There is substantial opportunity to improve the care of patients hospitalized for decompensated cirrhosis. Additional research is needed to identify effective strategies for closing gaps in care. Adherence to quality measures did not affect clinical outcomes, but if easily measured in other settings could be used to compare hospitals and practices.

In an urban referral clinic, 182 hepatitis C-infected adults including 110 (60%) with HIV coinfection were evaluated for pegylated interferon and ribavirin therapy. Overall, only 33% were eligible for treatment. Considering all patients together, the major barriers to treatment were nonadherence with the evaluation process (23%), refusal of treatment (10%), active substance abuse (9%), and medical contraindication (8%). There was a trend toward a higher rate of treatment eligibility in HIV coinfected patients (39% vs. 25%; p = 0.07), who were significantly more likely to be adherent with the evaluation process compared to those with hepatitis C alone (86% vs. 63%; p = <0.001). Acceptance of antiviral therapy for hepatitis C was similar between eligible persons with and without HIV. These findings highlight the need to develop interventions to improve adherence and to manage substance abuse and other comorbidities in order to maximize the impact of interferon and ribavirin therapy on urban patients with hepatitis C.

Background & Aims Patients with decompensated cirrhosis (DC) have significant morbidity, and resource utilization. In a cohort of patients with DC undergoing usual care (UC) in 2009, we demonstrated that quality indicators (QI) were met less than 50% of the time. We established a mandatory gastroenterology consultation (MC) to improve the care of patients with DC. We sought to evaluate the impact of the MC intervention on adherence to QI, and compared outcomes to UC. Methods Prospective cohort study with historic control examining all admissions in a year for DC at an academic medical center. All admissions were seen by a gastroenterologist encouraged to implement QI (MC). Scores were calculated for each group per admission as the proportion of QI met vs. QI for which the patient was eligible. QI scores were examined as a function of group assignment multivariable fractional logit regression. We evaluated the impact of the intervention on compliance with QIs, length of stay (LOS), 30-day readmission, and inpatient death. Results 303 patients were observed in 695 hospitalizations (149 patients in 379 admissions (UC); 154 patients in 316 admissions (MC)). The QI score was significantly higher in the MC group than the UC group (77.0% vs. 46.0%, p<0.001), reflecting a better management of ascites and documentation of transplant evaluation. The management of variceal bleeding improved also but did not reach statistical significance. Conclusion The MC intervention was associated with greater adherence to recommended care but was not powered to detect difference in LOS, readmission or mortality rates.

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