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Bergmans C, Tapper EB. Outpatient Management of Symptomatic Ascites: Bypassing the Path of Least Resistance. Dig Dis Sci 2024; 69:2284-2286. [PMID: 38700628 DOI: 10.1007/s10620-024-08403-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 03/21/2024] [Indexed: 07/19/2024]
Affiliation(s)
- Carrie Bergmans
- Division of Gastroenterology and Hepatology, University of Michigan, 3912 Taubman, SPC 5362, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, 3912 Taubman, SPC 5362, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
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2
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Tapper EB, Martinez B, Jepsen P, Chen X, Parikh ND. Bisphosphonate effectiveness in patients with cirrhosis: An emulated clinical trial. Aliment Pharmacol Ther 2024. [PMID: 38922994 DOI: 10.1111/apt.18127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/05/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024]
Abstract
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.
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Beanna Martinez
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Peter Jepsen
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, University of Aarhus, Aarhus, Denmark
| | - Xi Chen
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
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Tapper EB, Serper M, Goldberg D. Implementing pragmatic clinical trials in hepatology. Hepatology 2024; 79:704-712. [PMID: 36825597 PMCID: PMC10460456 DOI: 10.1097/hep.0000000000000345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 02/10/2023] [Indexed: 02/25/2023]
Abstract
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.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan
| | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine
| | - David Goldberg
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine
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4
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Batisti J, Jakab SS. Hospitalized patients with cirrhosis: Addressing gaps in care. Clin Liver Dis (Hoboken) 2024; 23:e0211. [PMID: 38961874 PMCID: PMC11221856 DOI: 10.1097/cld.0000000000000211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/15/2024] [Indexed: 07/05/2024] Open
Affiliation(s)
- Jennifer Batisti
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sofia S. Jakab
- Section of Digestive Diseases, Yale University School of Medicine, VA Connecticut Healthcare System, New Haven, Connecticut, USA
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Hagström H, Shang Y, Tapper EB, Wester A, Widman L. Secondary Prevention of Esophageal Variceal Bleeding Is Often Imperfect: A National, Population-Based Cohort Study of 3592 Patients. Clin Gastroenterol Hepatol 2023; 21:3336-3345.e2. [PMID: 37192714 DOI: 10.1016/j.cgh.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/28/2023] [Accepted: 05/02/2023] [Indexed: 05/18/2023]
Abstract
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.
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Affiliation(s)
- Hannes Hagström
- Division of Hepatology, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.
| | - Ying Shang
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Axel Wester
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Linnea Widman
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
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Yakovchenko V, Lamorte C, Chinman MJ, Goodrich DE, Gibson S, Park A, Bajaj JS, McCurdy H, Morgan TR, Rogal SS. Comparing the CFIR-ERIC matching tool recommendations to real-world strategy effectiveness data: a mixed-methods study in the Veterans Health Administration. Implement Sci 2023; 18:49. [PMID: 37828539 PMCID: PMC10571268 DOI: 10.1186/s13012-023-01307-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 09/25/2023] [Indexed: 10/14/2023] Open
Abstract
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.
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Affiliation(s)
- Vera Yakovchenko
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive C (151C), Building 30, Pittsburgh, PA, 15240-1001, USA
| | - Carolyn Lamorte
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive C (151C), Building 30, Pittsburgh, PA, 15240-1001, USA
| | - Matthew J Chinman
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive C (151C), Building 30, Pittsburgh, PA, 15240-1001, USA
- Mental Health Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- RAND Corporation, Pittsburgh, PA, USA
| | - David E Goodrich
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive C (151C), Building 30, Pittsburgh, PA, 15240-1001, USA
| | - Sandra Gibson
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive C (151C), Building 30, Pittsburgh, PA, 15240-1001, USA
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA
| | - Angela Park
- Department of Veterans Affairs, Office of Healthcare Transformation, Washington, DC, USA
| | - Jasmohan S Bajaj
- Division of Gastroenterology and Hepatology, Central Virginia VA Health Care System, Richmond, VA, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Timothy R Morgan
- Gastroenterology Section, VA Long Beach Healthcare System, Long Beach, CA, USA
- Department of Medicine, University of California Irvine, Orange, CA, USA
| | - Shari S Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive C (151C), Building 30, Pittsburgh, PA, 15240-1001, USA.
