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Hughes DL, Serper M. PRO: How satellite clinics can improve access to liver transplantation. Liver Transpl 2024; 30:1078-1081. [PMID: 39041929 DOI: 10.1097/lvt.0000000000000444] [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] [Received: 05/23/2024] [Accepted: 07/13/2024] [Indexed: 07/24/2024]
Affiliation(s)
- Dempsey L Hughes
- Division of Gastroenterology, Department of Medicine and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Marina Serper
- Division of Gastroenterology, Department of Medicine and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Bittermann T, Yagan L, Kathawate RG, Weinberg EM, Peyster EG, Lewis JD, Levy C, Goldberg DS. Real-world evidence for factors associated with maintenance treatment practices among US adults with autoimmune hepatitis. Hepatology 2024:01515467-990000000-00908. [PMID: 38865589 DOI: 10.1097/hep.0000000000000961] [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: 02/28/2024] [Accepted: 05/30/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND AND AIMS While avoidance of long-term corticosteroids is a common objective in the management of autoimmune hepatitis (AIH), prolonged immunosuppression is usually required to prevent disease progression. This study investigates the patient and provider factors associated with treatment patterns in US patients with AIH. APPROACH AND RESULTS A retrospective cohort of adults with the incident and prevalent AIH was identified from Optum's deidentified Clinformatics Data Mart Database. All patients were followed for at least 2 years, with exposures assessed during the first year and treatment patterns during the second. Patient and provider factors associated with corticosteroid-sparing monotherapy and cumulative prednisone use were identified using multivariable logistic and linear regression, respectively.The cohort was 81.2% female, 66.3% White, 11.3% Black, 11.2% Hispanic, and with a median age of 61 years. Among 2203 patients with ≥1 AIH prescription fill, 83.1% received a single regimen for >6 months of the observation year, which included 52.2% azathioprine monotherapy, 16.9% azathioprine/prednisone, and 13.3% prednisone monotherapy. Budesonide use was uncommon (2.1% combination and 1.9% monotherapy). Hispanic ethnicity (aOR: 0.56; p = 0.006), cirrhosis (aOR: 0.73; p = 0.019), osteoporosis (aOR: 0.54; p =0.001), and top quintile of provider AIH experience (aOR: 0.66; p = 0.005) were independently associated with lower use of corticosteroid-sparing monotherapy. Cumulative prednisone use was greater with diabetes (+441 mg/y; p = 0.004), osteoporosis (+749 mg/y; p < 0.001), and highly experienced providers (+556 mg/y; p < 0.001). CONCLUSIONS Long-term prednisone therapy remains common and unexpectedly higher among patients with comorbidities potentially aggravated by corticosteroids. The greater use of corticosteroid-based therapy with highly experienced providers may reflect more treatment-refractory disease.
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Affiliation(s)
- Therese Bittermann
- Division of Gastroenterology and Hepatology Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lina Yagan
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Ethan M Weinberg
- Division of Gastroenterology and Hepatology Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eliot G Peyster
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James D Lewis
- Division of Gastroenterology and Hepatology Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cynthia Levy
- Department of Medicine, Division of Digestive Health & Liver Diseases, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - David S Goldberg
- Department of Medicine, Division of Digestive Health & Liver Diseases, Miller School of Medicine, University of Miami, Miami, Florida, USA
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3
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Wong CR, Crespi CM, Glenn B, May FP, Han SHB, Bastani R, Macinko JA. Prevalence of Healthcare Barriers Among US Adults With Chronic Liver Disease Compared to Other Chronic Diseases. GASTRO HEP ADVANCES 2024; 3:796-808. [PMID: 39280913 PMCID: PMC11401582 DOI: 10.1016/j.gastha.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 05/07/2024] [Indexed: 09/18/2024]
Abstract
Background and Aims The extent of healthcare barriers and its association with acute care use among adults with chronic liver disease (CLD) relative to other chronic conditions remains understudied. We compared the probability of barriers and recurrent acute care use among persons with CLD and persons with chronic obstructive pulmonary disease (COPD) and/or cardiovascular disease (CVD). Methods We assembled a population-based, cross-sectional study using pooled self-reported National Health Interview Survey data (2011-2017) among community-dwelling persons. Probability of barriers by disease group (CLD vs COPD/CVD) was assessed using hurdle negative binomial regression. Results The sample included 47,037 adults (5062 with CLD, 41,975 with COPD/CVD). The CLD group was younger (median age 55 vs 62 years) and included more Hispanics (17.5% vs 8.6%) and persons with poverty (20.1% vs 15.3%) than the COPD/CVD group. More respondents with CLD vs COPD/CVD reported barriers (44.7% vs 34.4%), including unaffordability (27.5% vs 18.8%), transportation-related (6.1% vs 4.1%), and organizational barriers at entry to (17.6% vs 13.0%) and within healthcare (19.5% vs 14.2%). While adults with CLD were more likely to experience at least 1 barrier (adjusted incident rate ratio, 1.12 [1.01-1.24], P = .03), they were not associated with more (1.05 [1.00-2.71], P = .06). Probability of recurrent acute care use was associated with more healthcare barriers. Conclusion Findings from this nationally representative sample of over 43 million US adults reveal that persons with CLD have increased probability of healthcare barriers, likely related to their higher prevalence of socioeconomic vulnerabilities compared to persons with COPD/CVD. CLD warrants attention as a priority condition in public policies that direct resources towards high-risk populations.
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Affiliation(s)
- Carrie R Wong
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, University of California, Los Angeles, Los Angeles, California
- Kaiser Permanente Center for Health Equity, University of California, Los Angeles, Los Angeles, California
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, California
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - Catherine M Crespi
- Kaiser Permanente Center for Health Equity, University of California, Los Angeles, Los Angeles, California
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, California
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - Beth Glenn
- Kaiser Permanente Center for Health Equity, University of California, Los Angeles, Los Angeles, California
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, California
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - Folasade P May
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, University of California, Los Angeles, Los Angeles, California
- Kaiser Permanente Center for Health Equity, University of California, Los Angeles, Los Angeles, California
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, California
| | - Steven-Huy B Han
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Roshan Bastani
- Kaiser Permanente Center for Health Equity, University of California, Los Angeles, Los Angeles, California
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, California
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - James A Macinko
- Kaiser Permanente Center for Health Equity, University of California, Los Angeles, Los Angeles, California
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
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4
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Endo Y, Sasaki K, Moazzam Z, Woldesenbet S, Lima HA, Alaimo L, Munir MM, Shaikh CF, Yang J, Azap L, Katayama E, Kitago M, Schenk A, Washburn K, Pawlik TM. Liver transplantation access and outcomes: Impact of variations in liver-specific specialty care. Surgery 2024; 175:868-876. [PMID: 37743104 DOI: 10.1016/j.surg.2023.06.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/08/2023] [Accepted: 06/28/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND We sought to characterize the impact access to gastroenterologists/hepatologists has on liver transplantation listing, as well as time on the liver transplantation waitlist and post-transplant outcomes. METHODS Liver transplantation registrants aged >18 years between January 1, 2004 and December 31, 2019 were identified from the Scientific Registry of Transplant Recipients Standard Analytic Files. The liver transplantation registration ratio was defined as the ratio of liver transplant waitlist registrations in a given county per 1,000 liver-related deaths. RESULTS A total of 150,679 liver transplantation registrants were included. Access to liver transplantation centers and liver-specific specialty physicians varied markedly throughout the United States. Of note, the liver transplantation registration ratio was lower in counties with poor access to liver-specific care versus counties with adequate access (poor access 137.2, interquartile range 117.8-163.2 vs adequate access 157.6, interquartile range 127.3-192.2, P < .001). Among patients referred for liver transplantation, the cumulative incidence of waitlist mortality and post-transplant graft survival was comparable among patients with poor versus adequate access to liver-specific care (both P > .05). Among liver transplantation recipients living in areas with poor access, after controlling for recipient and donor characteristics, cold ischemic time, and model for end-stage liver disease score, the area deprivation index predicted graft survival (referent, low area deprivation index; medium area deprivation index, hazard ratio 1.52, 95% confidence interval 1.03-12.23; high area deprivation index, 1.45, 95% confidence interval 1.01-12.09, both P < .05). CONCLUSION Poor access to liver-specific care was associated with a reduction in liver transplantation registration, and individuals residing in counties with high social deprivation had worse graft survival among patients living in counties with poor access to liver-specific care.
