Evaluating and Improving Adherence to Guideline Based Care in Diagnosis and Management of Cirrhosis – A Quality Improvement Project

From the 2019 HVPAA National Conference

Dr. Ahmed Chatila (University of Texas Medical Branch), Dr. Mohammad Bilal (University of Texas Medical Branch), Dr. Lauren Clark (University of Texas Medical Branch), Mr. Ali Kassem (University of Texas Medical Branch), Ms. Lauren Lagrimas (University of Texas Medical Branch), Dr. Lola Carrete (University of Texas Medical Branch), Dr. Leah Low (University of Texas Medical Branch), Dr. Ojo Olugbenga (University of Texas Medical Branch), Dr. Shehzad Merwat (University of Texas Medical Branch), Dr. Steven Cohn (University of Texas Medical Branch), Dr. Lindsay Sonstein (University of Texas Medical Branch)

Background

Cirrhosis is a leading cause of hospital admissions with significant healthcare resource utilization. Most common reasons for admissions are gastrointestinal bleeding (GIB), complications of ascites, hepatic encephalopathy (HE) and acute kidney injury. The American College of Gastroenterology and the American Association for The Study of Liver Diseases published consensus guidelines outlining key diagnostic and management steps for cirrhosis.

Objective

We aim to evaluate our performance in regards to adherence to the benchmarks in management of cirrhosis outlined in these guidelines.

Methods

We designed a quality improvement project to evaluate and improve adherence with guideline based care in the management of cirrhosis at our institution. All patients admitted with cirrhosis at our institution between June 2017 to March 2018 were included.Baseline characteristics and patient demographics were noted. Data regarding adherence to guideline based benchmarks was collected. We also looked at outcomes including length of stay (LOS) and readmission rates (RR).

Results

Baseline characteristics of 247 patients included in our study are summarized in table 1. The average age was 60 years with a mean Model for End Stage Liver Disease score of 16.8. Of the patients with ascites, 79.3% received paracentesis during admission and median time to paracentesis was 17 hours. 6.9% of patients had SBP and 39.1% received appropriate treatment for SBP. 51.5% were discharged on the appropriate diuretic regimen, and 80.6% of patients received 2g Sodium diet. In the 56 patients with HE, work-up for infection was: blood cultures (60%), urine culture/analysis (53.6%), chest-X-ray (66.1%). In patients presenting with GIB, median time to EGD was 17.4 hour. Variceal band ligation was performed in 69% of patients, however only 65.7% received secondary prophylaxis with beta-blocker on discharge. Subsequent endoscopy was only performed in 27.1% of patients within 4 weeks. Mean LOS was 6 days and 30-day RR was 34%.

Conclusion

Adherence to evidence based guidelines in the diagnosis and management of cirrhosis was suboptimal. Improvements targeted at management of ascites, HE, and post GIB care have been identified. A multidisciplinary group has been formed and a standardized protocol integrated into the electronic health record is being created. Post-intervention data will be collected to assess the effectiveness of our interventions on adherence to guidelines and patient outcomes.

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