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
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Elhence H, Dodge JL, Farias AJ, Lee BP. Quantifying days at home in patients with cirrhosis: A national cohort study. Hepatology 2023; 78:518-529. [PMID: 36994701 PMCID: PMC10363198 DOI: 10.1097/hep.0000000000000370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/04/2023] [Indexed: 03/31/2023]
Abstract
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.
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Affiliation(s)
- Hirsh Elhence
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jennifer L. Dodge
- Department of Population Public Health Sciences, University of Southern California, Los Angeles, California
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California
| | - Albert J. Farias
- Department of Population Public Health Sciences, University of Southern California, Los Angeles, California
| | - Brian P. Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California
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Jones PD, Lai JC, Bajaj JS, Kanwal F. Actionable Solutions to Achieve Health Equity in Chronic Liver Disease. Clin Gastroenterol Hepatol 2023; 21:1992-2000. [PMID: 37061105 PMCID: PMC10330625 DOI: 10.1016/j.cgh.2023.03.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 02/08/2023] [Accepted: 03/26/2023] [Indexed: 04/17/2023]
Abstract
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.
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Affiliation(s)
- Patricia D Jones
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida.
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Jasmohan S Bajaj
- Virginia Commonwealth University and Central Virginia Veterans Health Care System, Richmond, Virginia
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, Texas
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Holman A, McKeown E, Quinn M, Parikh ND, Tapper EB. Medical malpractice claims in Hepatology: Rates, Reasons, and Results. Hepatol Commun 2023; 7:e0122. [PMID: 37058104 PMCID: PMC10109843 DOI: 10.1097/hc9.0000000000000122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/21/2023] [Indexed: 04/15/2023] Open
Abstract
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.
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Affiliation(s)
- Alexis Holman
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Ellen McKeown
- Patient Relations & Clinical Risk Department, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Moira Quinn
- Controlled Risk Insurance Company (CRICO) Strategies, Boston, Massachusetts, USA
| | - Neehar D. Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
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Parikh ND, Dehmlow C, Ellies T, Tapper EB, Lok ASF. Development and Implementation of a Hepatocellular Carcinoma Surveillance Quality Metric. Clin Gastroenterol Hepatol 2023; 21:576-580.e1. [PMID: 36535495 PMCID: PMC10634524 DOI: 10.1016/j.cgh.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan.
| | - Cheryl Dehmlow
- Health Information Technology & Services, University of Michigan, Ann Arbor, Michigan
| | - Tammy Ellies
- Department of Internal Medicine Clinical Experience and Quality, University of Michigan, Ann Arbor, Michigan
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Anna S F Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
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Serper M, Tapper EB, Kaplan DE, Taddei TH, Mahmud N. Patterns of Care Utilization and Hepatocellular Carcinoma Surveillance: Tracking Care Across the Pandemic. Am J Gastroenterol 2023; 118:294-303. [PMID: 36114778 PMCID: PMC9898115 DOI: 10.14309/ajg.0000000000002011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/09/2022] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Marina Serper
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, USA
- Gastroenterology Section, Ann Arbor Healthcare System, Ann Arbor, VA, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Tamar H. Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Tapper EB, Ufere NN, Huang DQ, Loomba R. Review article: current and emerging therapies for the management of cirrhosis and its complications. Aliment Pharmacol Ther 2022; 55:1099-1115. [PMID: 35235219 PMCID: PMC9314053 DOI: 10.1111/apt.16831] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/24/2022] [Accepted: 02/06/2022] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA
| | - Nneka N. Ufere
- Liver Center, Division of Gastroenterology, Department of MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Daniel Q. Huang
- Department of Medicine, Yong Loo Lin School of MedicineNational University of SingaporeSingapore,Division of Gastroenterology and Hepatology, Department of MedicineNational University Health SystemSingapore,NAFLD Research CenterDivision of Gastroenterology and Hepatology. University of California at San DiegoLa JollaCaliforniaUSA
| | - Rohit Loomba
- NAFLD Research CenterDivision of Gastroenterology and Hepatology. University of California at San DiegoLa JollaCaliforniaUSA
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An Electronic Decision Support Intervention Reduces Readmissions for Patients With Cirrhosis. Am J Gastroenterol 2022; 117:491-494. [PMID: 35020619 PMCID: PMC9034761 DOI: 10.14309/ajg.0000000000001608] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/23/2021] [Indexed: 12/11/2022]
Abstract
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.
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