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Affiliation(s)
- Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | | | - Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Chanza F Shaikh
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Jason Yang
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Lovette Azap
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Erryk Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Minoru Kitago
- Department of Surgery, Keio University, Tokyo, Japan
| | - Austin Schenk
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Kenneth Washburn
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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Lee BP, Dodge JL, Terrault NA. Geographic Density of Gastroenterologists Is Associated With Decreased Mortality From Alcohol-Associated Liver Disease. Clin Gastroenterol Hepatol 2023; 21:1542-1551.e6. [PMID: 35934291 PMCID: PMC10015926 DOI: 10.1016/j.cgh.2022.07.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/13/2022] [Accepted: 07/16/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Alcohol-associated liver disease (ALD) is the leading cause of liver-related mortality and has been increasing. To inform public health efforts to address the growing incidence of ALD, we assessed the association of geographic density of gastroenterologists with ALD-related mortality. METHODS National data were obtained for adults aged ≥25 years with state-level demographics and 2010-2019 mortality estimates by linking federally maintained registries (WONDER, NSSATS, BRFSS, HRSA, US Census Bureau). Multivariable linear regression was used to assess the association of state-level geographic density of gastroenterologists with ALD-related mortality, adjusting for age, sex, race/ethnicity, and other potential confounders. RESULTS Among 50 states and the District of Columbia, the national mean geographic density of gastroenterologists was 4.6 per 100,000 population, and annual ALD-related mortality rate was 85.6 per 1,000,000 population. There was greater than 5-fold differences in geographic density of gastroenterologists and ALD-related mortality across states. In multivariable analysis, the geographic density of gastroenterologists was significantly associated with lower ALD-related mortality (9.0 [95% confidence interval, 1.3-16.7] fewer ALD-related deaths per 1,000,000 population for each additional gastroenterologist per 100,000 population). The association appeared to peak at a threshold of ≥7.5 gastroenterologists per 100,000 population. We estimated that differences in geographic density of gastroenterologists across states may potentially represent 40% of national ALD-related mortality. Exploratory analyses to assess for confounding by generalized subspecialty care, transplant access, alcohol taxation, and substance use or mental health services, including negative control analyses, did not affect primary results. CONCLUSIONS State-level geographic density of gastroenterologists is associated with lower ALD-related mortality. These results may inform medical societies and health policymakers to address anticipated workforce gaps to address the growing epidemic of ALD.
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Affiliation(s)
- Brian P Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California.
| | - Jennifer L Dodge
- Division of Research Medicine and Preventive Medicine, University of Southern California, Los Angeles, California
| | - Norah A Terrault
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California
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Henson JB, Wegermann K, Patel YA, Wilder JM, Muir AJ. Access to technology to support telehealth in areas without specialty care for liver disease. Hepatology 2023; 77:176-185. [PMID: 35661393 DOI: 10.1002/hep.32597] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/17/2022] [Accepted: 06/01/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS Telehealth may be a successful strategy to increase access to specialty care for liver disease, but whether the areas with low access to care and a high burden of liver-related mortality have the necessary technology access to support a video-based telehealth strategy to expand access to care is unknown. APPROACH AND RESULTS Access to liver disease specialty care was defined at the county level as <160.9 km (100 miles) from a liver transplant (LT) center or presence of local gastroenterology (GI). Liver-related mortality rates were compared by access to care, and access to technology was compared by degree of access to care and burden of liver-related mortality. Counties with low access to liver disease specialty care had higher rates of mortality from liver disease, and this was highest in areas both >160.9 km from an LT center and without local GI. These counties were more rural, had higher poverty, and had decreased access to devices and internet at broadband speeds. Technology access was lowest in areas with low access to care and the highest burden of liver-related mortality. CONCLUSIONS Areas with poor access to liver disease specialty care have a greater burden of liver-related mortality, and many of their residents lack access to technology. Therefore, a telehealth strategy based solely on patient device ownership and internet access will exclude a large proportion of individuals in the areas of highest need. Further work should be done at the local and state levels to design optimal strategies to reach their populations of need.
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Affiliation(s)
- Jacqueline B Henson
- Division of Gastroenterology , Department of Medicine , Duke University , Durham , North Carolina , USA
| | - Kara Wegermann
- Division of Gastroenterology , Department of Medicine , Duke University , Durham , North Carolina , USA
| | - Yuval A Patel
- Division of Gastroenterology , Department of Medicine , Duke University , Durham , North Carolina , USA
| | - Julius M Wilder
- Division of Gastroenterology , Department of Medicine , Duke University , Durham , North Carolina , USA
- Duke Clinical Research Institute , Durham , North Carolina , USA
| | - Andrew J Muir
- Division of Gastroenterology , Department of Medicine , Duke University , Durham , North Carolina , USA
- Duke Clinical Research Institute , Durham , North Carolina , USA
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7
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Nguyen MH, Roberts LR, Engel-Nitz NM, Bancroft T, Ozbay AB, Singal AG. Gaps in hepatocellular carcinoma surveillance in a United States cohort of insured patients with cirrhosis. Curr Med Res Opin 2022; 38:2163-2173. [PMID: 36111416 DOI: 10.1080/03007995.2022.2124070] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Surveillance for hepatocellular carcinoma (HCC) is known to be underutilized; however, neither the variation of surveillance adherence by cirrhosis etiology nor the patient-side economic burden of surveillance are well understood. To identify potential barriers to HCC surveillance, we assessed utilization patterns and costs among US patients with cirrhosis monitored in routine clinical practice. METHODS We conducted a retrospective study of insured adult patients with cirrhosis using national administrative claims data from January 2013 through June 2019. Time up-to-date with recommended surveillance, correlates of surveillance receipt, and surveillance-associated costs were assessed during a ≥ 6-month follow-up. RESULTS Among 15,543 patients with cirrhosis (mean [SD] age 64.0 [11.1] years, 50.7% male), 45.8% and 58.7% had received any abdominal imaging at 6 and 12 months, respectively. Patients were up-to-date with recommended surveillance for only 31% of a median 1.3-year follow-up. Those with viral hepatitis were more likely to receive surveillance than those with other etiologies (hazard ratio [HR] 1.55, 95% CI 1.11-2.17, p = .010 for patients without a baseline gastroenterologist [GI] visit and 2.69, 95% CI 1.77-4.09, p < .001 for patients with a GI visit, relative to those with nonalcoholic fatty liver disease and no GI visit). For all etiologies except NAFLD, the HR (95% CI) for surveillance receipt was higher among patients with vs without a baseline GI visit (alcohol-related, 1.164 [1.002-1.351] vs 0.880 [0.796-0.972]; viral hepatitis, 2.688 [1.765-4.093] vs 1.553 [1.111-2.171]; Other, 0.612 [0.519-0.722] vs 0.549 [0.470-0.641]). Mean total and patient-paid daily surveillance-related costs ranged from $540 and $113, respectively (ultrasound) to $1580 and $300, respectively (magnetic resonance imaging), and mean estimated patient productivity costs were $730-$2514 annually. CONCLUSION HCC surveillance was underutilized and was lowest among patients with nonviral etiologies and those who had not seen a gastroenterologist. Surveillance-related out-of-pocket expenses and lost productivity were substantial. The development of surveillance strategies that reduce patient burden, such as those using blood-based biomarkers, may help improve surveillance adherence and effectiveness.
