1
|
Langberg KM, Kapo JM, Taddei TH. Palliative care in decompensated cirrhosis: A review. Liver Int 2018; 38:768-775. [PMID: 29112338 DOI: 10.1111/liv.13620] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 10/30/2017] [Indexed: 12/16/2022]
Abstract
Decompensated cirrhosis is an illness that causes tremendous suffering. The incidence of cirrhosis is increasing and rates of liver transplant, the only cure, remain stagnant. Palliative care is focused on improving quality of life for patients with serious illness by addressing advanced care planning, alleviating physical symptoms and providing emotional support to the patient and family. Palliative care is used infrequently in patients with decompensated cirrhosis. The allure of transplant as a potential treatment option for cirrhosis, misperceptions about the role of palliative care and difficulty predicting prognosis in liver disease are potential contributors to the underutilization of palliative care in this patient population. Studies have demonstrated some benefit of palliative care in patients with decompensated cirrhosis but the literature is limited to small observational studies. There is evidence that palliative care consultation in other patient populations lowers hospital costs and ICU utilization and improves symptom control and patient satisfaction. Prospective randomized control trials are needed to investigate the effects of palliative care on traditional- and patient-reported outcomes as well as cost of care in decompensated cirrhosis for transplant eligible and ineligible patient populations.
Collapse
Affiliation(s)
- Karl M Langberg
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer M Kapo
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Tamar H Taddei
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, West Haven, CT, USA
| |
Collapse
|
2
|
Affiliation(s)
- John I Allen
- Division of Gastroenerology and Hepatology, Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan.
| | - Neal Kaushal
- Division of Gastroenterology, Adventist Health Systems, Sonora, California
| |
Collapse
|
3
|
Sakata S, Kheir AO, Hewett DG. Optical diagnosis of colorectal neoplasia: A Western perspective. Dig Endosc 2016; 28:281-8. [PMID: 26841371 DOI: 10.1111/den.12625] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/25/2016] [Accepted: 02/01/2016] [Indexed: 02/08/2023]
Abstract
Optical diagnosis is an emerging paradigm in Western endoscopic practice for the colonoscopic management of diminutive polyps, and includes two complementary clinical strategies: 'resect and discard', in which diminutive high-confidence adenomas are identified, and then removed and discarded without pathological assessment; and 'diagnose and leave', where diminutive high-confidence hyperplastic polyps are identified in the rectosigmoid and then left without resection or biopsy. Like other aspects of colonoscopy performance, adoption of optical diagnosis in Western practice is limited by operator dependency and variation in clinical effectiveness. There is substantial potential for optical diagnosis of colorectal neoplasia during colonoscopy to alleviate the rising costs of health care in the West. However, operator dependence in diagnostic performance together with critical system factors such as informed consent, credentialing, medical legal support and reimbursement incentives must be overcome before optical diagnosis of diminutive lesions is considered for widespread adoption in Western clinical practice.
Collapse
Affiliation(s)
- Shinichiro Sakata
- School of Medicine, The University of Queensland, Brisbane, Australia.,Division of Gastroenterology, Queen Elizabeth II Jubilee Hospital, Brisbane, Australia
| | - Ammar O Kheir
- Division of Gastroenterology, Queen Elizabeth II Jubilee Hospital, Brisbane, Australia
| | - David G Hewett
- School of Medicine, The University of Queensland, Brisbane, Australia.,Division of Gastroenterology, Queen Elizabeth II Jubilee Hospital, Brisbane, Australia
| |
Collapse
|
4
|
Meier SK, Shah ND, Talwalkar JA. Adapting the Patient-centered Specialty Practice Model for Populations With Cirrhosis. Clin Gastroenterol Hepatol 2016; 14:492-6. [PMID: 26850230 DOI: 10.1016/j.cgh.2015.12.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Sarah K Meier
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.
| | - Nilay D Shah
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Jayant A Talwalkar
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota; William J. Von Liebig Center for Transplantation and Regenerative Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
5
|
Abstract
Colonoscopy is an effective colorectal cancer (CRC) screening and prevention modality as evidenced by a 30-year decline in both incident colon cancers and CRC mortality in the USA. The USA is unique among the developed countries in its use of colonoscopy as the most common method to screen for CRC. Individual patients gain maximum value from their colonoscopy experience when they undergo a comfortable exam that is of highest quality, during which all polyps are found and removed safely and completely, where their physicians adhere to all appropriate guidelines and when they (or their insurance) pay a reasonable amount for their care. Colonoscopy "quality" publications to date have been focused on how to improve the individual physician's procedural results and this narrow focus has birthed an entire industry (usually based on entering data into a national registry) that is focused on demonstrating a physician's success in achieving a certain threshold performance metric that is usually (a) marginally related to true health outcomes, (b) can be captured from the myriad electronic medical records (EMR) in existence today, and (c) is attainable by most practicing gastroenterologists. Medical societies have worked diligently to link these registries and recognition programs to commercial or federal payer-based incentive funds. As health care reform drives massive consolidation of delivery systems and reimbursement moves toward population-level two-sided financial risk models, our current measurement infrastructure will become irrelevant. The focus on "value" and the Triple Aim will drive development of a radically different approach. The process by which individual gastroenterologists (or practices) demonstrate the value of colonoscopy as a colorectal cancer (CRC) prevention tool will change dramatically. Essentially, six measures will be reported by a health system: (1) percent of eligible population screened, (2) access to colonoscopy services, (3) complication rates, (4) patient experience scores, (5) episode (bundle) cost, and (6) frequency with which interval cancers occur after a colonoscopy exam (likely using a 3-year interval). Each gastroenterologist within a health system will be evaluated using familiar metrics (cecal intubation, withdrawal time, adenoma detection rate) but these results will likely be used internally to determine whether they are included in a provider network. If they continue to be used in commercial or government incentive programs, then the enterprise electronic medical record will be constructed to populate external programs directly. Population-level metrics (listed above) will determine whether higher cost provider networks (including academic health centers) who might deliver better health outcomes can compete successfully for regional market share with lower cost providers. This article will outline a plan for a health system initiative focused on provision of colonoscopy for CRC prevention; a plan that will help a group of gastroenterologists (whether employed within a health system or independent) demonstrate why they should be a preferred provider and whether they will survive and thrive in the coming world of accountable care.
