technical skill (4%), house staff supervision (3%), or weekend/holiday care (1%). Fifty-one (55%) claims involved HCC.

CONCLUSION

We provide the rates and reasons for medical malpractice claims in hepatology.

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

INTRODUCTION

We studied longitudinal trends in mortality, outpatient, and inpatient care for cirrhosis in a national cohort in the first 2 years of the coronavirus disease-2019 pandemic. We evaluated trends in hepatocellular carcinoma (HCC) surveillance and factors associated with completion.

METHODS

Within the national cirrhosis cohort in the Veterans Administration from 2020 to 2021, we captured mortality, outpatient primary care provider, gastroenterology/hepatology (GI/HEP) visits, and hospitalizations. HCC surveillance was computed as percentage of time up to date with surveillance every 6 months (PTUDS). Multivariable models for PTUDS were adjusted for patient demographics, clinical factors, and facility-level variables.

RESULTS

The total cohort was 68,073; 28,678 were eligible for HCC surveillance. Outpatient primary care provider and GI/HEP appointment rates initially dropped from 30% to 7% with a rebound 1 year into the pandemic and steady subsequent use. Telemedicine monthly visit rates rose from less than 10% to a peak of 20% with a steady gradual decline. Nearly 70% of Veterans were up to date with HCC surveillance before the pandemic with an early pandemic nadir of approximately 50% and 60% PTUDS 2 years into the pandemic. In adjusted models, use of a population-based cirrhosis dashboard (β 8.5, 95% CI 6.9-10.2) and GI/HEP visits both in-person (β 3.2, 95% CI 2.9-3.6) and telemedicine (β 2.1, 95% CI 1.9-2.4) were associated with a higher PTUDS.

DISCUSSION

Outpatient utilization and HCC surveillance rates have rebounded but remain below at baseline. Population-based approaches and specialty care for cirrhosis were associated with a higher completion of HCC surveillance.

Review article: current and emerging therapies for the management of cirrhosis and its complications

BACKGROUND

Cirrhosis is increasingly common and morbid. Optimal utilisation of therapeutic strategies to prevent and control the complications of cirrhosis are central to improving clinical and patient-reported outcomes.

METHODS

We conducted a narrative review of the literature focusing on the most recent advances.

RESULTS

We review the aetiology-focused therapies that can prevent cirrhosis and its complications. These include anti-viral therapies, psychopharmacological therapy for alcohol-use disorder, and the current landscape of clinical trials for non-alcoholic steatohepatitis. We review the current standard of care and latest developments in the management of hepatic encephalopathy (HE), ascites and hepatorenal syndrome. We evaluate the promise and drawbacks of chemopreventative therapies that have been examined in trials and observational studies which may reduce the risk of hepatocellular carcinoma and cirrhosis complications. Finally, we examine the therapies which address the non-pain symptoms of cirrhosis including pruritis, muscle cramps, sexual dysfunction and fatigue.

CONCLUSION

The improvement of clinical and patient-reported outcomes for patients with cirrhosis is possible by applying evidence-based pharmacotherapeutic approaches to the prevention and treatment of cirrhosis complications.

An Electronic Decision Support Intervention Reduces Readmissions for Patients With Cirrhosis

INTRODUCTION

Rifaximin use in combination with lactulose is associated with a decreased risk of overt hepatic encephalopathy (HE).

METHODS

We prospectively evaluated the impact of an interruptive electronic medical record alert to indicate rifaximin for patients with cirrhosis and HE on lactulose.

RESULTS

The intervention was associated increased rifaximin utilization, particularly for nongastroenterology and hospitalist services odds ratio 1.20 95% confidence interval (1.09-1.31). For patients with HE, the intervention was associated with a lower readmission risk-adjusted subdistribution hazard ratio 0.63 95% confidence interval (0.48-0.82).

DISCUSSION

An interruptive alert in the electronic ordering system was associated with a lower risk of readmissions.