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Affiliation(s)
- Mindie H Nguyen
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford University Medical Center, Palo Alto, CA, USA
| | | | | | | | | | - Amit G Singal
- UT Southwestern Medical Center, Dallas, TX, USA
- North American Liver Cancer Consortium
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8
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Silverstein RG, McClurg AB, Moore KJ, Fliss MD, Louie M. Patient characteristics associated with access to minimally invasive gynecologic surgery: Changes during the COVID-19 pandemic. J Minim Invasive Gynecol 2022; 29:1110-1118. [PMID: 35750193 PMCID: PMC9216549 DOI: 10.1016/j.jmig.2022.06.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 11/10/2022]
Abstract
Study Objective To evaluate patient characteristics that affect access to minimally invasive gynecologic surgery (MIGS) subspecialty care and identify changes during the coronavirus disease 2019 pandemic. Design Retrospective cohort study of patients referred to MIGS from 2014 to 2016 (historic cohort) compared with those referred to MIGS in 2020 (pandemic cohort). Primary outcome was the interval between referral and first appointment. Setting Single-institution academic MIGS division. Patients Historic cohort (n = 1082) and pandemic cohort (n = 770). Interventions Not applicable. Measurements and Main Results Demographics and socioeconomic variables (race, ethnicity, language, insurance, employment, and socioeconomic factors by census tract) and distance from hospital were compared between historic and pandemic cohorts with respect to referral interval using the chi-square, Fisher exact tests, and logistic regression. After adjusting for referral indication, being unemployed and living in an area with less population density, less education, and higher percentage of poverty were associated with a referral interval >30 days in the historic cohort. In the pandemic cohort, only unemployment persisted as a covariate associated with prolonged referral interval and new associated variables were primary language other than English (odds ratio, 3.20; 95% confidence interval [CI], 1.60–6.40) and “other” race (odds ratio, 2.22; 95% CI, 1.34–3.68). The odds of waiting >30 days increased by 6% with the addition of 1 demographic risk factor (95% CI, 1.01–1.10) and by 17% for 3 risk factors (95% CI, 1.03–1.34) in the historic cohort whereas no significant intersectionality was identified in the pandemic cohort. Average referral intervals were significantly shorter during the pandemic (31 vs 50 days, p <.01). Telemedicine appointments had a significantly shorter referral interval than in-person appointments (27 vs 47 days, p <.01). Of patients using telemedicine, a greater proportion were non-Hispanic, English speaking, employed, privately insured, and lived further from the hospital (p <.05). Conclusion Time from referral to first appointment at a tertiary-care MIGS practice during the coronavirus disease 2019 pandemic was shorter than that before the pandemic, likely owing to the adoption of telemedicine. Differences in socioeconomic and demographic factors suggest that telemedicine improved access to care and decreased access disparities for many populations, but not for non–English-speaking patients.
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Affiliation(s)
- R Gina Silverstein
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC.
| | - Asha B McClurg
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
| | - Kristin J Moore
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
| | - Mike D Fliss
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
| | - Michelle Louie
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
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Verma M, Brahmania M, Fortune BE, Asrani SK, Fuchs M, Volk ML. Patient-centered care: Key elements applicable to chronic liver disease. Hepatology 2022. [PMID: 35712801 DOI: 10.1002/hep.32618] [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: 04/09/2022] [Revised: 06/07/2022] [Accepted: 06/09/2022] [Indexed: 12/08/2022]
Abstract
Chronic liver disease (CLD) is a progressive illness with high symptom burden and functional and cognitive impairment, often with comorbid mental and substance use disorders. These factors lead to significant deterioration in quality of life, with immense burden on patients, caregivers, and healthcare. The current healthcare system in the United States does not adequately meet the needs of patients with CLD or control costs given the episodic, reactive, and fee-for-service structure. There is also a need for clinical and financial accountability for CLD care. In this context, we describe the key elements required to shift the CLD care paradigm to a patient-centered and value-based system built upon the Porter model of value-based health care. The key elements include (1) organization into integrated practice units, (2) measuring and incorporating meaningful patient-reported outcomes, (3) enabling technology to allow innovation, (4) bundled care payments, (5) integrating palliative care within routine care, and (6) formalizing centers of excellence. These elements have been shown to improve outcomes, reduce costs, and improve overall patient experience for other chronic illnesses and should have similar benefits for CLD. Payers need to partner with providers and systems to build upon these elements and help align reimbursements with patients' values and outcomes. The national organizations such as the American Association for Study of Liver Diseases need to guide key stakeholders in standardizing these elements to optimize patient-centered care for CLD.
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Affiliation(s)
- Manisha Verma
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | | | - Brett E Fortune
- Montefiore Einstein Center for Transplantation, Bronx, New York, USA
| | | | - Michael Fuchs
- Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Michael L Volk
- Loma Linda University Health, Loma Linda, California, USA
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10
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Turse E, Aboona M, Charley E, Forlemu A, Bowie T, Bhattarai B, Chuang KY, Nadir A. Factors Associated with Survival of Hepatocellular Carcinoma (HCC) Patients at a Safety Net Hospital in Arizona without On-Site Liver Transplant Program. J Hepatocell Carcinoma 2022; 9:1-11. [PMID: 35096683 PMCID: PMC8791297 DOI: 10.2147/jhc.s341690] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/02/2021] [Indexed: 11/23/2022] Open
Abstract
Background With the rising incidence of hepatocellular carcinoma (HCC), ongoing efforts should be focused on providing equitable and state-of-the-art care to patients. Purpose The aim of this study was to determine the survival of patients with HCC seen at a high-proportion Safety Net Hospital (h-SNH), where loco-regional therapy and hepatology services are available and liver transplantation (LT) is referred to outside facilities. Patients and Methods A retrospective cohort study was conducted on all patients with HCC seen at Valley Wise Health Center (VWHC) over a ten-year period. Clinical variables, treatment modalities, survival duration, hospice, and LT referrals of 161 patients were collected from the medical records. Survival analysis was used to determine the relationship of clinically relevant variables and survival among patients with HCC. A Log rank test was used to compare univariate variables. A Cox regression analysis was used to compare and control for multiple variables. Results Of the 161 patients included in the study, 33% were uninsured. The median age was 59 (21 to >89) years with 47% Hispanic, 31% Caucasian, 15% African American and 7% other races included for the analysis. The median survival for the cohort was 20.1 months. In the multivariate model, insurance status, final MELD, tumor within the Milan criteria and having received treatment for HCC were associated with survival. Surveillance for HCC was associated with HCC in the univariate analysis, but not in the multivariable model. Thirty percent of patients were referred for LT and 1.25% of the entire cohort received it. Conclusion Despite the availability of treatment modalities available for HCC at VWHC and the option of liver transplantation for appropriate candidates at outside centers, OS was less than reported from programs with on-site liver transplant programs. Reasons for lower survival in centers without liver transplant programs should be further studied.
