858
Selected Summaries
past decade for black patients compared with white patients (J Clin Oncol 2013;31:1928–1930). The Delaware Cancer Treatment Program was established several years ago when black patients had a lesser CRC screening participation rate and a higher CRC mortality and incidence rate compared with white patients. In 2009, an equal number of black and white patients, almost three quarters, reported having undergone a colonoscopy. Furthermore, the CRC incidence as well as the CRC mortality was similar for black and white patients. These findings support the authors’ conclusions of the current study that a difference in screening uptake may account for observed CRC rate differences between black and white patients. Although the findings by Schroy et al need to be validated in other populations, these novel data should underscore the need to continue increasing the screening uptake for CRC, especially in black patients. JOSEPH C. ANDERSON Department of Veterans Affairs Medical Center White River Junction, Vermont and The Geisel School of Medicine at Dartmouth Medical Hanover, New Hampshire Acknowledgments The contents of this work do not represent the views of the Department of Veterans Affairs or the United States Government.
DIAGNOSTIC PARACENTESIS IS ASSOCIATED WITH IMPROVED SURVIVAL AMONG HOSPITALIZED PATIENTS WITH CIRRHOSIS Orman ES, Hayashi PH, Bataller R, et al. Paracentesis is associated with reduced mortality in patients hospitalized with cirrhosis and ascites. Clin Gastroenterol Hepatol 2014;12:496–503. Complications from cirrhosis, such as ascites, variceal bleeding, hepatic encephalopathy, and hepatocellular cancer, impose significant morbidity and healthcare costs. Survival of patients with cirrhosis decreases from >12 years to approximately 2 years once complications arise (J Hepatol 2006; 44:217–231). Quality medical care is thought to be vital to reducing associated mortality and morbidity. To help standardize and optimize the multifaceted care of patients with cirrhosis, Kanwal et al developed a set of quality indicator (QI) measures (Clin Gastroenterol Hepatol 2010;8:709–717). The goal of this expert consensus panel was to identify a set of process measures likely to improve outcomes in cirrhosis. A recent study by Orman et al examined 1 specific QI (receipt of diagnostic paracentesis) and its association with mortality in patients with ascites admitted for management of ascites or hepatic encephalopathy (Clin Gastroenterol Hepatol 2014;12:496–503). This retrospective study was performed using data from the 2009 Nationwide Inpatient Sample, an all-payer data source containing records of roughly 8 million US hospital discharges per year with
Gastroenterology Vol. 146, No. 3
information on demographics, diagnoses, procedures, length of stay, hospital charges, and patient disposition. International Classification of Diseases, Ninth Revision (ICD-9) codes were used to identify adult patients with cirrhosis and a primary discharge diagnosis of ascites or spontaneous bacterial peritonitis (SBP), or a primary diagnosis of hepatic encephalopathy with ascites as a secondary diagnosis. Patients transferred from another facility were excluded. The primary outcome was in-hospital mortality, with length of hospital stay and total hospital charges being secondary outcome measures. In addition to looking at receipt of paracentesis during the hospitalization, the study also examined early versus delayed paracentesis (defined as 1 vs >1 day after admission). Other independent variables included patient age, gender, race/ethnicity, weekday versus weekend admission, elective versus nonelective admission, comorbidity index, insurance status, median household income based on home zip code, and hospital factors (location, type of ownership, teaching status, and size). Of the 17,711 patients included in this study, 10,743 (60.7%) underwent a paracentesis during hospitalization. Among those who underwent paracentesis, 6,479 (66%) did so within 1 day after admission. Of patients with a primary diagnosis of SBP, 77.1% received a paracentesis compared with 55.5% for those with primary diagnosis of encephalopathy or ascites. In multivariate analysis, receipt of paracentesis was associated with self-pay status (odds ratio [OR], 1.41; 95% CI, 1.02–1.96), sepsis (OR, 1.43; 95% CI, 1.02–2.00), acute renal failure (OR, 1.53; 95% CI, 1.29–1.81), and hospital teaching status (OR, 1.32; 95% CI, 1.08–1.61). Paracentesis