The Quality and Outcomes of Care Provided to Patients with Cirrhosis by Advanced Practice Providers

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.

The Role of Advanced Practice Providers in the Care of Nonalcoholic Fatty Liver Disease

“…Our data suggested that, more so than visits with APPs without prior subspecialty consultation or subspecialist visits without APP involvement, care quality and outcomes were optimized for patients who saw APPs and subspecialists, including when the APP practiced independently. 20 The key finding from our study was that outcomes were most improved when patients were seen by both APPs and subspecialists.…”

“…23e25 Second, we recently studied the quality and outcomes of care provided by APPs to patients with cirrhosis in the United States. 20 We found that patients who received care from APPs were more likely to be screened for hepatocellular carcinoma and esophageal varices as well as receive evidence-based care for secondary prevention of overt hepatic encephalopathy. Furthermore, APPs were associated with a lower confounder-adjusted risk of both 30-day readmissions and mortality.…”

Advanced Practice Providers: Raising Our Defenses Against the Rising Tide of Cirrhosis

“…As Tapper et al state, “the U.S. health care system lacks enough physicians and specialists to adequately manage patients with cirrhosis.” As the prevalence of cirrhosis continues to rise, comprehensive care of this population that is mindful of their complex medical and psychosocial needs is essential. The authors provide evidence to justify improved quality and clinical outcomes with APP‐based care.…”

“…(3) In other complex medical conditions, the involvement of advance practice providers (APPs; physician assistants, nurse practitioners) has resulted in benefits across clinical outcomes, patient satisfaction, and quality of life. (4) There are limited data evaluating the impact of APPs on patient outcomes in cirrhosis care.In this issue of Hepatology, Tapper et al (5) present a retrospective analysis of the 2001-2015 Optum Clinformatics database of patients with private insurance. Using the records of 389,257 adult patients with 2 or more cirrhosis claims, the authors performed a detailed statistical analysis to evaluate the effect of APP care on cirrhosis-related outcomes (30-day readmissions, survival) and quality-of-care metrics (hepatocellular carcinoma [HCC] and variceal screening, rifaximin use after discharge for hepatic encephalopathy [HE]).…”

“…In this issue of H epatology , Tapper et al present a retrospective analysis of the 2001‐2015 Optum Clinformatics database of patients with private insurance. Using the records of 389,257 adult patients with 2 or more cirrhosis claims, the authors performed a detailed statistical analysis to evaluate the effect of APP care on cirrhosis‐related outcomes (30‐day readmissions, survival) and quality‐of‐care metrics (hepatocellular carcinoma [HCC] and variceal screening, rifaximin use after discharge for hepatic encephalopathy [HE]).…”