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Affiliation(s)
- Erica Turse
- Department of Medicine, Creighton University School of Medicine Program, Phoenix, AZ, USA
| | - Majd Aboona
- Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
- Correspondence: Majd Aboona, Email
| | - Ericka Charley
- Department of Medicine, Creighton University School of Medicine Program, Phoenix, AZ, USA
| | - Arnold Forlemu
- Department of Medicine, Creighton University School of Medicine Program, Phoenix, AZ, USA
| | - Tessa Bowie
- Department of Research, Valleywise Health Medical Center, Phoenix, AZ, USA
| | - Bikash Bhattarai
- Department of Research, Valleywise Health Medical Center, Phoenix, AZ, USA
| | - Keng-Yu Chuang
- Department of Medicine, Valleywise Health Medical Center, Phoenix, AZ, USA
| | - Abdul Nadir
- Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
- Department of Medicine, Valleywise Health Medical Center, Phoenix, AZ, USA
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11
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Differences in Hospitalization Outcomes of Kidney Disease between Patients Who Received Care by Nephrologists and Non-Nephrologist Physicians: A Propensity-Score-Matched Study. J Clin Med 2021; 10:jcm10225269. [PMID: 34830549 PMCID: PMC8623768 DOI: 10.3390/jcm10225269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/29/2021] [Accepted: 11/08/2021] [Indexed: 11/29/2022] Open
Abstract
The influence of physician specialty on the outcomes of kidney diseases (KDs) remains underexplored. We aimed to compare the complications and mortality of patients with admissions for KD who received care by nephrologists and non-nephrologist (NN) physicians. We used health insurance research data in Taiwan to conduct a propensity-score matched study that included 17,055 patients with admissions for KD who received care by nephrologists and 17,055 patients with admissions for KD who received care by NN physicians. Multivariable logistic regressions were conducted to calculate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for 30-day mortality and major complications associated with physician specialty. Compared with NN physicians, care by nephrologists was associated with a reduced risk of 30-day mortality (OR 0.29, 95% CI 0.25–0.35), pneumonia (OR 0.82, 95% CI 0.76–0.89), acute myocardial infarction (OR 0.68, 95% CI 0.54–0.87), and intensive care unit stay (OR 0.78, 95% CI 0.73–0.84). The association between nephrologist care and reduced admission adverse events was significant in every age category, for both sexes and various subgroups. Patients with admissions for KD who received care by nephrologists had fewer adverse events than those who received care by NN physicians. We suggest that regular nephrologist consultations or referrals may improve medical care and clinical outcomes in this vulnerable population.
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12
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Cohen-Mekelburg S, Waljee AK, Kenney BC, Tapper EB. Coordination of Care Is Associated With Survival and Health Care Utilization in a Population-Based Study of Patients With Cirrhosis. Clin Gastroenterol Hepatol 2020; 18:2340-2348.e3. [PMID: 31927111 PMCID: PMC7875119 DOI: 10.1016/j.cgh.2019.12.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/19/2019] [Accepted: 12/31/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Improving care coordination for patients with high-intensity specialty care needs, such as cirrhosis, can increase quality of healthcare and reduce utilization. We examined the relationship between care concentration and risk of hospitalization for patients with cirrhosis. METHODS We performed a retrospective cohort study of 26,006 Medicare enrollees with cirrhosis with more than 4 outpatient visits over 180 days. We collected data on 2 validated measures of care concentration: the usual provider of care (UPC) index, a measure of the proportion of a patient's total visits that is with their most regularly seen provider, and the continuity of care (COC) index, a measure of care density and dispersion. Both use a scale of 0 to 1. Time to death or liver transplantation was evaluated using a multivariable Cox proportional hazards model. Hospital days and 30-day readmissions per person-year were evaluated in negative binomial models. RESULTS The median COC score was 0.40 (interquartile range, 0.26-0.60) and the median UPC was 0.60 (interquartile range, 0.50-0.80). Increasing care concentration (based on COC and UPC index scores) were associated with increased mortality and hospitalization. The highest 25th percentile of COC and UPC scores were associated with adjusted hazard ratios for mortality of 1.20 (95% CI, 1.10-1.31) and 1.14 (95% CI, 1.06-1.24), adjusted incidence rate ratios for hospital days of 1.12 (95% CI, 1.02-1.23) and 1.10 (95% CI, 1.01-1.20), and adjusted incidence rate ratios for readmissions of 1.19 (95% CI, 1.06-1.34) and 1.12 (95% CI, 1.00-1.25), respectively. CONCLUSIONS Based on a study of Medicare enrollees, care concentration is low among patients with cirrhosis. However, increased concentration is associated with increased mortality and increased healthcare utilization. These data indicate that, to optimize outcomes for persons with cirrhosis, team-based care might be necessary.
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Affiliation(s)
- Shirley Cohen-Mekelburg
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan; Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| | - Akbar K. Waljee
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan;,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan;,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan;,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan;,Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor, Michigan
| | - Brooke C. Kenney
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan;,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan;,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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13
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Tapper EB, Aberasturi D, Zhao Z, Hsu CY, Parkih ND. Outcomes after hepatic encephalopathy in population-based cohorts of patients with cirrhosis. Aliment Pharmacol Ther 2020; 51:1397-1405. [PMID: 32363684 PMCID: PMC7266029 DOI: 10.1111/apt.15749] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 01/03/2020] [Accepted: 04/03/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatic encephalopathy is a devastating complication of cirrhosis. AIM To describe the outcomes after developing hepatic encephalopathy among contemporary, aging patients. METHODS We examined data for a 20% random sample of United States Medicare enrolees with cirrhosis and Part D prescription coverage from 2008 to 2014. Among 49 164 persons with hepatic encephalopathy, we evaluated the associations with transplant-free survival using Cox proportional hazard models with time-varying covariates (hazard ratios, HR) and incidence rate ratios (IRR) for healthcare utilisation measured in hospital-days and 30-day readmissions per person-year. We validated our findings in an external cohort of 2184 privately insured patients with complete laboratory values. RESULTS Hepatic encephalopathy was associated with median survivals of 0.95 and 2.5 years for those ≥65 or <65 years old and 1.1 versus 3.9 years for those with and without ascites. Non-alcoholic fatty-liver disease posed the highest adjusted risk of death among aetiologies, HR 1.07 95% CI (1.02, 1.12). Both gastroenterology consultation and rifaximin utilisation were associated with lower mortality, respective adjusted-HR 0.73 95% CI (0.67, 0.80) and 0.40 95% CI (0.39, 0.42). Thirty-day readmissions were fewer for patients seen by gastroenterologists (0.71 95% CI [0.57-0.88]) and taking rifaximin (0.18 95% CI [0.08-0.40]). Lactulose alone was associated with fewer hospital-days, IRR 0.31 95% CI (0.30-0.32), than rifaximin alone, 0.49 95% CI (0.45-0.53), but the optimal therapy combination was lactulose/rifaximin, IRR 0.28 95% CI (0.27-0.30). These findings were validated in the privately insured cohort adjusting for model for endstage liver disease-sodium score and serum albumin. CONCLUSIONS Hepatic encephalopathy remains morbid and associated with poor outcomes among contemporary patients. Gastroenterology consultation and combination lactulose-rifaximin are both associated with improved outcomes. These data inform the development of care coordination efforts for subjects with cirrhosis.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor
| | | | - Zhe Zhao
- Department of Biostatistics, University of Michigan
| | - Chia-Yang Hsu
- Division of Gastroenterology and Hepatology, University of Michigan
| | - Neehar D. Parkih
- Division of Gastroenterology and Hepatology, University of Michigan
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14
