Suboptimal Implementation of Evidence-based Therapy for Acute Variceal Hemorrhage: A Systematic Review of Observational Studies

Tapper, Elliot B.; Beste, Lauren A; Curry, Michael P.; Bonder, Alan; Waljee, Akbar K.; Saini, Sameer D.

doi:10.1016/j.cgh.2017.02.018

Cited by 12 publications

(13 citation statements)

References 47 publications

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“…This puzzling finding, like any finding in such datasets, is descriptive without explanation and raises uncertainty regarding the veracity of the coding. However, these data are also consistent with our findings from a systematic review of observational studies of AVH where no endoscopic intervention was provided in 14.3% of patients (95% CI, 9.7%‐20.6%) . The reasons for a failure to provide endoscopy or intervene effectively cannot be abstracted from these data.…”

Section: Discussionsupporting

confidence: 88%

“…However, these data are also consistent with our findings from a systematic review of observational studies of AVH where no endoscopic intervention was provided in 14.3% of patients (95% CI, 9.7%-20.6%). 4 The reasons for a failure to provide endoscopy or intervene effectively cannot be abstracted from these data. Yet, it is plausible that the rate at which a centre fails to provide endoscopy or endoscopic therapy speaks to centre-wide quality as does the BT utilization rate.…”

Section: Discussionmentioning

confidence: 99%

“…We recently showed that 14% of all patients with AVH receive no endoscopic therapy, 9% do not receive vasoactive medications and 37% do not receive prophlylactic antibiotics. 4 We hypothesized that if a patient received BT, many others would have been exposed to similar processes of care and thus higher BT utilization at the hospitallevel would be associated with poor outcomes. Herein we test this hypothesis in a study with two aims: one, to evaluate the rate, clinical associations and impact of BT utilization at the hospital-level and, two, to evaluate in a single-centre study whether BT use reflects gaps in quality of care.…”

Section: Some Proportion Of Bt Utilization May Be Preventable Particmentioning

confidence: 99%

“…In these cases, BT use speaks to problems in the delivery of AVH care. We recently showed that 14% of all patients with AVH receive no endoscopic therapy, 9% do not receive vasoactive medications and 37% do not receive prophlylactic antibiotics . We hypothesized that if a patient received BT, many others would have been exposed to similar processes of care and thus higher BT utilization at the hospital‐level would be associated with poor outcomes.…”

Section: Introductionmentioning

confidence: 99%

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Hospital‐level balloon tamponade use is associated with increased mortality for all patients presenting with acute variceal haemorrhage

Tapper

Ezaz

Patwardhan

et al. 2017

Liver International

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Section: Discussionsupporting

confidence: 88%

Section: Discussionmentioning

confidence: 99%

Section: Some Proportion Of Bt Utilization May Be Preventable Particmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Hospital‐level balloon tamponade use is associated with increased mortality for all patients presenting with acute variceal haemorrhage

Tapper

Ezaz

Patwardhan

et al. 2017

Liver International

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“…reported that the proportion of antibiotics was 30.6% in 2005 and increased up to 58.1% in 2013. Unfortunately, the proportion of cirrhotic patients who received antibiotic prophylaxis remained low . This meant that it could be because of physicians prescribing antibiotics due to poor clinical condition of patients, rather than the preventive concept.…”

Section: Discussionmentioning

confidence: 99%

The role of antibiotics in upper gastrointestinal bleeding among cirrhotic patients without major complications after endoscopic hemostasis

