Quality Measures, All-Cause Mortality, and Health Care Use in a National Cohort of Veterans With Cirrhosis

Abstract

Decompensated cirrhosis is associated with high morbidity and mortality. However, no standardized quality measures (QMs) have yet been adopted widely. The Veterans Affairs (VA) Advanced Liver Disease Technical Advisory Group recently developed a set of six internal QMs to guide quality improvement efforts in cirrhosis in the domains of access to care, hepatocellular carcinoma surveillance, variceal surveillance, quality of inpatient care for upper gastrointestinal bleeding, and cirrhosis-related rehospitalizations. We aimed to (1) quantify adherence to cirrhosis QMs and (2) determine whether adherence was associated with all-cause mortality and health care use within a large national cohort of veterans with cirrhosis. We performed a retrospective study using data from the Veterans Outcomes and Costs Asociated with Liver Disease cohort of 121,129 patients newly diagnosed with cirrhosis from January 1, 2008, to December 31, 2016, at 128 VA facilities. The mean follow-up time was 2.7 years (interquartile range, 1.1-5.1 years). Adherence to outpatient access to specialty care was 71%, variceal surveillance was 32%, and early postdischarge care was 54%. In adjusted analyses, outpatient access to specialty care (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.78-0.82), hepatocellular carcinoma surveillance (HR, 0.92; 95% CI, 0.90-0.95), variceal surveillance (HR, 0.93; 95% CI, 0.89-0.99), and early postdischarge care (HR, 0.57; 95% CI, 0.54-0.60) were associated with lower all-cause mortality. Readmissions after 30 days (HR, 1.53; 1.46-1.60) and 90 days (HR, 1.88; 95% CI, 1.54-1.70) were associated with higher all-cause mortality. Higher adherence to QMs was also associated with lower inpatient health care use. Conclusion: Five of the six proposed VA cirrhosis QMs were measurable using existing data sources, associated with mortality and health care use, and may be used to guide future quality improvement efforts in cirrhosis.

Figure 1

QM2. Unadjusted Kaplan-Meier survival estimates stratified by proportion of time under direct surveillance (PTUDS) for Hepatocellular Carcinoma (HCC) stratified by PTUDS >=50 versus < 50%. (A) HCC surveillance among patients with Child-Turcotte-Pugh A & B cirrhosis. Log rank: P < 0.001. Index date starts at 2 years after the cirrhosis diagnosis. (B) HCC surveillance among patients with Child-Turcotte-Pugh C cirrhosis. Log rank: P = 0.15.

Figure 1

QM2. Unadjusted Kaplan-Meier survival estimates stratified by proportion of time under direct surveillance (PTUDS) for Hepatocellular Carcinoma (HCC) stratified by PTUDS >=50 versus < 50%. (A) HCC surveillance among patients with Child-Turcotte-Pugh A & B cirrhosis. Log rank: P < 0.001. Index date starts at 2 years after the cirrhosis diagnosis. (B) HCC surveillance among patients with Child-Turcotte-Pugh C cirrhosis. Log rank: P = 0.15.

Figure 2

QM4. Unadjusted 90-day Kaplan-Meier survival estimates stratified by receipt of primary or specialty care appointment within 30 days of discharge from a cirrhosis-related hospitalization. Log rank P < 0.001.