Facility- and Patient-Level Factors Associated with Esophageal Variceal Screening in the USA

Abstract

Background and Aim The American Association for the Study of Liver Disease (AASLD) recommends screening for esophageal varices (EV) by esophagoduodenoscopy (EGD) in patients with cirrhosis to guide decisions regarding primary prophylaxis for EV hemorrhage. We aimed to identify patient and facility factors associated with EV screening in veterans with hepatitis C (HCV)-associated cirrhosis. Methods This was a population-based cohort study. Veterans with HCV and newly diagnosed cirrhosis between 1/1/2004 and 12/31/2005 and followed until 12/31/2011 were included. The primary outcome was receipt of EGD within 1 year of cirrhosis diagnosis. Patient- and facility-level factors associated with EV screening were determined. Results A total of 4230 patients with HCV cirrhosis were identified. During median follow-up of 6.1 years (IQR: 4.0–8.0), 21.5 % developed a decompensating event, and 38.3 % died. Fifty-four percent received an EGD, and 33.8 % had an EGD within guidelines. Median time from cirrhosis diagnosis to EGD was 72 days (IQR: 12–176). Factors independently associated with receipt of EV screening were a decompensation event (OR 1.16, CI 1.01–1.32) and gastroenterology/hepatology clinic access (OR 2.1, CI 1.73–2.46), whereas cardiovascular (OR 0.81, CI 0.69–0.95), mental health (OR 0.79, CI 0.68–0.91), and respiratory (OR 0.85, CI 0.72–0.99) comorbidities were associated with reduced likelihood of EV screening. Conclusion EV screening per AASLD guidelines occurs in only one-third of patients. This missed opportunity was strongly associated with access to gastroenterology/hepatology specialty care. Additionally, providers may be relying on clinical cues (i.e., decompensation) to prompt referral for endoscopy suggesting education to improve compliance with guidelines is needed.

Uptake of endoscopic screening for gastroesophageal varices and factors associated with variceal bleeding in patients with chronic hepatitis C infection and compensated cirrhosis, 2005‐2016: a national database linkage study

“…Screening rates in our cohort concur with findings of a large study using the US Veterans Health Administration database, in which 34% of HCV‐infected patients with cirrhosis were endoscopically screened per AASLD guidelines within the 1 year preceding or 1 year following cirrhosis diagnosis. In our study, 34% of patients diagnosed with compensated cirrhosis in 2005‐2016 had been screened within the 1 year preceding or following diagnosis.…”

Attitudes towards digital health tools for outpatient cirrhosis management in patients with decompensated cirrhosis

“…Evidence-based guidelines have made important advances in cirrhosis care; however, many of these guidelines are not sustained in practice 10 11. Reduced guideline compliance has been associated with poor outcomes, including readmissions for overdiuresis, delayed hepatocellular carcinoma (HCC) diagnosis, reduced curative HCC treatment and increased oesophageal variceal haemorrhage 6 10 12.…”

Health Disparities of Black Americans Hospitalized for Decompensated Liver Cirrhosis

“…26 Similar findings of suboptimal cirrhosis care have been reported in the setting of variceal bleeding, screening for varices, and HCC surveillance with ultrasound. 27,28,29 Compared to these previous studies, adherence to evidence based cirrhosis care at our institution was improved with 87-100% adherence to most quality indicators which may reflect increased awareness of cirrhosis care in the current era. No racial disparities in receipt of quality cirrhosis care were identified in our study, which suggests that racial disparities in cirrhosis outcomes occurred despite high quality cirrhosis care.…”