Yang

Liang

et al. 2019

J of Gastro and Hepatol

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Background and aim:Antibiotic prophylaxis should be instituted for cirrhotic patients with upper gastrointestinal bleeding (UGIB), but the benefit on compensated patients remains undetermined. We aimed to compare the clinical outcomes between cirrhotic patients without major complications with UGIB with and without antibiotic prophylaxis. Methods: We conducted this population-based cohort study by using Taiwanese Longitudinal Health Insurance Database 2000 (LHID2000, between 1997 to 2013), aged 18 years or older with a hospital discharge diagnosis of cirrhosis (n = 64,506), UGIB (n = 7,784), and endoscopic therapy (n = 2,292). After strict exclusions, 1205 patients were enrolled and were divided into antibiotic exposure (n = 558) and non-exposure (n = 647) groups. The outcomes were rebleeding and mortality. Results: After completing the analysis adjusted by death, the rebleeding rates within 4 weeks were significantly lower in patients with antibiotic prophylaxis (3.05% versus 6.03%, P = 0.0142) and those with endoscopic therapy (0.72% vs 3.09%, P = 0.0033) but not significant after 3 months and onwards. Male patients aged > 55, high CCI score ≧ 4, and UGIB of variceal etiologies were benefited from rebleeding. The use of antibiotics did not significantly impact 6-week mortality (adjusted hazard ratio: 1.07, 95%CI: 0.41~2.75; P = 0.8943). Old age, multiple comorbidities, and UGIB of variceal etiologies were risk factors of all-cause mortality. Conclusions: The current study suggested that cirrhotic patients without major complications who suffered from UGIB were benefited by the use of antibiotics to prevent rebleeding within 4 weeks after endoscopic treatment of UGIB especially for those with age > 55, high CCI score ≧ 4, and UGIB of variceal etiologies.

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Diagnosis and Management of Cirrhosis and Its Complications

Tapper

Parikh

2023

JAMA

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ImportanceCirrhosis affects approximately 2.2 million adults in the US. From 2010 to 2021, the annual age-adjusted mortality of cirrhosis increased from 14.9 per 100 000 to 21.9 per 100 000 people.ObservationsThe most common causes of cirrhosis in the US, which can overlap, include alcohol use disorder (approximately 45% of all cases of cirrhosis), nonalcoholic fatty liver disease (26%), and hepatitis C (41%). Patients with cirrhosis experience symptoms including muscle cramps (approximately 64% prevalence), pruritus (39%), poor-quality sleep (63%), and sexual dysfunction (53%). Cirrhosis can be diagnosed by liver biopsy but may also be diagnosed noninvasively. Elastography, a noninvasive assessment of liver stiffness measured in kilopascals, can typically confirm cirrhosis at levels of 15 kPa or greater. Approximately 40% of people with cirrhosis are diagnosed when they present with complications such as hepatic encephalopathy or ascites. The median survival time following onset of hepatic encephalopathy and ascites is 0.92 and 1.1 years, respectively. Among people with ascites, the annual incidence of spontaneous bacterial peritonitis is 11% and of hepatorenal syndrome is 8%; the latter is associated with a median survival of less than 2 weeks. Approximately 1% to 4% of patients with cirrhosis develop hepatocellular carcinoma each year, which is associated with a 5-year survival of approximately 20%. In a 3-year randomized clinical trial of 201 patients with portal hypertension, nonselective β-blockers (carvedilol or propranolol) reduced the risk of decompensation or death compared with placebo (16% vs 27%). Compared with sequential initiation, combination aldosterone antagonist and loop diuretics were more likely to resolve ascites (76% vs 56%) with lower rates of hyperkalemia (4% vs 18%). In meta-analyses of randomized trials, lactulose was associated with reduced mortality relative to placebo (8.5% vs 14%) in randomized trials involving 705 patients and reduced risk of recurrent overt hepatic encephalopathy (25.5% vs 46.8%) in randomized trials involving 1415 patients. In a randomized clinical trial of 300 patients, terlipressin improved the rate of reversal of hepatorenal syndrome from 39% to 18%. Trials addressing symptoms of cirrhosis have demonstrated efficacy for hydroxyzine in improving sleep dysfunction, pickle brine and taurine for reducing muscle cramps, and tadalafil for improving sexual dysfunction in men.Conclusions and RelevanceApproximately 2.2 million US adults have cirrhosis. Many symptoms, such as muscle cramps, poor-quality sleep, pruritus, and sexual dysfunction, are common and treatable. First-line therapies include carvedilol or propranolol to prevent variceal bleeding, lactulose for hepatic encephalopathy, combination aldosterone antagonists and loop diuretics for ascites, and terlipressin for hepatorenal syndrome.

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Suboptimal Implementation of Evidence-based Therapy for Acute Variceal Hemorrhage: A Systematic Review of Observational Studies

Cited by 12 publications

References 47 publications

Hospital‐level balloon tamponade use is associated with increased mortality for all patients presenting with acute variceal haemorrhage

Hospital‐level balloon tamponade use is associated with increased mortality for all patients presenting with acute variceal haemorrhage

The role of antibiotics in upper gastrointestinal bleeding among cirrhotic patients without major complications after endoscopic hemostasis

Diagnosis and Management of Cirrhosis and Its Complications

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