We sought to identify specific gaps in preventive care provided to outpatients with cirrhosis and to determine factors associated with high quality of care (QOC), to guide quality improvement efforts. Outpatients with cirrhosis who received care at a large, academic tertiary health care system in the United States were included. Twelve quality indicators (QIs), including preventive care processes for ascites, esophageal varices, hepatic encephalopathy, hepatocellular carcinoma (HCC), and general cirrhosis care, were measured. QI pass rates were calculated as the proportion of patients eligible for a QI who received that QI during the study period. We performed logistic regression to determine predictors of high QOC (≥ 75% of eligible QIs) and receipt of HCC surveillance. Of the 439 patients, the median age was 63 years, 59% were male, and 19% were Hispanic. The median Model for End-Stage Liver Disease-Sodium score was 11, 64% were compensated, and 32% had hepatitis C virus. QI pass rates varied by individual QIs, but were overall low. For example, 24% received appropriate HCC surveillance, 32% received an index endoscopy for varices screening, and 21% received secondary prophylaxis for spontaneous bacterial peritonitis. In multivariable analyses, Asian race (odds ratio [OR]: 3.7, 95% confidence interval [CI]: 1.3-10.2) was associated with higher QOC, and both Asian race (OR: 3.3, 95% CI: 1.2-9.0) and decompensated status (OR: 2.1, 95% CI: 1.1-4.2) were associated with receipt of HCC surveillance. A greater number of specialty care visits was not associated with higher QOC. Conclusion: Receipt of outpatient preventive cirrhosis QIs was variable and overall low in a diverse cohort of patients with cirrhosis. Variation in care by race/ethnicity and illness trajectory should prompt further inquiry into identifying modifiable factors to standardize care delivery and to improve QOC. (Hepatology Communications 2020;0:1-10). C irrhosis is a common condition associated with significant morbidity and mortality. (1,2) It is the twelfth leading cause of death in the United States (3) and carries a burden of disease that is projected to increase over the next decade due to a rising incidence of alcohol-associated liver disease and nonalcoholic steatohepatitis (NASH). (4,5) Cirrhosis is also associated with significantly decreased quality
involving the gastric fundus. Patient was started on a Pantoprazole drip and a nasogastric tube was placed with low intermittent suctioning for gastric decompression. Endoscopy revealed friable hemorrhagic and ulcerated mucosa; biopsy returned positive for active gastritis in the absence of H.pylori. This elucidated the underlying cause to be most likely secondary to ischemic gastritis. Following multiple blood transfusions and ultimately symptom resolution, the patient was extubated and repeat endoscopy revealed an improvement in gastritis from prior examination. (Figure ) Discussion: Hepatic portal venous gas is considered an imaging manifestation of various etiologies and cannot be used as a predictor of mortality by itself. Most cases are caused by intestinal ischemia. Other causes can largely be divided into iatrogenic and non-iatrogenic such as infection, trauma, and ulceration in the former to endoscopic procedures in the latter. Our case is unique in that ischemia is relatively uncommon in stomach, particularly in patients such as this one with relatively little atherosclerotic disease. It is important to differentiate the etiology of portal venous gas due to its varied presentation from benign to life-threatening, its mortality being determined by the underlying pathology.[3030] Figure 1. CT scan of abdomen showing large amount of portal venous gas in the liver (red arrow) with pneumatosis involving the gastric fundus (white arrows). Figure 2: Endoscopy showing severe mucosal changes characterized by dusky discoloration, friability, hemorrhagic appearance and ulceration along the lesser curvature of the stomach.
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