was less likely to occur if patients were admitted on the weekend (OR, 0.84; 95% CI, 0.71–1.00) and for those in the South region (OR, 0.76; 95% CI, 0.57–1.00). Patients who underwent paracentesis had lower inhospital mortality than those who did not (6.5% vs 8.5%; P ¼ .03), with an adjusted odds ratio of 0.55 (95% CI, 0.41–0.74) on multivariate analysis. On sensitivity analysis, after excluding the 2.3% of in-hospital deaths that occurred on the day of admission, paracentesis remained significantly associated with reduced mortality in multivariate analysis (OR, 0.59; 95% CI, 0.43–0.80). On subgroup analysis, a survival benefit was seen in patients with a primary diagnosis of ascites or encephalopathy (OR, 0.54; 95% CI, 0.38–0.76), but not in those with a primary diagnosis of SBP (OR, 0.91; 95% CI, 0.38–2.19). There was no mortality difference between early and delayed paracentesis on multivariate analysis (OR, 1.26; 95% CI, 0.78–2.02). The mean length of stay for those who underwent paracentesis was longer compared with those who did not (6.6 vs 5.3 days; P < .001). Likewise, hospital charges were higher for those who had a paracentesis ($44,586 vs $31,746; P < .001). Comment. With several studies highlighting inconsistency in medical management, there is increasing attention paid to quality in health care. Despite society guidelines and recommendations, pervasive deficits exist in current processes of care among patients with cirrhosis, ranging from preventive measures to treatment to follow-up. There is
March 2014
substantial underutilization of preventive measures including hepatitis A and B vaccination and hepatocellular carcinoma surveillance (Hepatology 2010;52:132–141; J Gen Intern Med 2012;27:861–867; Aliment Pharmacol Ther 2008;28:1078–1087). Likewise, Kanwal et al demonstrated that only one third of patients with cirrhosis in 3 Veterans Affairs centers receive all recommended ascites-related care (Gastroenterology 2012;143:70–77). Finally, nearly one-third of patients fail to receive appropriate follow-up endoscopy after initial presentation with variceal hemorrhage (Can J Gastroenterol 2007;21:85–90). This suboptimal level of care is at least in part related to lack of adequate patient education, inadequate provider knowledge, increased time constraints during clinic visits, and poor coordination between providers (Gastroenterology 2010;139:14–16.e1). Research regarding QI metrics is crucial given that implementation of the Affordable Care Act will require providers to report multiple QI measures to Centers for Medicare and Medicaid Services. The study by Orman et al is an important addition to the growing literature regarding quality of care in patients with cirrhosis. First, this study highlights the underuse of paracentesis in patients hospitalized with ascites, because 39.3% of admitted patients failed to receive a paracentesis. Perhaps more important, the study links this process measure with downstream outcomes, such as mortality. Although process measures are more sensitive to differences in quality of care, outcomes are often of greater interest. Given that this process measure recommendation is currently based on expert opinion (grade C recommendation), establishing an association with outcome measures may help to increase recognition of its importance and subsequent uptake in clinical practice. Similar studies linking process measures and outcomes have been performed for QI measures, such as hepatocellular carcinoma surveillance and endoscopy for variceal hemorrhage, but are still necessary for several other cirrhosis quality metrics (Am J Gastroenterol 2013;108:425–432; J Gastroenterol Hepatol 2009;24:1294–1299). A study by Ghaoui et al found that QI measures were only met in 45% of patients admitted with decompensated cirrhosis; however, they did not find any association between QI scores and inpatient mortality or 30-day mortality (Liver Int 2014; 34:202–210). Similarly, a pilot study of a chronic disease management program improved several QI indicators, but this failed to translate into improvements in cirrhosis-related admission rates, hospitalization days, or overall survival (Clin Gastroenterol Hepatol 2013;11:850–858 e1–e4). It is possible that improvements in process measures would translate to improved outcomes with longer follow-up or larger sample size; however, it is also possible that there is a disconnect between proposed QI metrics and outcomes of interest. Studies such as the one by Orman et al help to demonstrate the importance of these process measures and help to support the introduction of interventions to improve deficits in care delivery. Unfortunately, lack of detail in the Nationwide Inpatient Sample did not allow for firm conclusions regarding reasons