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Tapper EB, Hao S, Lin M, Mafi JN, McCurdy H, Parikh ND, Lok AS. The Quality and Outcomes of Care Provided to Patients with Cirrhosis by Advanced Practice Providers. Hepatology 2020; 71:225-234. [PMID: 31063262 PMCID: PMC6834870 DOI: 10.1002/hep.30695] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 05/01/2019] [Indexed: 12/24/2022]
Abstract
Cirrhosis is morbid and increasingly prevalent, yet the U.S. health care system lacks enough physicians and specialists to adequately manage patients with cirrhosis. Although advanced practice providers (APPs) can expand access to cirrhosis-related care, their impact on the quality of care remains unknown. We sought to determine the effect on care quality and outcomes for patients managed by APPs using a retrospective analysis of a nationally representative American commercial claims database (Optum), which included 389,257 unique adults with cirrhosis. We evaluated a complication of process measures (i.e., rates of hepatocellular carcinoma [HCC] screening, endoscopic varices screening, and use of rifaximin after hospitalization for hepatic encephalopathy) and outcomes (30-day readmissions and survival). Compared with patients without APP care, patients with APP care had higher rates of HCC screening (adjusted odds ratio [OR] 1.23, 95% confidence interval 1.19, 1.27), varices screening (OR 1.20 [1.13, 1.27]), use of rifaximin after a discharge for hepatic encephalopathy (OR 2.09 [1.80, 2.43]), and reduced risk of 30-day readmission (OR 0.68 [0.66, 0.70]). Gastroenterology/hepatology consultation was also associated with improved quality metric performance compared with primary care; however, shared visits between gastroenterologists/hepatologists and APPs were associated with the best performance and lower 30-day readmissions compared with subspecialty consultation without an APP (OR 0.91 [0.87, 0.95]. Multivariate analysis adjusting for comorbidities, liver disease severity, and other factors including gastroenterology/hepatology consultation showed that patients seen by APPs were more likely to receive consistent HCC and varices screening over time, less likely to experience 30-day readmissions, and had lower mortality (adjusted hazard ratio 0.57, 95% confidence interval 0.55, 0.60). Conclusion: APPs, particularly when working with gastroenterologists/hepatologists, are associated with improved quality of care and outcomes for patients with cirrhosis.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine. University of Michigan, Ann Arbor MI,Veterans Affairs, Ann Arbor MI
| | | | | | - John N. Mafi
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA,RAND Health, RAND Corporation
| | | | - Neehar D. Parikh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine. University of Michigan, Ann Arbor MI,Veterans Affairs, Ann Arbor MI
| | - Anna S. Lok
- Division of Gastroenterology and Hepatology, Department of Internal Medicine. University of Michigan, Ann Arbor MI,Veterans Affairs, Ann Arbor MI
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15
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Mauro E, Marciano S, Torres MC, Roca JD, Novillo AL, Gadano A. Telemedicine Improves Access to Hepatology Consultation with High Patient Satisfaction. J Clin Exp Hepatol 2020; 10:555-562. [PMID: 33311892 PMCID: PMC7719958 DOI: 10.1016/j.jceh.2020.04.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 04/24/2020] [Indexed: 02/06/2023] Open
Abstract
AIMS Telemedicine between health care providers could be useful for improving the access to hepatology consultations, which is challenging in some regions. The primary objective of this study was to estimate the proportion of consultations that were resolved through a telemedicine program. Additionally, we evaluated patient satisfaction with this strategy. METHODS Consecutive telemedicine consultations made by non-hepatologist health care providers from different regions of Argentina to a specialty hepatology team were included. Participants and hepatologists used e-mail, teleconference systems, WhatsApp, or telephone to interact, depending on their preferences. Consultations were considered to be resolved through telemedicine when a diagnosis and an adequate follow-up were achieved without the need to refer the patient to a hepatologist or other specialist. Patient satisfaction with telemedicine was evaluated using the Patient Satisfaction Questionnaire Short Form and Telemedicine Satisfaction Questionnaire. RESULTS A total of 200 telemedicine consultations made by 24 physicians from 10 different provinces of Argentina were evaluated, of which 145 (73%; 95% CI: 66%-79%) were resolved through telemedicine. Practitioners specialities were as follows: family physicians, internists, gastroenterologists, infectious diseases, and obstetrics. The most frequent final diagnoses for those patients whose consultation was resolved through telemedicine were non-alcoholic fatty liver disease, viral hepatitis, and benign hepatic lesions. A high degree of patient satisfaction with telemedicine was observed in both questionnaires. CONCLUSIONS Our results show the effectiveness of telemedicine in hepatology, with high resolution rate of consultations and rapid access to experts' assessment. Additionally, a high degree of patient satisfaction was observed using prevalidated questionnaires.
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Affiliation(s)
- Ezequiel Mauro
- Liver Unit, Hospital Italiano de Buenos Aires, Juan Domingo Perón 4190, 1199 ABH, Buenos Aires, Argentina
| | - Sebastián Marciano
- Liver Unit, Hospital Italiano de Buenos Aires, Juan Domingo Perón 4190, 1199 ABH, Buenos Aires, Argentina,Department of Research, Hospital Italiano de Buenos Aires, Juan Domingo Perón 4190, 1199 ABH, Buenos Aires, Argentina,Corresponding author. Sebastián Marciano, Liver Unit, Hospital Italiano de Buenos Aires, Perón 4190, Buenos Aires, C1199ABB, Argentina. Tel.: +54 11 4959 0200x5370; fax: +54 11 4959 0346.
| | - María C. Torres
- Liver Unit, Hospital Italiano de Buenos Aires, Juan Domingo Perón 4190, 1199 ABH, Buenos Aires, Argentina
| | - Juan D. Roca
- Grupo Integral Clínico Cardiológico, Alvear 154, 6300, Santa Rosa, La Pampa, Argentina
| | - Abel L. Novillo
- Sanatorio 9 de Julio, 25 de Mayo 372, 4000, San Miguel de Tucumán, Tucumán, Argentina
| | - Adrían Gadano
- Liver Unit, Hospital Italiano de Buenos Aires, Juan Domingo Perón 4190, 1199 ABH, Buenos Aires, Argentina,Department of Research, Hospital Italiano de Buenos Aires, Juan Domingo Perón 4190, 1199 ABH, Buenos Aires, Argentina
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16
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Serper M, Kaplan DE, Shults J, Reese PP, Beste LA, Taddei TH, Werner RM. Quality Measures, All-Cause Mortality, and Health Care Use in a National Cohort of Veterans With Cirrhosis. Hepatology 2019; 70:2062-2074. [PMID: 31107967 PMCID: PMC6864236 DOI: 10.1002/hep.30779] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 05/10/2019] [Indexed: 02/06/2023]
Abstract
Decompensated cirrhosis is associated with high morbidity and mortality. However, no standardized quality measures (QMs) have yet been adopted widely. The Veterans Affairs (VA) Advanced Liver Disease Technical Advisory Group recently developed a set of six internal QMs to guide quality improvement efforts in cirrhosis in the domains of access to care, hepatocellular carcinoma surveillance, variceal surveillance, quality of inpatient care for upper gastrointestinal bleeding, and cirrhosis-related rehospitalizations. We aimed to (1) quantify adherence to cirrhosis QMs and (2) determine whether adherence was associated with all-cause mortality and health care use within a large national cohort of veterans with cirrhosis. We performed a retrospective study using data from the Veterans Outcomes and Costs Asociated with Liver Disease cohort of 121,129 patients newly diagnosed with cirrhosis from January 1, 2008, to December 31, 2016, at 128 VA facilities. The mean follow-up time was 2.7 years (interquartile range, 1.1-5.1 years). Adherence to outpatient access to specialty care was 71%, variceal surveillance was 32%, and early postdischarge care was 54%. In adjusted analyses, outpatient access to specialty care (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.78-0.82), hepatocellular carcinoma surveillance (HR, 0.92; 95% CI, 0.90-0.95), variceal surveillance (HR, 0.93; 95% CI, 0.89-0.99), and early postdischarge care (HR, 0.57; 95% CI, 0.54-0.60) were associated with lower all-cause mortality. Readmissions after 30 days (HR, 1.53; 1.46-1.60) and 90 days (HR, 1.88; 95% CI, 1.54-1.70) were associated with higher all-cause mortality. Higher adherence to QMs was also associated with lower inpatient health care use. Conclusion: Five of the six proposed VA cirrhosis QMs were measurable using existing data sources, associated with mortality and health care use, and may be used to guide future quality improvement efforts in cirrhosis.
