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Quality of care standards appear unmet in patients hospitalized for decompensated cirrhosis

Quality of care indicators for decompensated cirrhosis were below standard levels among hospitalized patients at University of Vermont Medical Center, according to study data.

Nicholas Lim, MD, and Steven D. Lidofsky, MD, PhD, of University of Vermont Medical Center, Burlington, analyzed medical records of 247 patients with decompensated cirrhosis admitted to the medical center’s intensive care unit or general medical unit between June 2009 and July 2013. At this hospital, intensive care units were managed by intensivists and the general medical unit was run by hospitalists, according to the research.   The most common reasons patients had been admitted were upper gastrointestinal bleeding (GI), hepatic encephalopathy and spontaneous bacterial peritonitis. Of these patients, 65.6% were managed by hospitalists.

“Although hospitalists and intensivists achieve similar outcomes in comparable clinical settings, in selected critical conditions, superior outcomes are conferred by intensivists,” the researchers wrote. “We therefore speculated that differences between intensivists and hospitalists may also be present with respect to quality care delivery to hospitalized cirrhotic patients and tested whether adherence to guidelines for decompensated cirrhosis is higher in patients who are admitted by intensivists, compared with hospitalists.”

Quality care criteria was met by 147 of the 247 admissions (59.5%). Patients managed by intensivists had a higher rate of adherence to quality care criteria compared with those handled by hospitalists (71.7% vs. 53.1%; P = .006), specifically those with GI bleeding (P = .03) and hepatic encephalopathy (P = .005). Performance of a gastroenterology consultation was more common in admissions that met quality care criteria compared with those who did not (68.7% vs. 54%; P = .023). In hospitalist-managed patients, gastroenterology consultation was associated with a significantly higher adherence to quality indicators for hepatic encephalopathy, but not for other complications of cirrhosis (P = .004), according to the research.

Among the patients admitted for upper GI bleeding (n = 92), 65.2% met criteria for quality care and 2% died; of 83 patients admitted for hepatic encephalopathy, 67.5% met quality care criteria and 1.2% died; and of 33 patients admitted for spontaneous bacterial peritonitis, 33.3% met quality care criteria, 21.2% experienced in-hospital complications and 9% died.

Reduced complications in admission for refractory ascites and reduced length-of-stay in admission for spontaneous bacterial peritonitis was associated with timely diagnostic paracentesis (P = .02 for both).  

“Adherence to quality indicators for decompensated cirrhosis is suboptimal among hospitalized patients,” the researchers concluded. “Although quality care adherence appears to be higher among cirrhotic patients managed by intensivists than by hospitalists, opportunities for improvement exist in both groups. Rational and cost-effective strategies should be sought to achieve this end.” – by Melinda Stevens

Disclosure: The researchers report no relevant financial disclosures.