Selected Summaries
859
for underutilization of paracentesis. The authors hypothesize that it could be related to insufficient ascites, low index of suspicion for SBP, inadequate knowledge, or lack of comfort in performing the procedure. As has been done for other quality measures, studies characterizing reasons for underuse can help to identify potential intervention strategies to improve rates in the future (Cancer Prev Res (Phila) 2012;5:1124–1130). The association between paracentesis and improved survival may be attributable to increased diagnosis of asymptomatic SBP, which would have otherwise been missed. Although the authors did not find this association in the subset of patients with SBP, they hypothesize this effect may have been obscured by the use of empiric antibiotics in those with a paracentesis. Furthermore, there is the possibility of ascertainment bias; those with a paracentesis may have had unrecognized SBP. However, it is important to note that this study is only able to establish an association, and not causality, between paracentesis and survival given its retrospective nature. Although the authors adjusted for several important factors, such as patient age, insurance status, and comorbidity index, there are several other potential confounders, including severity of liver disease (Child Pugh or Model for End-Stage Liver Disease score). Alternatively, receipt of a paracentesis may simply be a surrogate for other quality measures. Other limitations of this study include potential misclassification of diagnostic versus therapeutic paracentesis owing to an inability to differentiate between these procedures based on ICD-9 code. In addition, the Nationwide Inpatient Sample does not provide details regarding the severity of illness necessitating hospitalization or the severity of underlying liver disease; thus, no conclusions can be drawn regarding the impact of illness severity on decisions (and potential benefits) regarding paracentesis. Notably, the authors performed a sensitivity analysis in which they excluded patients who died on the day of admission to reduce potential selection bias of moribund patients in whom paracentesis may be deemed futile. In conclusion, the study by Orman et al highlights the underuse of paracentesis in hospitalized patients with cirrhosis and ascites or hepatic encephalopathy. The authors demonstrate a strong association between the receipt of paracentesis and subsequent mortality. This lack of adherence mirrors the pervasive nonadherence to other quality measures in care of patients with cirrhosis. At this time, we need studies that better characterize potential barriers to adhering to this QI and to identify effective interventions to improve adherence to this QI, which may ultimately improve patient outcomes. CHENLU TIAN AMIT G. SINGAL Division of Gastroenterology University of Texas Southwestern Dallas, Texas
Selected Summaries
past decade for black patients compared with white patients (J Clin Oncol 2013;31:1928–1930). The Delaware Cancer Treatment Program was established several years ago when black patients had a lesser CRC screening participation rate and a higher CRC mortality and incidence rate compared with white patients. In 2009, an equal number of black and white patients, almost three quarters, reported having undergone a colonoscopy. Furthermore, the CRC incidence as well as the CRC mortality was similar for black and white patients. These findings support the authors’ conclusions of the current study that a difference in screening uptake may account for observed CRC rate differences between black and white patients. Although the findings by Schroy et al need to be validated in other populations, these novel data should underscore the need to continue increasing the screening uptake for CRC, especially in black patients. JOSEPH C. ANDERSON Department of Veterans Affairs Medical Center White River Junction, Vermont and The Geisel School of Medicine at Dartmouth Medical Hanover, New Hampshire Acknowledgments The contents of this work do not represent the views of the Department of Veterans Affairs or the United States Government.