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Affiliation(s)
- Marina Serper
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - David E. Kaplan
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia PA
| | - Justine Shults
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Peter P. Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Lauren A. Beste
- VA Puget Sound Health Care System, Health Services Research and Development, Seattle, WA
- VA Puget Sound Health Care System, General Medicine Service, Seattle, WA, USA
- Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Tamar H. Taddei
- VA Connecticut Healthcare System, West Haven, Connecticut CT
- Division of Gastroenterology, Yale University School of Medicine, New Haven, CT
| | - Rachel M. Werner
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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17
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Tapper EB, Henderson JB, Parikh ND, Ioannou GN, Lok AS. Incidence of and Risk Factors for Hepatic Encephalopathy in a Population-Based Cohort of Americans With Cirrhosis. Hepatol Commun 2019; 3:1510-1519. [PMID: 31701074 PMCID: PMC6824059 DOI: 10.1002/hep4.1425] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 08/13/2019] [Indexed: 12/12/2022] Open
Abstract
Hepatic encephalopathy (HE) is a devastating complication of cirrhosis. Data are limited regarding the incidence of and risk factors for HE among contemporary patients in the context of the shifting epidemiology of cirrhosis. We examined a 20% random sample of U.S. Medicare enrollees with cirrhosis and Part D prescription coverage from 2008 to 2014. We modelled incident HE using demographic, clinical, and pharmacologic data. Risk factors for HE were evaluated, including demographics/socioeconomics, cirrhosis etiology, severity of liver disease, and pharmacotherapy, along with gastroenterology consultation, as time-varying covariates. Among 166,192 Medicare enrollees with cirrhosis followed for 5.25 (interquartile range [IQR], 2.00-7.00) years, the overall incidence of HE was 11.6 per 100 patient-years. The cohort's median age was 65 years (IQR, 57-72), 31% had alcohol-related cirrhosis, and 49% had likely nonalcoholic fatty liver disease cirrhosis. The two strongest associations with HE were alcohol-related cirrhosis (adjusted hazard ratio [AHR], 1.44; 95% confidence interval [CI], 1.40, 1.47, relative to nonalcoholic nonviral cirrhosis) and the presence of portal hypertension (AHR, 3.42; 95% CI, 3.34, 3.50). Adjusting for confounders, benzodiazepines (AHR, 1.24; 95% CI, 1.21, 1.27), gamma aminobutyric acid (GABA)ergics (AHR, 1.17; 95% CI, 1.14, 1.21), opioids (AHR, 1.24; 95% CI, 1.21, 1.27), and proton pump inhibitors (PPIs) (AHR, 1.41; 95% CI, 1.38, 1.45) were all associated with incident HE. Only benzodiazepines, however, were associated with the risk of hospitalization with HE (incidence-rate ratio, 1.23; 95% CI, 1.20, 1.26). Conclusion: Novel data regarding the risk of HE for contemporary patients with cirrhosis are provided. The incidence of HE in an older population of Americans with cirrhosis is high, particularly among those with alcohol-related cirrhosis and portal hypertension. Several medication classes, namely PPIs, opiates, GABAergics, and benzodiazepines, represent potentially modifiable risk factors for HE.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMI
- Gastroenterology SectionVA Ann Arbor Healthcare SystemAnn ArborMI
| | - James B. Henderson
- Center for Statistical Consultation and ResearchUniversity of MichiganAnn ArborMI
| | - Neehar D. Parikh
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMI
- Gastroenterology SectionVA Ann Arbor Healthcare SystemAnn ArborMI
| | - George N. Ioannou
- Division of GastroenterologyDepartment of MedicineVeterans Affairs Puget Sound Healthcare System and University of WashingtonSeattleWA
| | - Anna S. Lok
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMI
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18
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Njei B, Esserman D, Krishnan S, Ohl M, Tate JP, Hauser G, Taddei T, Lim J. Regional and Rural-Urban Differences in the Use of Direct-acting Antiviral Agents for Hepatitis C Virus: The Veteran Birth Cohort. Med Care 2019; 57:279-285. [PMID: 30807449 PMCID: PMC6436819 DOI: 10.1097/mlr.0000000000001071] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Veterans with hepatitis C virus (HCV) infection may face geographic obstacles to obtaining treatment. OBJECTIVE We studied the influence of region and rural versus urban residence on receipt of direct-acting antiretroviral (DAA) medications for HCV. SUBJECTS Veterans receiving care within Veterans Affairs Healthcare System born between 1945 and 1965. RESEARCH DESIGN This is a observational study using national electronic health record data. MEASURES Receipt of DAAs was defined as ≥1 filled prescription from January 1, 2014 to December 31, 2016. Region (South, Northeast, Midwest, and West) and residence (urban, rural-micropolitan, small rural towns, and isolated rural towns) variables were created using residential zone improvement plan codes and rural-urban commuting area (RUCA) codes. Multivariable models were adjusted for age, race, sex, severity of liver disease, comorbidities, and prior treatment experience. RESULTS Among 166,353 eligible patients 64,854 received, DAAs. Variation by rural-urban residence depended on region. In unadjusted analyses, receipt varied by rural-urban designations within Midwest, and West regions (P<0.05) but did not vary within the South (P=0.12). Southern rural small town had the lowest incidence of DAA receipt (40.1%), whereas the incidence was 52.9% in Midwestern isolated rural towns. In adjusted logistic analyses, compared with southern urban residents (the largest single group), southern rural small town residents had the lowest odds ratio, 0.85 (95% confidence interval, 0.75-0.93), and Midwestern residents from isolated and small rural towns had the highest odds (odds ratio, both 1.27) to receive treatment. CONCLUSIONS Substantial geographic variation exists in receipt of curative HCV treatment. Efforts are needed to provide more equitable access to DAAs.
