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Veterans with cirrhosis, ascites may be receiving substandard health care

Patients with cirrhosis-related ascites treated at Veterans Affairs medical facilities may not receive all health care services recommended for their illness, according to recent results.

Researchers evaluated the quality of care for 774 patients with cirrhosis and ascites treated at three Veterans Affairs medical centers between 2000 and 2007. Quality was measured according to eight indicators, each with a maximum value of 100%, and all patients were eligible for at least one indicator.

Observed scores across all indicators ranged from 22.2% to 89.3%, with less than 33.2% of all patients (95% CI, 29.9%-32.9%) receiving recommended care. In general, care devoted to treatment, such as administering antibiotics for documented spontaneous bacterial peritonitis (SBP), was more likely to meet standards than preventive care such as primary or secondary antibiotic prophylaxis for SBP after discharge. Higher-quality care was most common in patients without comorbidities (OR=2.21; 95% CI, 1.43-3.43) and those treated by a gastroenterologist (OR=1.33; 95% CI, 1.01-1.74) or at a facility associated with an academic institution (OR=1.73; 95% CI, 1.29-2.35).

Investigators found inverse relationships between quality of care and serum sodium levels and also between higher quality of care and serum albumin levels.

Nonadherence to standards was considered justified according to chart documentation in 37.5% of cases. Explanation was more common for patients with paracentesis after ascites diagnosis (18 of 38 patients), those requiring diuretics (five of seven patients) and patients receiving antibiotics for gastrointestinal bleeding (10 of 22 patients). The majority of patients whose care did not adhere to incorporated standards did not have documented explanations in their charts.

“Our data show that quality of ascites care, measured according to whether patients received recommended services, leaves some room for improvement,” the researchers wrote. “ … specialist involvement, as well as focused efforts on preventive care in ascites and on patients with comorbidities can improve quality of care delivered to patients with cirrhosis and ascites.”