DIAGNOSTIC PARACENTESIS IS ASSOCIATED WITH IMPROVED SURVIVAL AMONG HOSPITALIZED PATIENTS WITH CIRRHOSIS Orman ES, Hayashi PH, Bataller R, et al. Paracentesis is associated with reduced mortality in patients hospitalized with cirrhosis and ascites. Clin Gastroenterol Hepatol 2014;12:496–503. Complications from cirrhosis, such as ascites, variceal bleeding, hepatic encephalopathy, and hepatocellular cancer, impose significant morbidity and healthcare costs. Survival of patients with cirrhosis decreases from >12 years to approximately 2 years once complications arise (J Hepatol 2006; 44:217–231). Quality medical care is thought to be vital to reducing associated mortality and morbidity. To help standardize and optimize the multifaceted care of patients with cirrhosis, Kanwal et al developed a set of quality indicator (QI) measures (Clin Gastroenterol Hepatol 2010;8:709–717). The goal of this expert consensus panel was to identify a set of process measures likely to improve outcomes in cirrhosis. A recent study by Orman et al examined 1 specific QI (receipt of diagnostic paracentesis) and its association with mortality in patients with ascites admitted for management of ascites or hepatic encephalopathy (Clin Gastroenterol Hepatol 2014;12:496–503). This retrospective study was performed using data from the 2009 Nationwide Inpatient Sample, an all-payer data source containing records of roughly 8 million US hospital discharges per year with
Gastroenterology Vol. 146, No. 3
information on demographics, diagnoses, procedures, length of stay, hospital charges, and patient disposition. International Classification of Diseases, Ninth Revision (ICD-9) codes were used to identify adult patients with cirrhosis and a primary discharge diagnosis of ascites or spontaneous bacterial peritonitis (SBP), or a primary diagnosis of hepatic encephalopathy with ascites as a secondary diagnosis. Patients transferred from another facility were excluded. The primary outcome was in-hospital mortality, with length of hospital stay and total hospital charges being secondary outcome measures. In addition to looking at receipt of paracentesis during the hospitalization, the study also examined early versus delayed paracentesis (defined as 1 vs >1 day after admission). Other independent variables included patient age, gender, race/ethnicity, weekday versus weekend admission, elective versus nonelective admission, comorbidity index, insurance status, median household income based on home zip code, and hospital factors (location, type of ownership, teaching status, and size). Of the 17,711 patients included in this study, 10,743 (60.7%) underwent a paracentesis during hospitalization. Among those who underwent paracentesis, 6,479 (66%) did so within 1 day after admission. Of patients with a primary diagnosis of SBP, 77.1% received a paracentesis compared with 55.5% for those with primary diagnosis of encephalopathy or ascites. In multivariate analysis, receipt of paracentesis was associated with self-pay status (odds ratio [OR], 1.41; 95% CI, 1.02–1.96), sepsis (OR, 1.43; 95% CI, 1.02–2.00), acute renal failure (OR, 1.53; 95% CI, 1.29–1.81), and hospital teaching status (OR, 1.32; 95% CI, 1.08–1.61). Paracentesis was less likely to occur if patients were admitted on the weekend (OR, 0.84; 95% CI, 0.71–1.00) and for those in the South region (OR, 0.76; 95% CI, 0.57–1.00). Patients who underwent paracentesis had lower inhospital mortality than those who did not (6.5% vs 8.5%; P ¼ .03), with an adjusted odds ratio of 0.55 (95% CI, 0.41–0.74) on multivariate analysis. On sensitivity analysis, after excluding the 2.3% of in-hospital deaths that occurred on the day of admission, paracentesis remained significantly associated with reduced mortality in multivariate analysis (OR, 0.59; 95% CI, 0.43–0.80). On subgroup analysis, a survival benefit was seen in patients with a primary diagnosis of ascites or encephalopathy (OR, 0.54; 95% CI, 0.38–0.76), but not in those with a primary diagnosis of SBP (OR, 0.91; 95% CI, 0.38–2.19). There was no mortality difference between early and delayed paracentesis on multivariate analysis (OR, 1.26; 95% CI, 0.78–2.02). The mean length of stay for those who underwent paracentesis was longer compared with those who did not (6.6 vs 5.3 days; P < .001). Likewise, hospital charges were higher for those who had a paracentesis ($44,586 vs $31,746; P < .001). Comment. With several studies highlighting inconsistency in medical management, there is increasing attention paid to quality in health care. Despite society guidelines and recommendations, pervasive deficits exist in current processes of care among patients with cirrhosis, ranging from preventive measures to treatment to follow-up. There is
March 2014