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Affiliation(s)
- Basile Njei
- Department of Gastroenterology and Hepatology, Yale University School of Medicine, VA Connecticut Healthcare System, 333 Cedar Street, New Haven, CT, 06516, (312) 415-7525,
| | - Denise Esserman
- Department of Biostatistics, Yale University School of Public Health, VA Connecticut Healthcare System, 300 George Street, New Haven, CT 06510-3210, (203)785-4297,
| | - Supriya Krishnan
- Department of Internal Medicine, Yale University School of Medicine, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, (203) 932-5711 ×5306,
| | - Michael Ohl
- University of Iowa Carver College of Medicine, Veterans Rural Health Resource Iowa City VA Medical Center, 601 Highway 6 West Iowa City, IA, 52246, (319)338-0581 ext. 3534,
| | - Janet P. Tate
- Department of Internal Medicine, Yale University School of Medicine, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT,06516, (203) 932-5711 ×5371,
| | - George Hauser
- Center for Biomedical Data Science, Yale University School of Medicine, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516 (203)932-5711 ×7140,
| | - Tamar Taddei
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT, 06516, (203) 932-5711 ×4696,
| | - Joseph Lim
- Department of Internal Medicine Yale University School of Medicine, VA Connecticut Healthcare System, 333 Cedar Street, New Haven CT, 06510, New Haven CT, (203)737-6063,
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19
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Su GL, Glass L, Tapper EB, Van T, Waljee AK, Sales AE. Virtual Consultations Through the Veterans Administration SCAN-ECHO Project Improves Survival for Veterans With Liver Disease. Hepatology 2018; 68:2317-2324. [PMID: 29729194 DOI: 10.1002/hep.30074] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/30/2018] [Indexed: 12/22/2022]
Abstract
Access to specialty care has been associated with improved survival in patients with liver disease but universal access is not always feasible. Methods of care delivery using virtual modalities including the SCAN-ECHO (Specialty Access Network-Extension of Community Healthcare Outcome) program were implemented by the Veterans Health Administration (VHA) to address this need but limited data are available on patient outcomes. We sought to evaluate the efficacy of a SCAN-ECHO visit within the context of a regional cohort of patients with liver disease in the VHA (n = 62,237) following implementation in the Ann Arbor SCAN-ECHO Liver Clinic from June 1, 2011, to March 31, 2015. The effect of a SCAN-ECHO visit on all-cause mortality was compared with patients with no liver clinic visit. To adjust for the differences among patients who had a SCAN-ECHO visit versus those with no visit, propensity score matching was performed on condition factors that affect the likelihood of a SCAN-ECHO visit: demographics, geographic location, liver disease diagnosis, severity, and comorbidities. During the study period, 513 patients who had a liver SCAN-ECHO visit were found within the cohort. Patients who had completed a virtual SCAN-ECHO visit were more likely younger, rural, with more significant liver disease, and evidence for cirrhosis. Propensity-adjusted mortality rates using the Cox Proportional Hazard Model showed that a SCAN-ECHO visit was associated with a hazard ratio of 0.54 (95% confidence interval 0.36-0.81, P = 0.003) compared with no visit. Conclusion: Improved survival in patients using SCAN-ECHO suggests that this approach may be an effective method to improve access for selected patients with liver disease, particularly in rural and underserved populations where access to specialty care is limited.
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Affiliation(s)
- Grace L Su
- Medicine Service, VA Ann Arbor Healthcare System, Ann Harbor, Michigan.,University of Michigan Medical School, Ann Arbor, Michigan
| | - Lisa Glass
- Medicine Service, VA Ann Arbor Healthcare System, Ann Harbor, Michigan.,University of Michigan Medical School, Ann Arbor, Michigan
| | - Elliot B Tapper
- Medicine Service, VA Ann Arbor Healthcare System, Ann Harbor, Michigan.,University of Michigan Medical School, Ann Arbor, Michigan
| | - Tony Van
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Akbar K Waljee
- Medicine Service, VA Ann Arbor Healthcare System, Ann Harbor, Michigan.,University of Michigan Medical School, Ann Arbor, Michigan.,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, Michigan
| | - Anne E Sales
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.,Department of Learning Health Science, University of Michigan, Ann Arbor, Michigan
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20
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Khaderi S, Sussman N, Kanwal F. Project ECHO: The Specialist Will See You Now. Hepatology 2018; 68:2066-2068. [PMID: 30033576 DOI: 10.1002/hep.30187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 12/07/2022]
Affiliation(s)
- Saira Khaderi
- Michael E. DeBakey Department of Surgery, Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX.,Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Norman Sussman
- Michael E. DeBakey Department of Surgery, Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX.,Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.,Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX
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21
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Park A, Gonzalez R, Chartier M, Rogal S, Yakovchenko V, Ross D, Morgan TR. Screening and Treating Hepatitis C in the VA: Achieving Excellence Using Lean and System Redesign. Fed Pract 2018; 35:24-29. [PMID: 30766371 PMCID: PMC6368013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The national effort to redesign care using Lean management strategies, develop local and regional teams, and centralize support allowed VA to maximize available resources to achieve higher rates of testing and treatment of patients with hepatitis C virus than that of any other health care system in the US.
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Affiliation(s)
- Angela Park
- is a Clinical Pharmacy Specialist and Pharmacy Process Improvement Program Manager at the Office of Strategic Integration and Veterans Engineering Resource Center. is the Program Manager of the National Hepatitis Consortium for Redesigning Care under the Research Service at VA Long Beach Healthcare System in California. is Director and is the Deputy Director at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at the VA Pittsburgh Healthcare System Center, and Assistant Professor at University of Pittsburgh in Pennsylvania. is a Health Science Specialist at Center for Healthcare Organization and Implementation Research and Bridging the Care Continuum Quality Enhancement Research Initiative at Bedford VA in Bedford, Massachusetts. is the Chief of Gastroenterology at VA Long Beach Healthcare System in California and Director of the National Hepatitis C Resource Center
| | - Rachel Gonzalez
- is a Clinical Pharmacy Specialist and Pharmacy Process Improvement Program Manager at the Office of Strategic Integration and Veterans Engineering Resource Center. is the Program Manager of the National Hepatitis Consortium for Redesigning Care under the Research Service at VA Long Beach Healthcare System in California. is Director and is the Deputy Director at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at the VA Pittsburgh Healthcare System Center, and Assistant Professor at University of Pittsburgh in Pennsylvania. is a Health Science Specialist at Center for Healthcare Organization and Implementation Research and Bridging the Care Continuum Quality Enhancement Research Initiative at Bedford VA in Bedford, Massachusetts. is the Chief of Gastroenterology at VA Long Beach Healthcare System in California and Director of the National Hepatitis C Resource Center
| | - Maggie Chartier
- is a Clinical Pharmacy Specialist and Pharmacy Process Improvement Program Manager at the Office of Strategic Integration and Veterans Engineering Resource Center. is the Program Manager of the National Hepatitis Consortium for Redesigning Care under the Research Service at VA Long Beach Healthcare System in California. is Director and is the Deputy Director at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at the VA Pittsburgh Healthcare System Center, and Assistant Professor at University of Pittsburgh in Pennsylvania. is a Health Science Specialist at Center for Healthcare Organization and Implementation Research and Bridging the Care Continuum Quality Enhancement Research Initiative at Bedford VA in Bedford, Massachusetts. is the Chief of Gastroenterology at VA Long Beach Healthcare System in California and Director of the National Hepatitis C Resource Center
| | - Shari Rogal
- is a Clinical Pharmacy Specialist and Pharmacy Process Improvement Program Manager at the Office of Strategic Integration and Veterans Engineering Resource Center. is the Program Manager of the National Hepatitis Consortium for Redesigning Care under the Research Service at VA Long Beach Healthcare System in California. is Director and is the Deputy Director at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at the VA Pittsburgh Healthcare System Center, and Assistant Professor at University of Pittsburgh in Pennsylvania. is a Health Science Specialist at Center for Healthcare Organization and Implementation Research and Bridging the Care Continuum Quality Enhancement Research Initiative at Bedford VA in Bedford, Massachusetts. is the Chief of Gastroenterology at VA Long Beach Healthcare System in California and Director of the National Hepatitis C Resource Center
| | - Vera Yakovchenko