Collapse
Affiliation(s)
- John I Allen
- Yale University School of Medicine, 40 Temple Street Suite 1 A, New Haven, CT, 06510, USA,
| |
Collapse
|
6
|
Fogel R. The small gastroenterology practice: how to survive in a changing world. Perspectives of a practicing clinician. Clin Gastroenterol Hepatol 2015; 13:419-21. [PMID: 25500132 DOI: 10.1016/j.cgh.2014.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Ronald Fogel
- Digestive Health Center of Michigan, Chesterfield Township, Michigan.
| |
Collapse
|
7
|
Solad Y, Wang C, Laine L, Deng Y, Schwartz H, Ciarleglio MM, Aslanian HR. Influence of colonoscopy quality measures on patients' colonoscopist selection. Am J Gastroenterol 2015; 110:215-9. [PMID: 25070055 PMCID: PMC4413895 DOI: 10.1038/ajg.2014.201] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 06/13/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The Affordable Care Act emphasizes the use of quality metrics and greater patient understanding of health-care options and access to physician performance data. The objectives of this study were to determine patients' familiarity with colonoscopy quality measures (CQMs) and their influence on patient selection of a colonoscopist. METHODS A prospective survey of patients before screening or surveillance colonoscopy at university hospital, community hospital, and ambulatory procedure center endoscopy units was performed from 2011 to 2012. RESULTS Among the 417 participants, 20% (85/417) researched their physician's rating. The rates of familiarity with CQM were 88 % (353/402) for adequate bowel preparation, 30% (118/398) for adenoma detection rate (ADR), 26% (102/397) for cecal intubation rate, and 21% (82/394) for greater-than-6-min withdrawal time. Ninety-six percent (366/386) believed that colonoscopists' reporting of ADR to other physicians was important or very important. In selecting a colonoscopist, primary care provider referral was ranked as the first or second-most important of four factors in 87% (339/391). Even among patients who responded "it is very important" to report CQM to other doctors and patients, none ranked CQM as the most important factor in selecting a colonoscopist. CONCLUSIONS Patient awareness of CQM, other than adequate bowel preparation, was low. Quality measure reporting is important to patients, but primary care provider referral was the most important factor in colonoscopist selection. This suggests that primary care providers, as well as patients, are important to include in educational strategies regarding quality metrics.
Collapse
Affiliation(s)
- Yauheni Solad
- Yale University, Yale Center for Biomedical Informatics, New Haven, CT
| | - Charles Wang
- Yale University, Section of Digestive Diseases, New Haven, CT
| | - Loren Laine
- Yale University, Section of Digestive Diseases, New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | - Yanhong Deng
- Yale University, Yale Center for Analytical Sciences, New Haven, CT
| | | | | | | |
Collapse
|
8
|
Talwalkar JA. Potential impacts of the Affordable Care Act on the clinical practice of hepatology. Hepatology 2014; 59:1681-7. [PMID: 24700278 DOI: 10.1002/hep.27071] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 01/24/2014] [Accepted: 02/11/2014] [Indexed: 01/18/2023]
Abstract
UNLABELLED The Patient Protection and Affordable Care Act (ACA), along with the Health Care and Education Reconciliation Act, was signed into law and upheld by the Supreme Court earlier this year. The ACA contains a variety of reforms that, if implemented, will significantly affect current models of healthcare delivery for patients with acute and chronic hepatobiliary diseases. One of the Act's central reforms is the creation of accountable care organizations (ACOs) whose mission will be to integrate different levels of care to improve the quality of services delivered and outcomes among populations while maintaining, or preferably reducing, the overall costs of care. Currently, there are clinical practice areas within hepatology, such as liver transplantation, that already have many of the desired features attributed to ACOs. The ACA is sure to affect all fields of medicine, including the practice of clinical hepatology. This article describes the components of the ACA that have the greatest potential to influence the clinical practice of hepatology. CONCLUSION Ultimately, it will be the responsibility of our profession to identify optimal healthcare delivery models for providing high-value, patient-centered care.
Collapse
Affiliation(s)
- Jayant A Talwalkar
- Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN; William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
| |
Collapse
|
9
|
Affiliation(s)
- John I Allen
- President-Elect, American Gastroenterological Association (AGA) Institute, Professor of Medicine, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
10
|
Rustgi AK, Allen JI. The house of gastrointestinal medicine: how academic medical centers can build a sustainable economic clinical model. Clin Gastroenterol Hepatol 2013; 11:1370-3. [PMID: 24139339 DOI: 10.1016/j.cgh.2013.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Academic Medical Centers (AMCs) have been given unique responsibilities to care for patients, educate future clinicians, and bring innovative research to the bedside. Over the last few decades, this tripartite mission has served the United States well, and payers (Federal, State, and commercial) have been willing to underwrite these missions with overt and covert financial subsidies. As cost containment efforts have escalated, the traditional business model of AMCs has been challenged. In this issue, Dr Anil Rustgi and I offer some insights into how AMCs must alter their business model to be sustainable in our new world of accountable care, cost containment, and clinical integration.
Collapse
Affiliation(s)
- Anil K Rustgi
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
| | | |
Collapse
|