substantial underutilization of preventive measures including hepatitis A and B vaccination and hepatocellular carcinoma surveillance (Hepatology 2010;52:132–141; J Gen Intern Med 2012;27:861–867; Aliment Pharmacol Ther 2008;28:1078–1087). Likewise, Kanwal et al demonstrated that only one third of patients with cirrhosis in 3 Veterans Affairs centers receive all recommended ascites-related care (Gastroenterology 2012;143:70–77). Finally, nearly one-third of patients fail to receive appropriate follow-up endoscopy after initial presentation with variceal hemorrhage (Can J Gastroenterol 2007;21:85–90). This suboptimal level of care is at least in part related to lack of adequate patient education, inadequate provider knowledge, increased time constraints during clinic visits, and poor coordination between providers (Gastroenterology 2010;139:14–16.e1). Research regarding QI metrics is crucial given that implementation of the Affordable Care Act will require providers to report multiple QI measures to Centers for Medicare and Medicaid Services. The study by Orman et al is an important addition to the growing literature regarding quality of care in patients with cirrhosis. First, this study highlights the underuse of paracentesis in patients hospitalized with ascites, because 39.3% of admitted patients failed to receive a paracentesis. Perhaps more important, the study links this process measure with downstream outcomes, such as mortality. Although process measures are more sensitive to differences in quality of care, outcomes are often of greater interest. Given that this process measure recommendation is currently based on expert opinion (grade C recommendation), establishing an association with outcome measures may help to increase recognition of its importance and subsequent uptake in clinical practice. Similar studies linking process measures and outcomes have been performed for QI measures, such as hepatocellular carcinoma surveillance and endoscopy for variceal hemorrhage, but are still necessary for several other cirrhosis quality metrics (Am J Gastroenterol 2013;108:425–432; J Gastroenterol Hepatol 2009;24:1294–1299). A study by Ghaoui et al found that QI measures were only met in 45% of patients admitted with decompensated cirrhosis; however, they did not find any association between QI scores and inpatient mortality or 30-day mortality (Liver Int 2014; 34:202–210). Similarly, a pilot study of a chronic disease management program improved several QI indicators, but this failed to translate into improvements in cirrhosis-related admission rates, hospitalization days, or overall survival (Clin Gastroenterol Hepatol 2013;11:850–858 e1–e4). It is possible that improvements in process measures would translate to improved outcomes with longer follow-up or larger sample size; however, it is also possible that there is a disconnect between proposed QI metrics and outcomes of interest. Studies such as the one by Orman et al help to demonstrate the importance of these process measures and help to support the introduction of interventions to improve deficits in care delivery. Unfortunately, lack of detail in the Nationwide Inpatient Sample did not allow for firm conclusions regarding reasons
Selected Summaries
859
for underutilization of paracentesis. The authors hypothesize that it could be related to insufficient ascites, low index of suspicion for SBP, inadequate knowledge, or lack of comfort in performing the procedure. As has been done for other quality measures, studies characterizing reasons for underuse can help to identify potential intervention strategies to improve rates in the future (Cancer Prev Res (Phila) 2012;5:1124–1130). The association between paracentesis and improved survival may be attributable to increased diagnosis of asymptomatic SBP, which would have otherwise been missed. Although the authors did not find this association in the subset of patients with SBP, they hypothesize this effect may have been obscured by the use of empiric antibiotics in those with a paracentesis. Furthermore, there is the possibility of ascertainment bias; those with a paracentesis may have had unrecognized SBP. However, it is important to note that this study is only able to establish an association, and not causality, between paracentesis and survival given its retrospective nature. Although the authors adjusted for several important factors, such as patient age, insurance status, and comorbidity index, there are several other potential confounders, including severity of liver disease (Child Pugh or Model for End-Stage Liver Disease score). Alternatively, receipt of a paracentesis may simply be a surrogate for other quality measures. Other limitations of this study include potential misclassification of diagnostic versus therapeutic paracentesis owing to an inability to differentiate between these procedures based on ICD-9 code. In addition, the Nationwide Inpatient Sample does not provide details regarding the severity of illness necessitating hospitalization or the severity of underlying liver disease; thus, no conclusions can be drawn regarding the impact of illness severity on decisions (and potential benefits) regarding paracentesis. Notably, the authors performed a sensitivity analysis in which they excluded patients who died on the day of admission to reduce potential selection bias of moribund patients in whom paracentesis may be deemed futile. In conclusion, the study by Orman et al highlights the underuse of paracentesis in hospitalized patients with cirrhosis and ascites or hepatic encephalopathy. The authors demonstrate a strong association between the receipt of paracentesis and subsequent mortality. This lack of adherence mirrors the pervasive nonadherence to other quality measures in care of patients with cirrhosis. At this time, we need studies that better characterize potential barriers to adhering to this QI and to identify effective interventions to improve adherence to this QI, which may ultimately improve patient outcomes. CHENLU TIAN AMIT G. SINGAL Division of Gastroenterology University of Texas Southwestern Dallas, Texas