- is a Clinical Pharmacy Specialist and Pharmacy Process Improvement Program Manager at the Office of Strategic Integration and Veterans Engineering Resource Center. is the Program Manager of the National Hepatitis Consortium for Redesigning Care under the Research Service at VA Long Beach Healthcare System in California. is Director and is the Deputy Director at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at the VA Pittsburgh Healthcare System Center, and Assistant Professor at University of Pittsburgh in Pennsylvania. is a Health Science Specialist at Center for Healthcare Organization and Implementation Research and Bridging the Care Continuum Quality Enhancement Research Initiative at Bedford VA in Bedford, Massachusetts. is the Chief of Gastroenterology at VA Long Beach Healthcare System in California and Director of the National Hepatitis C Resource Center
| | - David Ross
- is a Clinical Pharmacy Specialist and Pharmacy Process Improvement Program Manager at the Office of Strategic Integration and Veterans Engineering Resource Center. is the Program Manager of the National Hepatitis Consortium for Redesigning Care under the Research Service at VA Long Beach Healthcare System in California. is Director and is the Deputy Director at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at the VA Pittsburgh Healthcare System Center, and Assistant Professor at University of Pittsburgh in Pennsylvania. is a Health Science Specialist at Center for Healthcare Organization and Implementation Research and Bridging the Care Continuum Quality Enhancement Research Initiative at Bedford VA in Bedford, Massachusetts. is the Chief of Gastroenterology at VA Long Beach Healthcare System in California and Director of the National Hepatitis C Resource Center
| | - Timothy R Morgan
- is a Clinical Pharmacy Specialist and Pharmacy Process Improvement Program Manager at the Office of Strategic Integration and Veterans Engineering Resource Center. is the Program Manager of the National Hepatitis Consortium for Redesigning Care under the Research Service at VA Long Beach Healthcare System in California. is Director and is the Deputy Director at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at the VA Pittsburgh Healthcare System Center, and Assistant Professor at University of Pittsburgh in Pennsylvania. is a Health Science Specialist at Center for Healthcare Organization and Implementation Research and Bridging the Care Continuum Quality Enhancement Research Initiative at Bedford VA in Bedford, Massachusetts. is the Chief of Gastroenterology at VA Long Beach Healthcare System in California and Director of the National Hepatitis C Resource Center
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22
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Reddy K, Patrick C, Liaquat H, Rodriquez E, Stocker A, Cave B, Cave MC, Smart L, Cutts T, Abell T. Differences in Referral Access to Care Between Gastrointestinal Subspecialty Patients: Barriers and Opportunities. Health Equity 2018; 2:103-108. [PMID: 30283855 PMCID: PMC6071906 DOI: 10.1089/heq.2018.0001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Purpose: Referral access to subspecialty care for patients with gastrointestinal (GI) diseases is not well defined, but has significant importance to patients. We hypothesized that patients experience barriers to care in two common gastroenterology subspecialties, Hepatology and Motility, in a university medical center. Methods: Two hundred thirteen clinic patients (mean age 46.5 years; 66.5% female; 85.6% Caucasians) completed a formatted questionnaire on access to care. Hepatology patients were older (49.7 years, p=0.008); motility patients predominantly female (76.8%, p<0.001). Gender distribution was even for hepatology (51.2% female). Both groups were overweight (mean body mass index 28.4). Results: Patients waited a mean 89.5 days to be seen by a subspecialist. There were differences by subspecialty (107.6 days for motility vs. 64.3 days for hepatology, p=0.022). A larger percentage of motility patients were told nothing was wrong with them (16.8%, p<0.01) and could not be helped (42.1%, p=0.000). Conclusions: Access to care for subspecialty gastroenterology patients in a university center appears to be impacted by a number of variables. While there are similarities, differences exist between these two subspecialties. Motility patients were more likely to have been told they have nothing wrong with them, suffer setbacks financially, and suffer mood problems. Their wait time for appointments was also greater than hepatology patients. Further investigations of referral access for gastroenterology patients may yield additional insights into disease-specific barriers to accessing subspecialty care.
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Affiliation(s)
- Kartika Reddy
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Caitlyn Patrick
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Hammad Liaquat
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Edmundo Rodriquez
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Abigail Stocker
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Barbra Cave
- University of Louisville Hepatitis C Center, Louisville, Kentucky
| | - Matt C. Cave
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Laura Smart
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Teresa Cutts
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Thomas Abell
- Department of Medicine, University of Louisville, Louisville, Kentucky
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23
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A stepwise algorithm using an at-a-glance first-line test for the non-invasive diagnosis of advanced liver fibrosis and cirrhosis. J Hepatol 2017; 66:1158-1165. [PMID: 28088581 DOI: 10.1016/j.jhep.2017.01.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 12/29/2016] [Accepted: 01/03/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Chronic liver diseases (CLD) are common, and are therefore mainly managed by non-hepatologists. These physicians lack access to the best non-invasive tests of liver fibrosis, and consequently cannot accurately determine the disease severity. Referral to a hepatologist is then needed. We aimed to implement an algorithm, comprising a new first-line test usable by all physicians, for the detection of advanced liver fibrosis in all CLD patients. METHODS Diagnostic study: 3754 CLD patients with liver biopsy were 2:1 randomized into derivation and validation sets. Prognostic study: longitudinal follow-up of 1275 CLD patients with baseline fibrosis tests. RESULTS Diagnostic study: the easy liver fibrosis test (eLIFT), an "at-a-glance" sum of points attributed to age, gender, gamma-glutamyl transferase, aspartate aminotransferase (AST), platelets and prothrombin time, was developed for the diagnosis of advanced fibrosis. In the validation set, eLIFT and fibrosis-4 (FIB4) had the same sensitivity (78.0% vs. 76.6%, p=0.470) but eLIFT gave fewer false positive results, especially in patients ≥60years old (53.8% vs. 82.0%, p<0.001), and was thus more suitable as screening test. FibroMeter with vibration controlled transient elastography (VCTE) was the most accurate among the eight fibrosis tests evaluated. The sensitivity of the eLIFT-FMVCTE algorithm (first-line eLIFT, second-line FibroMeterVCTE) was 76.1% for advanced fibrosis and 92.1% for cirrhosis. Prognostic study: patients diagnosed as having "no/mild fibrosis" by the algorithm had excellent liver-related prognosis with thus no need for referral to a hepatologist. CONCLUSION The eLIFT-FMVCTE algorithm extends the detection of advanced liver fibrosis to all CLD patients and reduces unnecessary referrals of patients without significant CLD to hepatologists. LAY SUMMARY Blood fibrosis tests and transient elastography accurately diagnose advanced liver fibrosis in the large population of patients having chronic liver disease, but these non-invasive tests are only currently available in specialized centers. We have developed an algorithm including the easy liver fibrosis test (eLIFT), a new simple and widely available blood test. It is used as a first-line procedure that selects at-risk patients who need further evaluation with the FibroMeterVCTE, an accurate fibrosis test combining blood markers and transient elastography result. This new algorithm, called the eLIFT-FMVCTE, accurately identifies the patients with advanced chronic liver disease who need referral to a specialist, and those with no or mild liver lesions who can remain under the care of their usual physician. CLINICAL TRIAL REGISTRATION No registration (analysis of pooled data from previously published diagnostic studies).
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Abstract
PURPOSE OF REVIEW Approximately, one quarter of patients discharged after a hospitalization for decompensated cirrhosis will be readmitted within 30 days. These readmissions have been associated with increased morbidity and mortality, can be financially harmful to the health system, and may be partially preventable. This review summarizes the literature on readmissions, providing clinicians with tools for risk prediction and a taxonomy for preventative interventions. RECENT FINDINGS Readmission strategies can be categorized according to complexity (simple versus complex) and specificity (focused versus broad). The literature thus far provides the following generalizable inferences: 1) Interventions should be integrated in the clinical workflow, 2) default options are more powerful than voluntary actions, 3) knowledge improvement should focus on the front line clinicians, 4) process improvements do not always translate into better outcomes, and 5) any successful intervention must include viable alternatives to hospitalization. A growing body of literature provides concrete and actionable guidance for interventions to reduce readmissions in patients with cirrhosis.
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology/Hepatology, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Michael Volk
- Division of Gastroenterology/Hepatology and Transplantation Institute, Loma Linda University Health, Loma Linda, CA, USA.
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