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.

Figure 1. Association of Provider Type with Process Measures and 30-day Readmissions

Adjusted odds ratios for multiple metrics are presented to show the quality of care provided by various healthcare providers. Raw data including unadjusted estimates are presented in the online supplement (Supplementary Tables 3a–3d). A: Compared to patients who were never seen by an advanced practice provider (APP), those who were seen by an APP, regardless of presence or absence of gastroenterologist/hepatologist consultation, were marginally more likely to receive screening for hepatocellular carcinoma (HCC) and varices, more likely to receive rifaximin after discharge for hepatic encephalopathy (HE), and less likely to experience a 30-day readmission. B: Patients seen by APP without gastroenterologists/hepatologists were less likely to receive care that satisfies the practice metrics but also less likely to experience a 30-day readmission compared to patients seen by gastroenterologists/hepatologists without APPs. C: Patients seen by gastroenterologists/hepatologists with assistance from APPs received better care and had less readmissions compared to those seen by gastroenterologists/hepatologists alone except for varices screening where there was no difference. D: Patients seen by gastroenterologists/hepatologists alone received better care for all measures and had less readmissions compared to those not seen by gastroenterologists/hepatologists or APPs.